Robot-Assisted Rehabilitation

Review

The present and future of robotic technology in rehabilitation

Laut J, Porfiri M & Raghavan P.

Curr Phys Med Rehabil Rep Nov 2016

DOI: 10.1007/s40101-016-0139-0

Link to abstract: link.springer.com/article/10.1007/s40141-016-0139-0>

Robot-assisted rehabilitation can contribute to conventional therapy by delivering consistent training and by benchmarking and monitoring progress. Robots can offer efficiencies in time and over distance. They may act passively or actively, and may be “end-effector robots” which act through an handle that is gripped or provide an exo-skeleton that mimics the movements of the limb. Robot-assisted rehabilitation can function remotely through telerehabilitation, reaching clients in their homes.

Robot therapies leverage entertainment software to provide motivation and engagement with an aim to boost compliance with interventions, and, through distance technologies, may offer efficiencies to the therapist. Equipment costs and the need for therapist-friendly software that targets rehabilitation intervention goals remain challenges to wider adoption.

Add a Sensor = + Data

Pilot study

Kinecting the Moves: The kinematic potential of rehabilitation-specific gaming to inform treatment for hemiplegia

Glegg SMN, Hung CT, Valdés BA, Kim BDG, & Van der Loos HFM

International journal of child health and human development 9(3):351-360 · September 2016

Link to abstract: https://www.researchgate.net/publication/309737850_Kinecting_the_Moves_The_kinematic_potential_of_rehabilitation-specific_gaming_to_inform_treatment_for_hemiplegia

Objective: For upper extremity rehabilitation candidates, can the development of data capture and analysis systems contribute to better rehabilitation game treatment decisions?

Process: to use video games with an additional data collector (Kinect sensor) to promote bimanual therapy, improve data collection and identify therapist-relevant data. Three subjects completed a 90 minute session of game play.

Findings: “With the integration of the Kinect sensor, motion tracking data can be harvested to inform treatment program development and progression by therapists”. This paper supplements the groundwork for further rehabilitation-specific videogame development.

Getting to know VR: Using a Knowledge Translation tool for therapists

A knowledge translation intervention to enhance clinical application of a virtual reality system in stroke rehabilitation

Single Group

Levac D, Glegg SMN, Sveistrup H, Colquhoun H, Miller PA, Finestone H, DePaul V, Harris JA & Velikonja D

BMC Health Serv Res. 2016; 16: 557. Published online 2016 Oct 6. doi: 10.1186/s12913-016-1807-6

Full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC5052802/

Objective: In a sample of therapists, does a Knowledge Translation (KT) tool result in pre- to post-intervention improvements in VR technology adoption?

Process: Therapists were rated on the ADOPT-VR tool (Assessing Determinants of Prospective Takeup - Virtual Reality) before and after the KT intervention which included interactive e-learning modules, hands-on workshops and experiential learning practice sessions.

Outcomes: Pre- to post-intervention changes included improvement in therapists’ sense of agency and in increased facilitating conditions. Therapist knowledge and skills for using VR also increased. Barriers to use, intention to use and actual use did not change with the KT intervention for using VR. Low perceived usability of the VR system and some IREX-specific problems represented barriers, too.

Veridicality: Blending the Virtual with the Reality in Autism Research

Authenticity in Virtual Reality for assessment and intervention in Autism: A conceptual review

Literature Review

Parsons, S

Educational Research Review 19: (2016) 138 - 157

Link to abstract http://eprints.soton.ac.uk/399407/

A challenge of behavioural research is how to create experimental, laboratory settings that relate to real world experiences. Virtual reality has the capability to provide a blend of experimental control and realistic scenarios; a characteristic is called veridicality.

This literature review looks at the way virtual reality veridicality is used to find the different factors affecting the social interactions of people with autism. The review findings fall into two main categories. Veridicality is a way of blending synthetic and realistic social scenarios to provide learning and a way that transfers knowledge and skills to the real world. It can also be a way of providing authentic but controlled social settings where responses can be assessed to help understand the autism difference.

Autism research in virtual reality will at best be made up using the best ideas of researchers, influenced by the perspective of people with autism spectrum disorder and leveraging the capabilities of veridicality.

Amadeo robot for kids rehab

Hand Robotic Therapy in Children with Hemiparesis

Pilot Study

Bishop L, Gordon AM & Kim H

American Journal of Physical Medicine and Rehabilitation 2016;00,00-00

DOI: 10.1097/PHM.0000000000000537

Objective: In a sample of children with hemiparetic upper extremity cerebral palsy, is the Amadeo Hand Robot System feasible for retraining grasp and release?
Amadeo Hand Robot System

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/27386804

Method: 12 participants, 6 – 17 years old with upper extremity hemiparesis were measured initially, after a 6 week pre-intervention stage and following 6 weeks of three- hour long sessions. The Assisting Hand Assessment was chosen as the primary measure.

Findings: Participants tolerated the Amadeo, and the Assisting Hand Assessment showed significant change pre- to post-test. The Jebson-Taylor Test of Hand Function, the Upper Extremity Fugl-Meyer and the Quality of Upper Skills Test all revealed non-significant positive change; and the Pediatric Evaluation of Disability Inventory showed no change.

Freely motivated game play

Single group

Using Free Internet Videogames in Upper Extremity Motor Training for Children with Cerebral Palsy

Servik M, Eklund E, Mensch A, Forman M, Standeven J & Engsberg J

Behavioral Sciences, 2016 6:10

DOI: 10:3390/bs6020010

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/27338485

Objectives: Motion-based virtual reality rehabilitation can be an engaging and motivating form of therapy. “Tedium and lack of motivation are substantial barriers to performance improvements.” In children with cerebral palsy, is using free internet games feasible and motivating enough to encourage participation in movement therapy and increase function?

Process: Four 8-to-17 year old children with mild to moderate upper extremity limitations played 26 games over 12 weeks. The games were freely accessed internet games adapted for the Kinect controller with free Flexible Action and Articulated Skeleton Toolkit (FAAST) software. “Internet games eliminate the high cost of game development, permit games to be paired with an individual’s interests and allow for changing of games to maintain novelty. Matching the interest of the child makes the therapy increasingly client-centered and motivating.”

Outcomes:All children “progressed through the pre-set 12 week plan”, thus demonstrating feasibility. Children averaged nearly 900 repetitions per training session, and 2 of the participants showed improved range of motion.
The participants demonstrated motivation with an aggregated score of 46 of 49 possible points on the Intrinsic Motivation Inventory (IMI).

Rating game play

Single group

Development and Reliability Evaluation of the Movement Rating Instrument for Virtual Reality Video Game Play

Levac D, Nawrotek J, Deschenes E, Giguere T, Serafin J, Bilodeau M & Sveistrup H

JMIR Serious Games 2016;4(1):e9
URL: http://games.jmir.org/2016/1/e9/
doi:10.2196/games.5528
PMID:27251029

Objective: to "develop and evaluate the feasibility and reliability" of a measure for separating and quantifying the movements children make during VR therapy. The Movement Rating Instrument for Virtual Reality Video Game Play (MRI-VRGP) was applied to IREX and Kinect game systems.

Process: Movements were parsed into items and after several iterations, the selected items were trialled. Reviewers watched videotapes of subjects to rate upper extremity movements (unilateral or bilateral; close or far) and lower extremity movements within or without the base of support. They rated the activities as movements on a spectrum of easy to difficult and rated their confidence in making the rating.

Outcome: Within-rater reliability was higher (good) than inter-rater reliability (moderate). Finer movements were harder to rate consistently within therapists. Inter-rater reliability varied widely, and upper extremity fine (close) movements were rated less consistently.
More "item definition clarification and further psychometric property evaluation" will allow therapists to sort VR games by the type and frequency of their body movements.

Game play at home, is it effective?

RCT

Impact of multi-modal web-based rehabilitation on occupational performance and upper limb outcomes: pilot randomized trial in children with cerebral palsy

Sakzewski L, Lewis MJ, McKinley L, Ziviani J & Boyd RN

Developmental Medicine and Child Neurology, 2016 May 27 Epub

DOI: 10.1111/dmcn.13157

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/27230022

Objective: For children with acquired brain injury, is a program of web-based and home-delivered rehabilitation better than the wait list treatment for occupational performance and upper limb measures?

Procedure: 58 9 – 14 year old children were matched using their age, Manual Abilities Classification Scale, full-scale IQ and other demographic and physical characteristics. The intervention group was encouraged to use the Mitii game system 30 minutes daily, 6 days per week for 20 weeks. The control group was wait-listed to receive the intervention. Mitii is based on Microsoft Kinect and comprises visual-perceptual, cognitive, upper limb and gross motor activities, accessed by internet.

Findings: Game play averaged less than an hour per week, substantially less than the recommended 3 hours weekly. “A home-delivered, multi-modal web-based rehabilitation programme did not achieve the anticipated dose of therapy for children with acquired brain injury… Results highlight issues around feasibility and acceptability of a… home-delivered intervention.”

A Survey of Low-cost Virtual Reality Rehab Game Properties

Survey

Usability evaluation of low-cost virtual reality hand and arm rehabilitation games

Seo NJ, Kumar JA, Hur P, Crocher V, Motawar B & Lakshminarayanan K

Journal of Rehabilitation Research and Development, 53(23), 2016

DOI: http://dx.doi.org/10.1682/JRRD.2015.03.0045

Link to content: hurgroup.net/sub/external/data/papers/Seo_2016_jrrd_usability.pdf

Objective: to survey user expectations of low-cost virtual reality rehabilitation games (VRRG), and to determine factors that will enhance usability.

Process: 10 community-dwelling adults with CVA (ages 43 – 73 years; time post-stroke 3 – 13 years) were surveyed before and after exposure to low-cost VRRG. Microsoft Kinect and a P5 glove were used as low-cost interfaces for the virtual games.

Findings: The pre-game survey of the virtual games rated ease of understanding, ease of use and clinical feedback most highly. After exposure to the games, subjects rated motivation as the best aspect of the VRRG, and rated clinical effectiveness and clinical evidence as most in need of improvement, by means of a “House of Quality” matrix. en.wikipedia.org/wiki/House_of_Quality

ICF-inflenced VR for CP and DCD

Review

Integrating New Technologies into the Treatment of CP and DCD

Wilson P, Green D, Caeyenberghs K, Steenbergen B & Duckworth J

Disorders Of Motor (PH Wilson, Section Editor), Current Developmental Disorders Reports pp 1-14 First online: 11 April 2016

DOI: 10.1007/s40474-016-0083-9

Link to abstract: link.springer.com/article/10.1007%2Fs40474-016-0083-9

Intention: From the perspective of the International Classification of Functioning, Disability and Health (ICF) http://www.who.int/classifications/icf/en/ , how does the current understanding of childhood participation and motor development shape opportunities for developing new rehabilitation technologies?

Process: The authors examine the ICF framework, its holistic perspective on neurodevelopmental disorders, and then the implications that could influence technology-mediated treatments. “…interventions should have a clear focus on enhancement of participation.” Virtual reality and interactive games for both CP and DCD are considered.

Conclusion: “VR technologies have the potential to expand the opportunities available for engaging children in therapeutic activities across physical, social [,] and cognitive domains.”

Un-Robots for Therapy

Review

Robotic Therapies for Children with Cerebral Palsy: A Systematic Review

Bayon C, Raya R, Sergio LL, Ramirez O, Serrano J I & Rocon E

Translational Biomedicine 2016, 7(1):44

Link to full text article: www.transbiomedicine.com/translational-biomedicine/robotic-therapies-for-children-with-cerebral-palsy-a-systematic-review.php?aid=8788

Objective: For children with cerebral palsy, what is the evidence for robot-based rehabilitation?

Process: The authors performed a systematic review using the PRISMA protocol http://www.prisma-statement.org/ They searched 4 terms: robot, children, therapies and cerebral palsy. This resulted in 44 included studies that were broken into 4 groups: lower extremities (gait), upper extremities, virtual reality as an adjunct to the therapy and clinical applications. The authors do not define the term ‘robot’, and although the search results in articles that include the word robot, the articles are not specifically about robots, but assistive machines. Robots possess a degree of autonomy, this key quality separates robots from machines. The upper and lower extremity devices discussed in this review are passive (mechanical) or power-assistive (electro-mechanical) machines: (NF-walker, Innowalk, LOKOMAT, GT-1 RehaStim, Inmotionarm, ARMEO, Yougrabber and REAplan).

Findings: “There is still a lack of randomised clinical trials with a representative number of subjects, which makes it difficult to evaluate the impact of robot-based therapy, especially the long-term effects. The inclusion of cognitive aspects into the therapies and the design of virtual scenarios in combination with robotic devices provide promising results.”

Virtual Reality Inspires Treadmill Gains

Paired Groups

Treadmill training with virtual reality improves gait, balance and muscle strength in children with cerebral palsy

Cho C, Hwang W, Hwang S & Chung Y

Tohoku Journal of Experimental Medicine 238:3, 213-218 (2016)

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/26947315

Objective: For children with cerebral palsy, does virtual reality (VR) as a distraction/motivator while doing treadmill training (compared to no virtual reality) increase performance?

Process: 18 children with GMFCS levels I – III were randomly assigned to VR or non-VR treadmill training treatment groups. All participants received training for 30 minutes, 3 times weekly for 8 weeks. Jogging program from Nintendo Wii was used for the VR group. Pre- and post-tests included GMFM, Pediatric Balance Scale (PBS), Ten Meter Walk Test (10WT) and Two Minute Walk Test (2MWT). Evaluators were blinded to test condition.

Outcomes: the virtual reality group showed significantly different improvements compare to the non VR group in gait, balance, muscle strength and gross motor function in children with cerebral palsy. There is no evidence of enduring, longer term benefits.

What qualities should a rehab robot have?

Pilot study

Robots in Rehab: Towards socially assistive robots for paediatric rehabilitation

McMarthy C, Butchart J, George M, Kerr D, Kingsley H, Scheinberg A M & Sterling L

OzCHI '15 Proceedings of the Annual Meeting of the Australian Special Interest Group for Computer Human Interaction, pp. 39-43

Link to abstract: dx.doi.org/10.1145/2838739.2838791

Objective: What are the possible clinical benefits of social robots in rehabilitation for children? This preliminary study explores the characteristics required of robots which interact with children in a post-surgery inpatient setting.

Process: In this setting, NAO robot was used to mimic exercises and motivate children when the therapist was not present. Children had two sessions weekly with a therapist, followed by a third session with NAO, over a period of five months. NAO speaks and demonstrates each exercise, provides a focus during the exercises to minimize boredom, provides encouraging and rewarding vocalizations and records the child’s activity for later review.

Findings: Outcomes of interest are specific to the characteristics of the device. Issues that detracted from NAO’s functionality were movement and speech slowness, physical stability and limited balance, voice clarity and battery life.

Therapy Robots: What Therapists Think

Survey

Views of Physiatrists and Physical Therapists on the use of Gait-training Robots for Stroke Patients

Journal of Physical Therapy Science 28: pp. 202 – 206, 2016

Kang, CG, Chun, MH, Jang, MC, Kim, W & Do, KH

Link to full text: www.jstage.jst.go.jp/article/jpts/28/1/28_jpra-2015-652/_article

Objective: to survey therapists on the desired characteristics of gait-training robots.

Process: 100 physiatrists and 100 physical therapists from 38 hospitals were given questionnaires. One-third of the respondents had worked with a gait-training robot before, and a third had more than 5 years experience with stroke rehabilitation.

Results: therapists thought that treadmill type gait-training robots should be used with non-independent ambulators to "improve treatment effects" one to three months after stroke. Sensors should detect electromyography, foot pressure, joint torque, tilt sensor. Qualities of design and production should include: stability, comfort, easiness on-and-off, "fitting sense" and light weight.

Therapists Report on Virtual Reality Adoption Barriers

Single group

Evaluating change in virtual reality adoption for brain injury rehabilitation following knowledge translation

Glegg, SMN, Holsti, L, Stanton, S, Hanna, S, Velikonja, D, Ansley, B, Sartor, D & Brum, C

Disability and Rehabilitation: Assistive Technology, 2016

Link to abstract: dx.doi.org/10.3109/17483107.2015.1111944

Objective: to explore the barriers to adoption of VR technology by clinicians before and after training and support.

Method: 42 therapists at 2 rehabilitation centres were surveyed using the “Assessing Determinants of Prospective Uptake of Virtual Reality (ADOPT-VR) Instrument”. They completed the assessment before and following training, including receiving a manual and support.

Findings: The most often reported pre-test barrier of limited knowledge in how to use the system is absent in post-test reporting. The most significant barriers at post-test included “lack of time, appropriate clients, poor client motivation, technical issues, difficulty explaining the system to clients, and compatibility issues with wheelchair users”.

Article contact: Stephanie Glegg sglegg@cw.bc.ca

Studying Themes in Therapeutic Gameplay

Qualitative Study

Understanding Engagement in Home-Based Interactive Computer Play: Perspectives of Children with Unilateral Cerebral Palsy and Their Caregivers

James, S., Ziviani, J., King, G. & &. Boyd, R. N.

Physical & Occupational Therapy In Pediatrics (2015), DOI: 10.3109/01942638.2015.1076560

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/26606419

Purpose: using qualitative methodology, therapy researchers studied themes arising from children with CP and their caregivers on therapeutic computer game play. The software " (Mitii™) is intended to improve physical and mental skills and to be used in the home setting.

Method: Ten 8 - 18 year old children with one-sided cerebral palsy and their caregivers participated in semi-structured interviews following use of the Mitii game in a 20 week trial reported elsewhere (Boyd et al., 2013) Inclusion for the study required children to be of GMFCS level 1 or 2, and MACS study level 1 to 3. The theoretical positioning of the authors and their perspective as therapists is made explicit.

Findings: The inductive methodology identified three key themes: child and caregiver, themes relating to the intervention and themes that related to therapists’ involvement.
"Child/family characteristics: children's interest captured through novelty and technology, motivation declines as novelty wears off, children require "finely tuned" programs, strong family support facilitates engagement, and children develop confidence and ownership."
"Intervention characteristics: increased therapy frequency with reduced caregiver involvement, Mitii™ "becomes therapy" and competes with other interests; convenience within family routine, lack of real-time feedback and technical issues, and therapist guidance is essential."
"Service provider characteristics: initial and ongoing therapist input, family-friendly therapy approach, and tailored strategies to sustain engagement."

Reference
Boyd, R.N., Mitchell, L.Ee, James, S.T., Ziviani, J., Sakzewski, L., Smith, A. et al. (2013). Move it to improve it (Mitii): Study protocol of a randomised controlled trial of a novel web-based multimodal training program for children and adolescents with cerebral palsy.
Link to full text: bmjopen.bmj.com/content/3/4/e002853.full