Enhancing and measuring upper limb function with a rehabilitation robot
This article discusses the potential of the ICone upper limb rehabilitation robot as an evaluation tool as well as an upper limb therapy delivery product. Robots such as the ICone can of course introduce efficiences in therapy but it's important to note that it can also provide objective and outcome measure data that are not available via conventional therapy and assessment processes.
The potential for upper limb rehabilitation by using robotic therapy is widely recognised even if there are debates about the best approaches, products and systems of deployment.
The demand for rehabilitation
No one ever complained they received too much rehabilition training following a stroke or other neurological condition. The demand for services has never been higher, with general demand for conventional therapy driven up by an ageing population but with service delivery attenuated down by a global pandemic.
Maybe it's true that patient expectations are higher these days. At the start of my professional life patients simply accepted the word of anyone wearing a "white coat". These days the white coats have gone - and we have Google so everyone is an expert. We need to do things differently if we are to rise to the challenge.
No one ever complained they received too much rehabilition training following a stroke or other neurological condition.
Medical science has improved survival rate for many conditions. This of course increases the challenge for rehabilitation services as many more people must potentially live with disability for many years. There is a high demand with little chance of meeting that demand if we try to use the conventional therapy processes that have been "mainstream" up until now. Robot assisted training may be part of the solution of addressing the demand from stroke patients and others needing upper extremity rehabilitation.
Not so long ago the emphasis in neurorehabilitation would be upon primarily compensating for any motor or sensory function deficit. As the reality of neuroplasticity held out the promise of motor recovery, expectations of reduced impairment have grown. Whilst complete upper limb recovery may still be unrealistic in many cases, at least we can have hope of increased restitution with "ideal interventions". In clinical practice it makes sense in an ideal world to strive to recover and reduce motor function impairment as much as possible and only then compensate for arm function that cannot be recovered.
Whilst most attempts at robot aided therapy have been focused upon stroke survivors, we should also think more broadly about who could benefit. The numbers are staggering - and include spinal cord injury, acquired brain injury, Parkinson's disease, cerebral palsy and multiple sclerosis to name just the most common conditions.
According to Aspire, new data estimates that 2,500 people are injured or diagnosed with a spinal cord injury every year in the UK. This is greater than previous estimates of around 1,000 new persons every year. The total number of persons living with a spinal cord injury are likely to be around 50,000.
Acquired brain injury includes traumatic injury as well as non-trauma cases such as stroke, tumours and infections. Approximately 1.4 million people live with a brain injury in the UK with a cost to the economy of ￡15 billion per annum. This amounts to around 10% of the whole NHS budget.
If the above were not enough, there are about 137,000 people living with Parkinson's disease in the UK and each year there are about 17,300 new cases in people aged 45 years and above.
The Robot Gym
A growing number of UK facilities offer robotic training for upper limb stroke rehabilitation. Many of these facilities are private and offer 'packages of care'. The offer is largely going to be composed of a recipe of frequent, intensive and targeted, passive or active, guided movement interventions. The problem is we still don't know exactly how the recipe should be put together for an individual. We dont know exactly what works and what doesn't. It's like baking a cake without knowing how much of each ingredient should be in there to get the best result.
We always want upper limb recovery for patients of course but this is a broad term. Individuals will vary in their attitude for what constitutes meaningful recovery for them. They will place more value on something that we can promise to achieve than something with a vague outcome.
Research literature featuring upper limb rehabilitation and robotic interventions is currently of variable quality. Despite this we can be optimistic that robot aided rehabilitation can be beneficial. The worst we can expect is that robot assisted therapy is at least as good as conventional therapy. We just need to have a better grasp of how the many variables interact. The effort to refine this needs to be multidisciplinary and involve patients and their families as well as clinicians and engineers. As long as we have a relatively high cost to adopt this technology and an uncertain benefit only the minority of clinicians will embrace it.
What robots do
This is not a review of all upper limb rehabilitation robots. A growing number of designs exist and more will no doubt emerge with different strengths and weaknesses.
We will focus on the ICone from Heaxel Srl, which has some novel features which enable some flexibility in how and where the robot can be deployed. With any technology, we need to be conscious of the overall systems and processes for deployment that will either facilitate or deter it's use.
The ICone's pedigree goes back to the MIT-MANUS robot for planar shoulder and elbow therapy. This development started in 1989 at the Massachusetts Institute of Technology and hints at the motto "Mens et Manus" - Mind and Hand.
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Although there were many industrial robots around at that time the developers recognised a different approach was needed due to the close contact of the robot with humans. The approach they took can be referred to as fixed-based (sometimes called a end-effector) design. This has the great advantage of being faster to doff and don compared with exoskeletal designs. The design needed to offer a number of modes of interaction with the patient. Depending on the individual's needs the robot could allow the patient to move their arm without impedance or to be moved in various ways by the robot.
A series of exergames were devised to provide movement goals for the patient's (mind and hand) upper extremity. This design evolved to be a commercial offering and boasts the largest evidence base for any rehabilitation robot. Most of that evidence focused on chronic stroke but also covered cerbral palsy, spinal cord injury, MS and Parkinsons.
What's the flaw? The MIT-MANUS was designed to be used in a hospital environment which is fine except the majority of rehabilitation will not be carried out in a hospital envirnoment.
The Heaxel team have taken the MIT-MANUS protocols to the next level by putting the efficacy of the design into a smaller package. The design fits easily onto a table top and is portable - it can move easily between home, clinic or hospital. In fact the team has set out to demonstrate that from many points of view ICone can bring robotic technology safely into the home.
The exergames have been revised and updated. These are an essential element as they "lubricate" the mind-body connection which we feel is essential to upper limb recovery. They provide a tangible goal for patients and encourage commitment.
The deployment of serious games as part of the visual feedback and user engagement is something that I suspect has great potential even if we dont understand it too well yet.
We dont know enough yet about how to fine tune the necessary balance between offering a “fun” experience and engagement that delivers results. Research has shown that serious games can impact upon users in 5 ways - influencing the amount of practice, the content, context, structure and mechanics.
Cloud Based Architecture
One of the real benefits of the ICone is the fact that software and data are stored in a secure cloud-based architecture. This takes advantage of the internet to provide a number of advantages. During the pandemic this was extremely useful to facilitate remote supervision of users. A trained therapist could logon to the portal and create a therapy package to be performed by a patient. This package could be executed safely by a support person on site. At the end of the session the results can again be viewed remotely.
Evaluation via Robot
This is the secret sauce. There are validated assessment scales for upper limb function of course but the robot is able to provide much more precise information on the patient's ability to perform cordinated arm movements. We want to have quantitative information on each patient's state and ICone has an extensive evaluation suite of sessions that can calculate clinical parameters. There are six exercises in the evaluation protocols
In some of these evaluations, the robot is transparent and the patient moves their arm without impedance to track an object on the screen. In others the patient is ask to maintain their arm position whilst the robot attempts to move the end effector in different directions.
For example, in the Circle drawing task the patient must draw 4 sets of circles with the ICone by moving the end-effector. The ICone is in "transparent mode" so provides neither resistance nor assistance to the patient. The robot can then calculate a couple of related indexes such as how precisely circular were the movements and how large were the circles being drawn. As the patient's inter-joint coordination improves we have available precise indicators for that.
A Clinical Report is generated after each evaluation session and is made up of a list of each of the exercises and a histogram of the measured trends along with an explanation of their meaning. The robot tracks the speed, path and applied force on the end-effector so that any errors and changes over time are recorded.
Some tasks require predominately shoulder motion and others elbow motion. Other tasks require the coordination of both elbow and shoulder.
Whilst a great deal of attention is naturally placed on how upper extremity function might be improved by intensive therapy with a robot, this is not all that matters. Robots such as the ICone have a remarkable ability to evaluate the quality of arm movement. The rich detail available is much more sensitive to change than the classical assessment scales. Also the ICone can potentially contribute to the continuum of care by allowing rehabilitation training by robot to follow the patient rather than being restricted to a hospital setting.
About the Author
Derek Jones PhD, MBA is a Bioengineer and Director of Anatomical Concepts (UK) Lt who represent Heaxel Srl in the UK
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