Use of robotics in spinal cord injury: a case report

Computer-assisted robotic device for upper limb interventions for a patient with an incomplete cervical level spinal cord injury

A man in his 50s with an incomplete cervical spinal cord injury underwent a 3-week occupational therapy programme using a computer-assisted robotic device for the upper limbs (Diego) in an acute care spinal injury unit. The patient and their partner reported their experience. Range of motion (ROM), muscle strength, pain, fatigue, independence and occupational performance are reported. Improvements occurred in upper limb ROM (shoulder and elbow), muscle strength (right elbow extensors), fatigue and functional status. Whether the results in this patient with the Diego were the same or better than standard care could not be determined. Preliminary findings suggest that the Diego was feasible for rehabilitation in an acute setting in our patient. However, it may not be suitable for all patients and a large comparative study with other therapies is needed. A limitation in the use of the Diego relates to the initial cost of the device ($A150 000).

The Impact of Robotic Therapy on the Self-Perception of Upper Limb Function in Cervical Spinal Cord Injury: A Pilot Randomized Controlled Trial

BACKGROUND

The aim of the present study was to evaluate the impact of robotic therapy in patients with cervical spinal cord injury (SCI), measured on the basis of the patients' self-perception of limited upper limb function and level of independence in activities of daily living.

METHODS

Twenty-six patients with cervical SCI completed the treatment after being randomly assigned to the intervention or control group. The training consisted of 40 experimental sessions 1 h in duration, ideally occurring 5 days/week for 8 weeks. In addition to the conventional daily therapy (30 min), the control group received another 30 min of conventional therapy, whereas the intervention group received 30 min of robotic therapy. Patients were evaluated by means of the Capabilities of Upper Extremity Questionnaire (CUE) and Spinal Cord Independence Measure (SCIM) clinical scales.

RESULTS

The improvement in the feeding item of SCIM was significantly higher in the intervention group than in the control group after the treatment (2.00 (0.91) vs. 1.18 (0.89), p = 0.03). The correlation between the CUE and SCIM scales was higher at the ending than at baseline for both groups.

CONCLUSIONS

Although both groups improved, the clinical relevance related to the changes observed for both assessments was slightly higher in the intervention group than in the control group.

Identifying Homogeneous Outcome Groups in Adult Rehabilitation Using Cluster Analysis

IMPORTANCE

Adults receiving occupational therapy in inpatient rehabilitation are a heterogeneous population with differing needs, outcomes, and rehabilitation processes. Outcome studies based on what works for all clients may obscure the needs of population subgroups who benefit unequally from rehabilitation services.

OBJECTIVE

To identify subgroups on the basis of client satisfaction and progress in functional self-care among a diverse rehabilitation population and to understand subgroup differences in occupational therapy and rehabilitation processes and client discharge status.

DESIGN

Using an existing dataset, we used K-means cluster analysis of demographics, status at admission, and the outcomes of satisfaction and change in self-care to identify five homogeneous outcome groups. Occupational therapy and rehabilitation processes and discharge status were compared across subgroups.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

The dataset included 1,099 inpatients age 18 yr and older who received occupational therapy over a 27-mo period.

MEASURES

Admission measures included the Inpatient Rehabilitation Facility-Patient Assessment Instrument and self-care items of the FIM™. The Satisfaction with Continuum of Care-Revised was administered after discharge.

RESULTS

Five subgroups showed statistically different patterns of medical complications, functional self-care, rates of progress, satisfaction with intervention, and course of treatment. The profile of each group suggests differing therapeutic needs. Although all groups made significant gains in functional self-care, two groups continued to need physical assistance at discharge.

CONCLUSION

and Relevance: Cluster analysis proved useful in segmenting a typical heterogeneous rehabilitation population into more homogeneous subgroups to enhance understanding of clinical needs and to potentially increase the potency of outcomes research.

WHAT THIS ARTICLE ADDS

This research identified subgroups within a typical population of rehabilitation clients receiving occupational therapy and identified their unique needs and outcomes using cluster analysis techniques.

A single-subject study of robotic upper limb training in the subacute phase for four persons with cervical spinal cord injury

Study design

Single-subject design, standard training ("B") compared with Robotic training ("C").

Objectives

To explore the impact of robotic training on upper limb function, activities of daily living (ADL) and training experience in subacute tetraplegic inpatients.

Setting

Inpatient subacute Norwegian spinal cord injury (SCI) unit.

Methods

Four participants (C4-7, AIS A-C) completed 11 sessions of robotic training using a passive robotic exoskeleton (Armeo Spring®). Descriptive statistics and visual analyses were used for comparing standard occupational therapy and robotic training. Outcome measures included the Spinal Cord Independence Measure (SCIM-III), the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), and a questionnaire.

Results

All of the participants exhibited an increase in assessments of upper limb function (GRASSP-total) right side (0.4%-61.2%), and all except for one participant (-8%) showed an increase on their left side (20.9%-106.2%). Three out of four participants had improvements in ADL function SCIM-III (ranging from 5.6% to 46.7%). Results demonstrated improvements during the robotic intervention period in five out of 28 measurements. The participants enjoyed the exercise, and found it motivating and relevant to their injury (median ranged from 3.5 to 6.5 on a 0-7 scale).

Conclusions

Three out of four participants improved upper limb function and ADL independence, but the study could not confirm that improvements were due to the robotic intervention. The participants enjoyed the robotic training and found it relevant to their injury.

Robot-assisted upper extremity rehabilitation for cervical spinal cord injuries: a systematic scoping review

Abstact Purpose: To provide an overview of the feasibility and outcomes of robotic-assisted upper extremity training for individuals with cervical spinal cord injury (SCI), and to identify gaps in current research and articulate future research directions.

MATERIALS AND METHODS

A systematic search was conducted using Medline, Embase, PsycINFO, CCTR, CDSR, CINAHL and PubMed on June 7, 2017. Search terms included 3 themes: (1) robotics; (2) SCI; (3) upper extremity. Studies using robots for upper extremity rehabilitation among individuals with cervical SCI were included. Identified articles were independently reviewed by two researchers and compared to pre-specified criteria. Disagreements regarding article inclusion were resolved through discussion. The modified Downs and Black checklist was used to assess article quality. Participant characteristics, study and intervention details, training outcomes, robot features, study limitations and recommendations for future studies were abstracted from included articles.

RESULTS

Twelve articles (one randomized clinical trial, six case series, five case studies) met the inclusion criteria. Five robots were exoskeletons and three were end-effectors. Sample sizes ranged from 1 to 17 subjects. Articles had variable quality, with quality scores ranging from 8 to 20. Studies had a low internal validity primarily from lack of blinding or a control group. Individuals with mild-moderate impairments showed the greatest improvements on body structure/function and performance-level measures. This review is limited by the small number of articles, low-sample sizes and the diversity of devices and their associated training protocols, and outcome measures.

CONCLUSIONS

Preliminary evidence suggests robot-assisted interventions are safe, feasible and can reduce active assistance provided by therapists. Implications for rehabilitation Robot-assisted upper extremity training for individuals with cervical spinal cord injury is safe, feasible and can reduce hands-on assistance provided by therapists. Future research in robotics rehabilitation with individuals with spinal cord injury is needed to determine the optimal device and training protocol as well as effectiveness.

Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review

Mobility after spinal cord injury (SCI) is among the top goals of recovery and improvement in quality of life. Those with tetraplegia rank hand function as the most important area of recovery in their lives, and those with paraplegia, walking. Without hand function, emphasis in rehabilitation is placed on accessing one's environment through technology. However, there is still much reliance on caretakers for many activities of daily living. For those with paraplegia, if incomplete, orthoses exist to augment walking function, but they require a significant amount of baseline strength and significant energy expenditure to use. Options for those with motor complete paraplegia have traditionally been limited to the wheelchair. While wheelchairs provide a modified level of independence, wheelchair users continue to face difficulties in access and mobility. In the past decade, research in SCI rehabilitation has expanded to include external motorized or robotic devices that initiate or augment movement. These robotic devices are used with 2 goals: to enhance recovery through repetitive, functional movement and increased neural plasticity and to act as a mobility aid beyond orthoses and wheelchairs. In addition, lower extremity exoskeletons have been shown to provide benefits to the secondary medical conditions after SCI such as pain, spasticity, decreased bone density, and neurogenic bowel. In this review, we discuss advances in robot-guided rehabilitation after SCI for the upper and lower extremities, as well as potential adjuncts to robotics.

EVALUATION OF MUSCLE STRENGTH IN MEDULLAR INJURY: A LITERATURE REVIEW

ABSTRACT Objective: To identify the tools used to evaluate muscle strength in subjects with spinal cord injury in both clinical practice and scientific research. Methods: Initially, the literature review was carried out to identify the tools used in scientific research. The search was conducted in the following databases: Virtual Health Library (VHL), Pedro, and PubMed. Studies published between 1990 and 2016 were considered and selected, depicting an evaluation of muscle strength as an endpoint or for characterization of the sample. Next, a survey was carried out with physiotherapists to identify the instruments used for evaluation in clinical practice, and the degree of satisfaction of professionals with respect to them. Results: 495 studies were found; 93 were included for qualitative evaluation. In the studies, we verified the use of manual muscle test with different graduation systems, isokinetic dynamometer, hand-held dynamometer, and manual dynamometer. In clinical practice, the manual muscle test using the motor score recommended by the American Spinal Cord Injury Association was the most used method, despite the limitations highlighted by the physiotherapists interviewed. Conclusion: In scientific research, there is great variation in the methods and tools used to evaluate muscle strength in individuals with spinal cord injury, differently from clinical practice. The tools available and currently used have important limitations, which were highlighted by the professionals interviewed. No instrument depicts direct relationship of muscle strength and functionality of the subject. There is no consensus as to the best method for assessing muscle strength in spinal cord injury, and new instruments are needed that are specific for use in this population.

Creating Evidence for Practice Using Data-Driven Decision Making

To realize the American Occupational Therapy Association's Centennial Vision, occupational therapy practitioners must embrace practices that are not only evidence based but also systematic, theoretically grounded, and driven by data related to outcomes. This article presents a framework, the Data-Driven Decision Making (DDDM) process, to guide clinicians' occupational therapy practice using systematic clinical reasoning with a focus on data. Examples are provided of DDDM in pediatrics and adult rehabilitation to guide practitioners in using data-driven practices to create evidence for occupational therapy.

Motor imagery reinforces brain compensation of reach-to-grasp movement after cervical spinal cord injury

Individuals with cervical spinal cord injury (SCI) that causes tetraplegia are challenged with dramatic sensorimotor deficits. However, certain rehabilitation techniques may significantly enhance their autonomy by restoring reach-to-grasp movements. Among others, evidence of motor imagery (MI) benefits for neurological rehabilitation of upper limb movements is growing. This literature review addresses MI effectiveness during reach-to-grasp rehabilitation after tetraplegia. Among articles from MEDLINE published between 1966 and 2015, we selected ten studies including 34 participants with C4 to C7 tetraplegia and 22 healthy controls published during the last 15 years. We found that MI of possible non-paralyzed movements improved reach-to-grasp performance by: (i) increasing both tenodesis grasp capabilities and muscle strength; (ii) decreasing movement time (MT), and trajectory variability; and (iii) reducing the abnormally increased brain activity. MI can also strengthen motor commands by potentiating recruitment and synchronization of motoneurons, which leads to improved recovery. These improvements reflect brain adaptations induced by MI. Furthermore, MI can be used to control brain-computer interfaces (BCI) that successfully restore grasp capabilities. These results highlight the growing interest for MI and its potential to recover functional grasping in individuals with tetraplegia, and motivate the need for further studies to substantiate it.

Moving Toward 2017: Progress in Rehabilitation Intervention Effectiveness Research

Halfway into the 10-yr American Occupational Therapy Association Centennial Vision initiative, occupational therapy has made notable progress in establishing itself as a science-driven profession. Through the diligent work of many talented occupational therapy scholars, 42 research studies exploring interventions used in rehabilitation research were published in the past 5 years. A variety of both novel and established intervention strategies were investigated using diverse research designs and measurement tools. A predominant number of studies were conducted with the poststroke population. Moving forward to 2017 and building on our success, we can recognize our full potential by fostering knowledge translation, expanding participant numbers, exploring less-studied populations, increasing the volume of systematic reviews published, and reporting occupation-centered outcomes, the unique and defining component of our profession.

Improved motor performance in chronic spinal cord injury following upper-limb robotic training

BACKGROUND

Recovering upper-limb motor function has important implications for improving independence of patients with tetraplegia after traumatic spinal cord injury (SCI).

OBJECTIVE

To evaluate the feasibility, safety and effectiveness of robotic-assisted training of upper limb in a chronic SCI population.

METHODS

A total of 10 chronic tetraplegic SCI patients (C4 to C6 level of injury, American Spinal Injury Association Impairment Scale, A to D) participated in a 6-week wrist-robot training protocol (1 hour/day 3 times/week). The following outcome measures were recorded at baseline and after the robotic training: a) motor performance, assessed by robot-measured kinematics, b) corticospinal excitability measured by transcranial magnetic stimulation (TMS), and c) changes in clinical scales: motor strength (Upper extremity motor score), pain level (Visual Analog Scale) and spasticity (Modified Ashworth scale).

RESULTS

No adverse effects were observed during or after the robotic training. Statistically significant improvements were found in motor performance kinematics: aim (pre 1.17 ± 0.11 raduans, post 1.03 ± 0.08 raduans, p = 0.03) and smoothness of movement (pre 0.26 ± 0.03, post 0.31 ± 0.02, p = 0.03). These changes were not accompanied by changes in upper-extremity muscle strength or corticospinal excitability. No changes in pain or spasticity were found.

CONCLUSIONS

Robotic-assisted training of the upper limb over six weeks is a feasible and safe intervention that can enhance movement kinematics without negatively affecting pain or spasticity in chronic SCI. In addition, robot-assisted devices are an excellent tool to quantify motor performance (kinematics) and can be used to sensitively measure changes after a given rehabilitative intervention.

Five years later: achieving professional effectiveness to move neurorehabilitation forward

The AOTA Centennial Vision outlined in 2007 challenged the occupational therapy profession to become a "powerful, widely recognized, science-driven, and evidence-based" profession that could adapt to changing societal and cultural needs and flourish well into the future. That challenge can be met by simply being effective at what we do; this will increase our value and validate our worth. Neurorehabilitation in occupational therapy can also thrive if we verify that the interventions we use and the strategies we implement are grounded in evidence. Professional effectiveness will emerge by (1) increasing the dissemination of research that supports the methods we use and informs others of the successful patient outcomes we achieve and (2) expanding development and validation of instruments that quantitatively and qualitatively measure functional outcomes. Occupational therapists can individually develop professional effectiveness by fostering greater academic-clinical alliances, objectifying evaluation and intervention methods, and preparing future practitioners appropriately for evidence-driven practice.