Web-based telerehabilitation for the upper extremity after stroke

Human-Scale Motion Capture with an Accelerometer-Based Gaming Controller

Gaming controllers are attractive devices for research due to their onboard sensing capabilities and low cost. However, a proper quantitative analysis regarding their suitability for motion capture has yet to be fully reported. In this paper, a detailed analysis of the accelerometers of the Nintendo Wiimote is presented. The gravity-compensated acceleration data from the accelerometers of theWiimote were plotted, compared and correlated with computed acceleration data derived from a six-camera motion capture system. The results show high correlation and low mean absolute error between the gravity-compensated data from the accelerometers of the controllers and computed acceleration from position data of the motion capture system. From the results obtained, it can be inferred that the Wiimote is well suited for motion capture applications where post-processing of data is practical.

Game motivated and constraint induced therapy in late stroke with FMRI studies pre and post therapy

20 patients with stroke more than one year earlier were evaluated, admitted to a novel therapy including constraint-induced and computer game-motivated therapy. Statistically significant improvements after 4 weeks of late therapy were seen in all 20 patients on nine out of eleven quantified clinical evaluation scales. The patients looked forward to and enjoyed the therapy. These same late stroke patients were studied via fMRI BOLD immediately before therapy and post therapy. fMRI BOLD studies confirm brain functional reorganization; 3 of the 20 fMRI cases are presented here. We propose that fMRI can help in the process of designing effective stroke therapy programs based on biological principles of brain plasticity.

Application of wearable inertial sensors in stroke rehabilitation

We introduce a human arm movement tracking system that has been developed to aid the rehabilitation of stroke patients. A wearable 3-axis inertial sensor is used to capture arm movements in 3-D space and in real time. The tracking algorithm is based on a kinematical model that considers the upper and lower forearm. To improve accuracy and consistency, a weighted least square filtering strategy is adopted. The calculated motion trajectory was compared with that measured using a commerically available Qualysis tracking system. For 3D cyclical rotation, the mean wrist position error was 2.45 cm without filtering and 1.79 cm after the filtering alogorithm was applied. The experimental results demonstrate the favorable performance of the proposed framework in estimation of upper limb motion in stroke rehabilitation.

Fully-automated test of upper-extremity function

With the advent of new approaches to upper extremity recovery after stroke and spinal cord injury, the quantitative evaluation of hand function has become a crucial component of outcome evaluation. Recently we developed a workstation, the ReJoyce (Rehabilitation Joystick for Computer Exercise) on which subjects perform a variety of movement tasks while playing computer games. An important feature of the system is the ReJoyce Automated Hand Function Test (RAHFT). In this study we compared and validated the RAHFT against two widely-used clinical tests, the Action Research Arm Test (ARAT) [1][2] and the Fugl-Meyer Assessment (FMA) [3]. All three tests were performed in 34 separate sessions in 13 tetraplegic individuals. Principal component and regression analyses revealed that both the ARAT and the RAHFT correlated well with the first principle component fitted to the scores of the three tests. The FMA was less well correlated. These data help validate the RAHFT as a quantitative, automated alternative to the ARAT and FMA. The RAHFT is the first comprehensive test of hand function that does not depend on human judgment.

Estimation of Finger Joint Angles from sEMG Using a Neural Network Including Time Delay Factor and Recurrent Structure

Background. The surface electromyogram (sEMG) is strongly related to human motion and is useful as a human interface in robotics and rehabilitation. The purpose of this study was to establish a new system for estimating finger joint angles using few sEMG channels. Methods. To deal with a dynamic system, the proposed method adopts time delay factors and a feedback stream into a neural network (NN) with 6 system parameters. The 2 target motion patterns were each tested with 5 subjects. 1000 combinations of system parameter sets were tested. Results. A system with only 4 channels can estimate angles with 7.1–11.8% root mean square (RMS) error, which is approximately the same level of accuracy achieved by other systems using 15 channels. Conclusions. The use of so few channels is a great advantage in an sEMG system because it provides a convenient interface system. This advantage is conferred by the proposed NN system.

Stroke Therapy through Motion-Based Games

In the United States alone, more than five million people are living with long term motor impairments caused by a stroke. Recently, video games with affordable motion-based input devices have been proposed as a part of therapy to help people recover lost range of motion and motor control. While researchers have demonstrated the potential utility of therapeutic games through controlled studies, relatively little work has explored their long-term home-based use. We conducted a six-week home study with a 62-year-old woman who was seventeen years post-stroke. She played therapeutic games for approximately one hour a day, five days a week. Over the six weeks, she recovered significant motor abilities, which is unexpected given the time since her stroke. We explore detecting such improvements early, using game logs for daily measurements of motor ability to complement the standard measurements that are taken less often. Through observations and interviews, we present lessons learned about the barriers and opportunities that arise from long-term home-based use of therapeutic games.

Pilot study to test effectiveness of video game on reaching performance in stroke

Robotic systems currently used in upper-limb rehabilitation following stroke rely on some form of visual feedback as part of the intervention program. We evaluated the effect of a video game environment (air hockey) on reaching in stroke with various levels of arm support. We used the Arm Coordination Training 3D system to provide variable arm support and to control the hockey stick. We instructed seven subjects to reach to one of three targets covering the workspace of the impaired arm during the reaching task and to reach as far as possible while playing the video game. The results from this study showed that across subjects, support levels, and targets, the reaching distances achieved with the reaching task were greater than those covered with the video game. This held even after further restricting the mapped workspace of the arm to the area most affected by the flexion synergy (effectively forcing subjects to fight the synergy to reach the hockey puck). The results from this study highlight the importance of designing video games that include specific reaching targets in the workspace compromised by the expression of the flexion synergy. Such video games would also adapt the target location online as a subject's success rate increases.

The development of an adaptive upper-limb stroke rehabilitation robotic system

Background

Stroke is the primary cause of adult disability. To support this large population in recovery, robotic technologies are being developed to assist in the delivery of rehabilitation. This paper presents an automated system for a rehabilitation robotic device that guides stroke patients through an upper-limb reaching task. The system uses a decision theoretic model (a partially observable Markov decision process, or POMDP) as its primary engine for decision making. The POMDP allows the system to automatically modify exercise parameters to account for the specific needs and abilities of different individuals, and to use these parameters to take appropriate decisions about stroke rehabilitation exercises.

Methods

The performance of the system was evaluated by comparing the decisions made by the system with those of a human therapist. A single patient participant was paired up with a therapist participant for the duration of the study, for a total of six sessions. Each session was an hour long and occurred three times a week for two weeks. During each session, three steps were followed: (A) after the system made a decision, the therapist either agreed or disagreed with the decision made; (B) the researcher had the device execute the decision made by the therapist; (C) the patient then performed the reaching exercise. These parts were repeated in the order of A-B-C until the end of the session. Qualitative and quantitative question were asked at the end of each session and at the completion of the study for both participants.

Results

Overall, the therapist agreed with the system decisions approximately 65% of the time. In general, the therapist thought the system decisions were believable and could envision this system being used in both a clinical and home setting. The patient was satisfied with the system and would use this system as his/her primary method of rehabilitation.

Conclusions

The data collected in this study can only be used to provide insight into the performance of the system since the sample size was limited. The next stage for this project is to test the system with a larger sample size to obtain significant results.

In-home tele-rehabilitation improves tetraplegic hand function

BACKGROUND

Spinal cord injury (SCI) survivors with tetraplegia have great difficulty performing activities of daily living (ADLs). Functional electrical stimulation (FES) combined with exercise therapy (ET) can improve hand function, but delivering the treatment is problematic.

OBJECTIVE

To compare 2 ET treatments delivered by in-home tele-therapy (IHT).

METHODS

Each treatment involved ET, tele-supervised 1 h/d, 5 d/wk for 6 weeks. Treatment 1: "conventional ET" comprised strength training, computer games played with a trackball, and therapeutic electrical stimulation (TES). Treatment 2: "ReJoyce ET" comprised FES-ET on a workstation, the Rehabilitation Joystick for Computerized Exercise (ReJoyce) with which participants played computer games associated with ADLs. Participants were block-randomized into group 1 receiving conventional ET first, followed by 1-month washout, and then ReJoyce ET and group 2 in reverse order. In all, 13 participants took part, 5 completing the study with both hands, such that both groups had a sample size of 9.

PRIMARY OUTCOME MEASURE

Action Research Arm Test (ARAT).

SECONDARY OUTCOME MEASURES

grasp and pinch forces and the ReJoyce automated hand function test (RAHFT).

RESULTS

ARAT scores improved more after ReJoyce ET (13.0% ± 9.8%) than after conventional ET (4.0% ± 9.6%; F = 10.6, P < .01). RAHFT scores also improved more after ReJoyce ET (16.9% ± 8.6%) than conventional ET (3.3% ± 10.2%; F = 20.4, P < .01).

CONCLUSIONS

FES-ET on a workstation, supervised over the Internet, is feasible and may be effective for patients who can meet the residual motor function requirements of our study.

Finger Rehabilitation Support System Using a Multifingered Haptic Interface Controlled by a Surface Electromyogram

This paper presents a new type of finger rehabilitation system using a multifingered haptic interface that is controlled by the patient though a surface electromyogram. We have developed the multifingered haptic interface robot: HIRO III that can give 3-directional forces to 5 fingertips. This robot can also be used as a rehabilitation device that can provide various fingertip exercises and measure various types of information. The sEMG works together with the HIRO III to consider the patient's intent. The proposed system is intended for patients having paralysis in the hand and fingers, and the motions will be provided as biofeedback to the fingertips with the device. In contrast to completely passive rehabilitation, the proposed system can provide active rehabilitation using sEMG. The experiment involved finger opening and closing with this system by ten able-bodied subjects. The results show that almost all subjects felt appropriate motion support from the device.

Active-passive bilateral therapy as a priming mechanism for individuals in the subacute phase of post-stroke recovery: a feasibility study

OBJECTIVE

To assess the feasibility of treating inpatient stroke survivors with active-passive bilateral therapy as a motor priming technique before occupational therapy.

DESIGN

Single case series with two matched pairs in the subacute post-stroke rehabilitation phase. The test patients received active-passive bilateral therapy plus upper limb motor training. Control patients received only the motor training.

RESULTS

Both Fugl-Meyer Upper Extremity scores and Action Research Arm Test scores improved in this small group of test and control patients. The magnitude of improvement was greater in test patients who received active-passive bilateral therapy plus unilateral training.

CONCLUSIONS

We conclude that it is feasible and safe to administer active-passive bilateral therapy in a hospital setting.

A comparison of age difference reaction to computer interface

In this work, a simplified interface system for education of people with disabilities is presented. This platform allows the control of different tools (PC games, robot, and electric wheelchair) using different interfaces (mouse, joysticks, etc.). This interface system can be automatically reconfigured to match user’s ability, and it is operated locally or remotely through the internet. Saving of experimental progress data for later analysis can be done. Quantitative indicators are defined for evaluation purposes and to determine the needed assistance and adaptation. The system is tested on different age groups for people without physical disability. Results are presented and discussed.

Incorporating verbal feedback into a robot-assisted rehabilitation system

This paper presents a control architecture, which has the potential to monitor the task and safety issues, to provide assessment of the progress and alter the task parameters, and to incorporate patient's feedback in order to make the necessary modifications to impart effective therapy during the execution of the task in an automated manner. Experimental results are presented to demonstrate the efficacy of the proposed control architecture.

Normalized movement quality measures for therapeutic robots strongly correlate with clinical motor impairment measures

In this paper, we analyze the correlations between four clinical measures (Fugl-Meyer upper extremity scale, Motor Activity Log, Action Research Arm Test, and Jebsen-Taylor Hand Function Test) and four robotic measures (smoothness of movement, trajectory error, average number of target hits per minute, and mean tangential speed), used to assess motor recovery. Data were gathered as part of a hybrid robotic and traditional upper extremity rehabilitation program for nine stroke patients. Smoothness of movement and trajectory error, temporally and spatially normalized measures of movement quality defined for point-to-point movements, were found to have significant moderate to strong correlations with all four of the clinical measures. The strong correlations suggest that smoothness of movement and trajectory error may be used to compare outcomes of different rehabilitation protocols and devices effectively, provide improved resolution for tracking patient progress compared to only pre- and post-treatment measurements, enable accurate adaptation of therapy based on patient progress, and deliver immediate and useful feedback to the patient and therapist.

Design and development of a hand robotic rehabilitation device for post stroke patients

Robot-mediated rehabilitation is a rapidly advancing discipline that seeks to develop improved treatment procedures using new technologies, e.g., robotics, coupled with modern theories in neuroscience and rehabilitation. A robotic device was designed and developed for rehabilitation of upper limbs of post stroke patients. A novel force feedback bimanual working mode provided real-time dynamic sensation of the paretic hand. Results of the preliminary clinical tests revealed a quantitative evaluation of the patient's level of paresis and disability.

Feasibility of modified remotely monitored in-home gaming technology for improving hand function in adolescents with cerebral palsy

The convergence of game technology, the Internet, and rehabilitation science forms the second-generation virtual rehabilitation framework. This paper presents the first pilot study designed to look at the feasibility of at-home use of gaming technology adapted to address hand impairments in adolescents with hemiplegia due to perinatal stroke or intraventricular hemorrhage. Three participants trained at home for approximately 30 min/day, several days a week, for six to ten months. During therapy, they wore a fifths dimension technologies ultra sensing glove and played custom-developed Java 3D games on a modified PlayStation 3. The games were designed to accommodate the participants' limited range of motion, and to improve finger range and speed of motion. Trials took place in Indiana, while monitoFring/data storage took place at Rutgers Tele-Rehabilitation Institute (New Jersey). Significant improvements in finger range of motion (as measured by the sensing glove) were associated with self- and family-reported improvements in activities of daily living. In online subjective evaluations, participants indicated that they liked the system ease of use, clarity of instructions, and appropriate length of exercising. Other telerehabilitation studies are compared to this study and its technology challenges. Directions for future research are included.

Telerehabilitation and Electrical Stimulation: An Occupation-Based, Client-Centered Stroke Intervention

OBJECTIVE. We examined the efficacy of a remotely based arm rehabilitation regimen. A 62-year-old man participated in occupation-based, task-specific practice of activities of daily living (ADLs) &gt;3 years after stroke. The entire regimen was administered over the Internet using personal computer–based cameras and free network meeting software.

METHOD. Fugl-Meyer Assessment (FM), Action Research Arm Test (ARA), and Canadian Occupational Performance Measure (COPM) were administered before intervention. One week after treatment, FM, ARA, and COPM were readministered.

RESULTS. The participant exhibited reduced impairment and reduced functional limitation. He also expressed enhanced satisfaction with his ability to perform ADLs and rated his ADL performance better after intervention. The participant could now drive using both hands, use eating utensils, and catch and throw a ball.

CONCLUSION. Data suggest feasibility and efficacy of a remotely based, inexpensive approach using functional electrical stimulation for affected arm rehabilitation after stroke.

Design and Usability of a Home Telerehabilitation System to Train Hand Recovery Following Stroke

Current theories of stroke rehabilitation point toward paradigms of intense concentrated use of the afflicted limb as a means for motor program reorganization and partial function restoration. A home-based system for stroke rehabilitation that trains recovery of hand function by a treatment of concentrated movement was developed and tested. A wearable goniometer measured finger and wrist motions in both hands. An interface box transmitted sensor measurements in real-time to a laptop computer. Stroke patients used joint motion to control the screen cursor in a one-dimensional tracking task for several hours a day over the course of 10–14 days to complete a treatment of 1800 tracking trials. A telemonitoring component enabled a therapist to check in with the patient by video phone to monitor progress, to motivate the patient, and to upload tracking data to a central file server. The system was designed for use at home by patients with no computer skills. The system was placed in the homes of 20 subjects with chronic stroke and impaired finger motion, ranging from 2–305 mi away from the clinic, plus one that was a distance of 1057 miles. Fifteen subjects installed the system at home themselves after instruction in the clinic, while nine required a home visit to install. Three required follow-up visits to fix equipment. A post-treatment telephone survey was conducted to assess ease of use and most responded that the system was easy to use. Functional improvements were seen in the subjects enrolled in the formal treatment study, although the treatment period was too short to trigger cortical reorganization. We conclude that the system is feasible for home use and that tracking training has promise as a treatment paradigm.

Investigation of goal change to optimize upper-extremity motor performance in a robotic environment

Robotic devices for therapy have the potential to enable intensive, fully customized home rehabilitation over extended periods for individuals with stroke and traumatic brain injury, thus empowering them to maximize their functional recovery. For robotic rehabilitation to be most effective, systems must have the capacity to assign performance goals to the user and to increment those goals to encourage performance improvement. Otherwise, individuals may plateau at an artificially low level of function. Frequent goal change is needed to motivate improvements in performance by individuals with brain injury; but because of entrenched habits, these individuals may avoid striving for goals that they perceive as becoming ever more difficult. For this reason, implicit, undetectable goal change (distortion) may be more effective than explicit goal change at optimizing the motor performance of some individuals with brain injury. This paper reviews a body of work that provides a basis for incorporating implicit goal change into a robotic rehabilitation paradigm. This work was conducted with individuals without disability to provide foundational knowledge for using goal change in a robotic environment. In addition, we compare motor performance with goal change to performance with no goal or with a static goal for individuals without brain injury. Our results show that goal change can improve motor performance when participants attend to visual feedback. Building on these preliminary results can lead to more effective robotic paradigms for the rehabilitation of individuals with brain injury, including individuals with cerebral palsy.

Motor tele-rehabilitation in post-stroke patients

PRIMARY OBJECTIVE

The advanced communication technology may allow rehabilitative interventions to patients living at home from a remote provider. We evaluated the effects of a tele-rehabilitation system for the therapy of arm motor impairments due to a stroke.

RESEARCH DESIGN

Experimental observational study.

METHODS AND PROCEDURES

We selected five patients suffering from mild/intermediate arm motor impairments due to a long-lasting ischaemic stroke. Two workstations were utilized, one in the patient's house and the other in the rehabilitation hospital, connected through the phone lines. A virtual reality based software allowed the patient to perform adequate motor tasks created by the physiotherapist. During performance, the patient could see not only their movement but also the correct trajectory that they had to accomplish. The feedback derived from the patient's action, its outcome, and feedback from the supervision of the physiotherapist may favour the acquisition of new motor abilities.

MAIN OUTCOME MEASURES

The arm motor performance and the activities of daily living were evaluated using the Fugl-Meyer and Functional Independence Measure scale, together with the determination of the velocity and duration of 10 representative reaching movements.

RESULTS

Subjects underwent the tele-rehabilitation programme for 4 weeks. The therapy significantly improved the Fugl-Meyer mean score, the mean duration and the velocity of the movements, but not the Functional Independence Measure scale score.

CONCLUSIONS

These results indicated that this tele-rehabilitation system did not appear to adversely affect rehabilitation; rather it may improve arm motor deficits due to a stroke. If these evidences are further confirmed, tele-rehabilitation may represent a new home-based therapy to treat disabled people.

Review of control strategies for robotic movement training after neurologic injury

There is increasing interest in using robotic devices to assist in movement training following neurologic injuries such as stroke and spinal cord injury. This paper reviews control strategies for robotic therapy devices. Several categories of strategies have been proposed, including, assistive, challenge-based, haptic simulation, and coaching. The greatest amount of work has been done on developing assistive strategies, and thus the majority of this review summarizes techniques for implementing assistive strategies, including impedance-, counterbalance-, and EMG- based controllers, as well as adaptive controllers that modify control parameters based on ongoing participant performance. Clinical evidence regarding the relative effectiveness of different types of robotic therapy controllers is limited, but there is initial evidence that some control strategies are more effective than others. It is also now apparent there may be mechanisms by which some robotic control approaches might actually decrease the recovery possible with comparable, non-robotic forms of training. In future research, there is a need for head-to-head comparison of control algorithms in randomized, controlled clinical trials, and for improved models of human motor recovery to provide a more rational framework for designing robotic therapy control strategies.

Feasibility of a home-based telerehabilitation system compared to usual care: arm/hand function in patients with stroke, traumatic brain injury and multiple sclerosis

We conducted a randomized controlled multicentre trial to investigate the feasibility of a telerehabilitation intervention for arm/hand function (the Home Care Activity Desk [HCAD] training) in a home setting. Usual care was compared to HCAD training. The hypothesis was that the clinical outcomes of the HCAD intervention would be at least the same as those measured after a period of usual care for patients with stroke, traumatic brain injury (TBI) and multiple sclerosis (MS) with respect to their arm/hand function. Eighty-one patients with affected arm/hand function resulting from either stroke, MS or TBI were recruited in Italy, Spain and Belgium; 11 were lost during follow-up (14%). The outcome measures were the Action Research Arm Test (ARAT) and the Nine Hole Peg Test (NHPT). There were no significant differences between the two groups on the outcome measures (ARAT and NHPT); in both groups, patients maintained or even improved their arm/hand function. The HCAD training was found to be as feasible as usual care in terms of clinical outcomes, and both therapists and patients were satisfied with the HCAD intervention. A telerehabilitation intervention using HCAD may increase the efficiency of care.

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

Background

It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.

Methods

A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).

Results

One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.

Conclusion

This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

A perspective on intelligent devices and environments in medical rehabilitation

Globally, the number of people older than 65 years is anticipated to double between 1997 and 2025, while at the same time the number of people with disabilities is growing at a similar rate, which makes technical advances and social policies critical to attain, prolong, and preserve quality of life. Recent advancements in technology, including computation, robotics, machine learning, communication, and miniaturization of sensors have been used primarily in manufacturing, military, space exploration, and entertainment. However, few efforts have been made to utilize these technologies to enhance the quality of life of people with disabilities. This article offers a perspective of future development in seven emerging areas: translation of research into clinical practice, pervasive assistive technology, cognitive assistive technologies, rehabilitation monitoring and coaching technologies, robotic assisted therapy, and personal mobility and manipulation technology.

A home-care system for the telemonitoring and telerehabilitation of the hand incorporating interactive biofeedback

We have designed and constructed force measurement equipment to assess hand–finger function in pressing tasks. The equipment was used for monitoring the follow-up of five hand-transplanted subjects. Interactive software was integrated into the instrument to monitor the functionality of the hand and fingers during exercises in realtime. The interactive software included biofeedback to provide realtime quantitative responses for the patient and the therapist. Acceptance of the system was investigated with patients and therapists: the system was found to be user-friendly and effective; it was practical both for patients and therapists. The system could be used in a telerehabilitation centre or in a patient's home.

Human factors in the development and implementation of telerehabilitation systems

Telemedicine services must be designed and implemented with the users in mind. When conducting telerehabilitation, factors such as age, education and technology experience must be taken into account. In addition, telerehabilitation must also accommodate a range of potential patient impairments, including deficits in language, cognition, motor function, vision and voice. Telerehabilitation technology and treatment environments should adhere to universal design standards so as to be accessible, efficient, usable and understandable to all. This will result in improved access to a wider range of telerehabilitation services that will facilitate and enhance the rehabilitative treatment and recovery of people living with varying levels of injury, impairment and disability.

An interactive Internet-based system for tracking upper limb motion in home-based rehabilitation

In this paper, we introduce an interactive telecommunication system that supports video/audio signal acquisition, data processing, transmission, and 3D animation for post stroke rehabilitation. It is designed for stroke patients to use in their homes. It records motion exercise data, and immediately transfers this data to hospitals via the internet. A real-time videoconferencing interface is adopted for patients to observe therapy instructions from therapists. The system uses a peer-to-peer network architecture, without the need for a server. This is a potentially effective approach to reducing costs, allowing easy setup and permitting group-rehabilitation sessions. We evaluate this system using the following steps: (1) motion detection in different movement patterns, such as reach, drink, and reach-flexion; (2) online bidirectional visual telecommunication; and (3) 3D rendering using a proposed offline animation package. This evaluation has subjectively been proved to be optimal.

Poststroke upper extremity rehabilitation: a review of robotic systems and clinical results

Although the use of robotic devices to address neuromuscular rehabilitative goals represents a promising technological advance in medical care, the large number of systems being developed and varying levels of clinical study of the devices make it difficult to follow and interpret the results in this new field. This article is a review of the current state-of-the-art in robotic applications in poststroke therapy for the upper extremity, written specifically to help clinicians determine the differences between various systems. We concentrate primarily on systems that have been tested clinically. Robotic systems are grouped by rehabilitation application (e.g., gross motor movement, bilateral training, etc.), and, where possible, the neurorehabilitation strategies employed by each system are described. We close with a discussion of the benefits and concerns of using robotics in rehabilitation and an indication of challenges that must be addressed for therapeutic robots to be applied practically in the clinic.

In the Spotlight: Neuroengineering

This article reviews current researches in the field of neuroengineering. Special focus is given to neural prosthesis, neuroprosthetic control and brain-computer interfaces (BCIs) for anthropomorphic and sensory prosthetic control.

An interactive framework for personalized computer-assisted neurorehabilitation

This paper presents the implementation of a framework for computer-assisted neurorehabilitation that intends to address the need for more personalized healthcare technologies. This framework called UniTherapy is applied to home neurorehabilitation for individuals with stroke-induced disability. It supports interactive upper limb assessment and therapy that makes use of mass-marketed force-reflecting joysticks and wheels, as well as some customized therapeutic devices. A novel service-oriented technical infrastructure is presented, which includes a rich menu of performance assessment capabilities and support features that include telerehabilitation links, protocol design, and data analysis tools. Results are presented that demonstrate its potential as a sensor-based assessment tool. User feedback is summarized.

Effects of robot-assisted therapy on upper limb recovery after stroke: a systematic review

OBJECTIVE

The aim of the study was to present a systematic review of studies that investigate the effects of robot-assisted therapy on motor and functional recovery in patients with stroke.

METHODS

A database of articles published up to October 2006 was compiled using the following Medline key words: cerebral vascular accident, cerebral vascular disorders, stroke, paresis, hemiplegia, upper extremity, arm, and robot. References listed in relevant publications were also screened. Studies that satisfied the following selection criteria were included: (1) patients were diagnosed with cerebral vascular accident; (2) effects of robot-assisted therapy for the upper limb were investigated; (3) the outcome was measured in terms of motor and/or functional recovery of the upper paretic limb; and (4) the study was a randomized clinical trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for motor recovery and functional ability (activities of daily living [ADLs]) using fixed and random effect models. Ten studies, involving 218 patients, were included in the synthesis. Their methodological quality ranged from 4 to 8 on a (maximum) 10-point scale.

RESULTS

Meta-analysis showed a nonsignificant heterogeneous SES in terms of upper limb motor recovery. Sensitivity analysis of studies involving only shoulder-elbow robotics subsequently demonstrated a significant homogeneous SES for motor recovery of the upper paretic limb. No significant SES was observed for functional ability (ADL).

CONCLUSION

As a result of marked heterogeneity in studies between distal and proximal arm robotics, no overall significant effect in favor of robot-assisted therapy was found in the present meta-analysis. However, subsequent sensitivity analysis showed a significant improvement in upper limb motor function after stroke for upper arm robotics. No significant improvement was found in ADL function. However, the administered ADL scales in the reviewed studies fail to adequately reflect recovery of the paretic upper limb, whereas valid instruments that measure outcome of dexterity of the paretic arm and hand are mostly absent in selected studies. Future research into the effects of robot-assisted therapy should therefore distinguish between upper and lower robotics arm training and concentrate on kinematical analysis to differentiate between genuine upper limb motor recovery and functional recovery due to compensation strategies by proximal control of the trunk and upper limb.

Technical and patient performance using a virtual reality-integrated telerehabilitation system: preliminary finding

Telerehabilitation is the provision of rehabilitation services at a distance by a therapist at a remote location. Integration with virtual reality (VR) is a relatively new addition to this field. This paper describes the technical and patient performance of a telerehabilitation application the remote console (ReCon) that is integrated with a VR system. The VR system consists of the Rutgers Ankle prototype robot, a local PC which is connected with a remote PC connected over the Internet. Six individuals in the chronic phase poststroke participated in a four week training program. They used the robot to interact with two VR simulations, while the therapist was in the same room during the first three weeks or in another room during the fourth week. Technical and patient performance was assessed in the transition from the third to the fourth week of training. Technical performance of the system was assessed based on bandwidth and lag of message transmission, which were found to be suitable for clinic-to-clinic communication. Patient performance (in terms of accuracy of ankle movement, exercise duration and training efficiency, mechanical power of the ankle, and number of repetitions) did not decrease during telerehabilitation in the fourth week. These preliminary findings over a short telerehabilitation intervention support the feasibility of remote monitoring of VR-based telerehabilitation without adverse effects on patient performance.

Comparison of Finger Tracking Versus Simple Movement Training via Telerehabilitation to Alter Hand Function and Cortical Reorganization After Stroke

Objective. To compare 2 telerehabilitation training strategies, repetitive tracking movements versus repetitive simple movements, to promote brain reorganization and recovery of hand function. Methods. Twenty subjects with chronic stroke and 10 degrees of voluntary finger extension were randomly assigned to receive 1800 telerehabilitation trials over 2 weeks of either computerized tracking training (track group) with the affected finger and wrist involving temporospatial processing to achieve accuracy or movement training (move group) with no attention to accuracy. Following movement training, the move group crossed over to receive an additional 2 weeks of tracking training. Behavioral changes were measured with the Box and Block test, Jebsen Taylor test, and finger range of motion, along with a finger-tracking activation paradigm during fMRI. Results. The track group showed significant improvement in all 4 behavioral tests; the move group improved in the Box and Block and Jebsen Taylor tests. The improvement for the track group in the Box and Block and Jebsen Taylor tests did not surpass that for the move group. A consistent group pattern of brain reorganization was not evident. The move group, after crossing over, did not show further significant improvements. Conclusion . Telerehabilitation may be effective in improving performance in subjects with chronic stroke. Tracking training with reinforcement to enhance learning, however, did not produce a clear advantage over the same amount of practice of random movements. Two weeks of training may be insufficient to demonstrate a behavioral advantage and associated brain reorganization.

Telerehabilitation Using a Virtual Environment Improves Upper Extremity Function in Patients With Stroke

In this paper, we describe our experience in designing a virtual environment-based (VE) telerehabilitation system, and the results of a clinical study of the first 11 subjects with stroke to use the system. Our telerehabilitation system allows a therapist to conduct interactive VE treatment sessions remotely with a patient who is located at home. The system, software architecture, and development experience are described. Results of the clinical study on subjects with stroke showed significant improvements in upper extremity function following 30 1-h VE treatment sessions as measured by three standard clinical tests: Fugl-Meyer test of motor recovery (FM) (p < 0.0001), Wolf motor test (WMT) (p = 0.0097, and shoulder strength (ShS) (p = 0.0027). Grip strength (GS) showed a trend toward improvement (p = 0.025). These changes were maintained, for the most part, at four-months follow-up (FM +7.6, WMT -18.4 s, ShS, +169%, GS, +53%).

Potential of a suite of robot/computer-assisted motivating systems for personalized, home-based, stroke rehabilitation

Background

There is a need to improve semi-autonomous stroke therapy in home environments often characterized by low supervision of clinical experts and low extrinsic motivation. Our distributed device approach to this problem consists of an integrated suite of low-cost robotic/computer-assistive technologies driven by a novel universal access software framework called UniTherapy. Our design strategy for personalizing the therapy, providing extrinsic motivation and outcome assessment is presented and evaluated.

Methods

Three studies were conducted to evaluate the potential of the suite. A conventional force-reflecting joystick, a modified joystick therapy platform (TheraJoy), and a steering wheel platform (TheraDrive) were tested separately with the UniTherapy software. Stroke subjects with hemiparesis and able-bodied subjects completed tracking activities with the devices in different positions. We quantify motor performance across subject groups and across device platforms and muscle activation across devices at two positions in the arm workspace.

Results

Trends in the assessment metrics were consistent across devices with able-bodied and high functioning strokes subjects being significantly more accurate and quicker in their motor performance than low functioning subjects. Muscle activation patterns were different for shoulder and elbow across different devices and locations.

Conclusion

The Robot/CAMR suite has potential for stroke rehabilitation. By manipulating hardware and software variables, we can create personalized therapy environments that engage patients, address their therapy need, and track their progress. A larger longitudinal study is still needed to evaluate these systems in under-supervised environments such as the home.

Progress toward universal interface technologies for telerehabilitation

One of the overriding needs in the field of telerehabilitation is for user-centered interfaces that provide individuals with differing abilities with access to effective remote communication. This paper provides a foundation for developing and evaluating interfaces that move towards the aim of universal accessibility, and reports on progress for four types of interfaces: multimedia conferencing technologies involving persons with different roles and disabilities participating in goal-directed tasks; physical devices for therapy and assessment; communication/control for computer-assisted teletherapy; and an intelligent telerehabilitation assistant that supports the dynamic rehabilitative process.

Recent trends in robot-assisted therapy environments to improve real-life functional performance after stroke

Upper and lower limb robotic tools for neuro-rehabilitation are effective in reducing motor impairment but they are limited in their ability to improve real world function. There is a need to improve functional outcomes after robot-assisted therapy. Improvements in the effectiveness of these environments may be achieved by incorporating into their design and control strategies important elements key to inducing motor learning and cerebral plasticity such as mass-practice, feedback, task-engagement, and complex problem solving.

This special issue presents nine articles. Novel strategies covered in this issue encourage more natural movements through the use of virtual reality and real objects and faster motor learning through the use of error feedback to guide acquisition of natural movements that are salient to real activities. In addition, several articles describe novel systems and techniques that use of custom and commercial games combined with new low-cost robot systems and a humanoid robot to embody the " supervisory presence" of the therapy as possible solutions to exercise compliance in under-supervised environments such as the home.

Automating arm movement training following severe stroke: functional exercises with quantitative feedback in a gravity-reduced environment

An important goal in rehabilitation engineering is to develop technology that allows individuals with severe motor impairment to practice arm movement without continuous supervision from a rehabilitation therapist. This paper describes the development of such a system, called Therapy WREX or ("T-WREX"). The system consists of an orthosis that assists in arm movement across a large workspace, a grip sensor that detects hand grip pressure, and software that simulates functional activities. The arm orthosis is an instrumented, adult-sized version of the Wilmington Robotic Exoskeleton (WREX), which is a five degrees-of-freedom mechanism that passively counterbalances the weight of the arm using elastic bands. After providing a detailed design description of T-WREX, this paper describes two pilot studies of the system's capabilities. The first study demonstrated that individuals with chronic stroke whose arm function is compromised in a normal gravity environment can perform reaching and drawing movements while using T-WREX. The second study demonstrated that exercising the affected arm of five people with chronic stroke with T-WREX over an eight week period improved unassisted movement ability (mean change in Fugl-Meyer score was 5 points +/- 2 SD; mean change in range of motion of reaching was 10%, p < 0.001). These results demonstrate the feasibility of automating upper-extremity rehabilitation therapy for people with severe stroke using passive gravity assistance, a grip sensor, and simple virtual reality software.

The Jerusalem TeleRehabilitation System, a new low-cost, haptic rehabilitation approach

Survivors of brain injury or stroke can improve movement ability with intensive, supervised practice. Since the hours of supervised therapy with a physical or occupational therapist are limited, telerehabilitation will enable patients to greatly expand the hours that they practice therapeutic exercises. The Jerusalem TeleRehabilitation System (JTRS) consists of patient and therapist systems plus a central server and database connected via the internet. The system can work in two modes: (1) a cooperative mode in which the therapist and patient are online at the same time, and (2) a stand-alone mode in which the patient uses the system on his own. In both cases, the system will monitor the status and progress of the patient and various parameters of his movement abilities, and prepare reports for the patient and for the therapist. From the clinic, the therapist will be able to change the screen seen by the patient and change the level and types of tasks, as needed. Compared to existing systems, our system will have the following advantages: (1) inexpensive and easy to use; (2) remote monitoring and control of the patient's computer by the therapist in the clinic; (3) more detailed analysis of patient status and progress; (4) a "smart" system which self-adapts to the patient's capabilities in real time, increasing or decreasing the difficulty of the exercise as needed; and (5) a central, international database which, by gathering data on many patients over time, will provide the basis for "smart" therapy and will also facilitate coordinated multicenter research studies.

Recent developments in biofeedback for neuromotor rehabilitation

The original use of biofeedback to train single muscle activity in static positions or movement unrelated to function did not correlate well to motor function improvements in patients with central nervous system injuries. The concept of task-oriented repetitive training suggests that biofeedback therapy should be delivered during functionally related dynamic movement to optimize motor function improvement. Current, advanced technologies facilitate the design of novel biofeedback systems that possess diverse parameters, advanced cue display, and sophisticated control systems for use in task-oriented biofeedback. In light of these advancements, this article: (1) reviews early biofeedback studies and their conclusions; (2) presents recent developments in biofeedback technologies and their applications to task-oriented biofeedback interventions; and (3) discusses considerations regarding the therapeutic system design and the clinical application of task-oriented biofeedback therapy. This review should provide a framework to further broaden the application of task-oriented biofeedback therapy in neuromotor rehabilitation.

User satisfaction with a telemedicine amputee clinic in Saskatchewan

A group of 15 patients with amputee-related diagnoses were given a satisfaction survey after telemedicine assessment. Most of the videoconferencing sessions used an IP connection at 768 kbit/s. The patients were seen at four sites. The average connection time was less than 5 min and the average time for a session was approximately 40 min. Thirteen questions required scaled responses (poor, fair, good, excellent) and two required yes/no answers. The 13 categories broadly related to satisfaction with the telemedicine service and the quality of specialist care. In all categories, 97% of the responses fell in the good to excellent range. Concerns were raised about ease of access to local telemedicine sites, connection waiting times and lack of familiarity with telemedicine technology. The study showed that telemedicine was acceptable to patients with amputations and provided a reliable assessment of the amputee.

Integrating Haptic-Tactile Feedback into a Video-Capture–Based Virtual Environment for Rehabilitation

Video-capture virtual reality (VR) systems are gaining popularity as intervention tools. To date, these platforms offer visual and audio feedback but do not provide haptic feedback. We contend that adding haptic feedback may enhance the quality of intervention for various theoretical and empirical reasons. This study aims to integrate haptic-tactile feedback into a video capture system (GX VR), which is currently applied for rehabilitation. The proposed multi-modal system can deliver audio-visual as well as vibrotactile feedback. The latter is provided via small vibratory discs attached to the patient's limbs. This paper describes the system, the guidelines of its design, and the ongoing usability study.