A Clinically Relevant Method of Analyzing Continuous Change in Robotic Upper Extremity Chronic Stroke Rehabilitation

A robot goes to rehab: a novel gamified system for long-term stroke rehabilitation using a socially assistive robot-methodology and usability testing

Background

Socially assistive robots (SARs) have been proposed as a tool to help individuals who have had a stroke to perform their exercise during their rehabilitation process. Yet, to date, there are no data on the motivating benefit of SARs in a long-term interaction with post-stroke patients.

Methods

Here, we describe a robot-based gamified exercise platform, which we developed for long-term post-stroke rehabilitation. The platform uses the humanoid robot Pepper, and also has a computer-based configuration (with no robot). It includes seven gamified sets of exercises, which are based on functional tasks from the everyday life of the patients. The platform gives the patients instructions, as well as feedback on their performance, and can track their performance over time. We performed a long-term patient-usability study, where 24 post-stroke patients were randomly allocated to exercise with this platform—either with the robot or the computer configuration—over a 5–7 week period, 3 times per week, for a total of 306 sessions.

Results

The participants in both groups reported that this rehabilitation platform addressed their arm rehabilitation needs, and they expressed their desire to continue training with it even after the study ended. We found a trend for higher acceptance of the system by the participants in the robot group on all parameters; however, this difference was not significant. We found that system failures did not affect the long-term trust that users felt towards the system.

Conclusions

We demonstrated the usability of using this platform for a long-term rehabilitation with post-stroke patients in a clinical setting. We found high levels of acceptance of both platform configurations by patients following this interaction, with higher ratings given to the SAR configuration. We show that it is not the mere use of technology that increases the motivation of the person to practice, but rather it is the appreciation of the technology’s effectiveness and its perceived contribution to the rehabilitation process. In addition, we provide a list of guidelines that can be used when designing and implementing other technological tools for rehabilitation.

Trial registration: This trial is registered in the NIH ClinicalTrials.gov database. Registration number NCT03651063, registration date 21.08.2018. https://clinicaltrials.gov/ct2/show/NCT03651063.

Robot enhanced stroke therapy optimizes rehabilitation (RESTORE): a pilot study

BACKGROUND

Robotic rehabilitation after stroke provides the potential to increase and carefully control dosage of therapy. Only a small number of studies, however, have examined robotic therapy in the first few weeks post-stroke. In this study we designed robotic upper extremity therapy tasks for the bilateral Kinarm Exoskeleton Lab and piloted them in individuals with subacute stroke. Pilot testing was focused mainly on the feasibility of implementing these new tasks, although we recorded a number of standardized outcome measures before and after training.

METHODS

Our team developed 9 robotic therapy tasks to incorporate feedback, intensity, challenge, and subject engagement as well as addressing both unimanual and bimanual arm activities. Subacute stroke participants were assigned to a robotic therapy (N = 9) or control group (N = 10) in a matched-group manner. The robotic therapy group completed 1-h of robotic therapy per day for 10 days in addition to standard therapy. The control group participated only in standard of care therapy. Clinical and robotic assessments were completed prior to and following the intervention. Clinical assessments included the Fugl-Meyer Assessment of Upper Extremity (FMA UE), Action Research Arm Test (ARAT) and Functional Independence Measure (FIM). Robotic assessments of upper limb sensorimotor function included a Visually Guided Reaching task and an Arm Position Matching task, among others. Paired sample t-tests were used to compare initial and final robotic therapy scores as well as pre- and post-clinical and robotic assessments.

RESULTS

Participants with subacute stroke (39.8 days post-stroke) completed the pilot study. Minimal adverse events occurred during the intervention and adding 1 h of robotic therapy was feasible. Clinical and robotic scores did not significantly differ between groups at baseline. Scores on the FMA UE, ARAT, FIM, and Visually Guided Reaching improved significantly in the robotic therapy group following completion of the robotic intervention. However, only FIM and Arm Position Match improved over the same time in the control group.

CONCLUSIONS

The Kinarm therapy tasks have the potential to improve outcomes in subacute stroke. Future studies are necessary to quantify the benefits of this robot-based therapy in a larger cohort.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04201613, Registered 17 December 2019-Retrospectively Registered, https://clinicaltrials.gov/ct2/show/NCT04201613 .

The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis

Background. High-intensity repetitive training is challenging to provide poststroke. Robotic approaches can facilitate such training by unweighting the limb and/or by improving trajectory control, but the extent to which these types of assistance are necessary is not known. Objective. The purpose of this study was to examine the extent to which robotic path assistance and/or weight support facilitate repetitive 3D movements in high functioning and low functioning subjects with poststroke arm motor impairment relative to healthy controls. Methods. Seven healthy controls and 18 subjects with chronic poststroke right-sided hemiparesis performed 300 repetitions of a 3D circle-drawing task using a 3D Cable-driven Arm Exoskeleton (CAREX) robot. Subjects performed 100 repetitions each with path assistance alone, weight support alone, and path assistance plus weight support in a random order over a single session. Kinematic data from the task were used to compute the normalized error and speed as well as the speed-error relationship. Results. Low functioning stroke subjects (Fugl-Meyer Scale score = 16.6 ± 6.5) showed the lowest error with path assistance plus weight support, whereas high functioning stroke subjects (Fugl-Meyer Scale score = 59.6 ± 6.8) moved faster with path assistance alone. When both speed and error were considered together, low functioning subjects significantly reduced their error and increased their speed but showed no difference across the robotic conditions. Conclusions. Robotic assistance can facilitate repetitive task performance in individuals with severe arm motor impairment, but path assistance provides little advantage over weight support alone. Future studies focusing on antigravity arm movement control are warranted poststroke.

Smallest real differences for robotic measures of upper extremity function after stroke: Implications for tracking recovery

Introduction

Measurements from upper limb rehabilitation robots could guide therapy progression, if a robotic assessment’s measurement error was small enough to detect changes occurring on a time scale of a few days. To guide this determination, this study evaluated the smallest real differences of robotic measures, and of clinical outcome assessments predicted from these measures.

Methods

A total of nine older chronic stroke survivors took part in 12-week study with an upper-limb end-effector robot. Fourteen robotic measures were extracted, and used to predict Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) scores using multilinear regression. Smallest real differences and intraclass correlation coefficients were computed for the robotic measures and predicted clinical outcomes, using data from seven baseline sessions.

Results

Smallest real differences of robotic measures ranged from 8.8% to 26.9% of the available range. Smallest real differences of predicted clinical assessments varied widely depending on the regression model (1.3 to 36.2 for FMA-UE, 1.8 to 59.7 for ARAT), and were not strongly related to a model’s predictive performance or to the smallest real differences of the model inputs. Models with acceptable predictive performance as well as low smallest real differences were identified.

Conclusions

Smallest real difference evaluations suggest that using robotic assessments to guide therapy progression is feasible.

Do children and adolescent ice hockey players with and without a history of concussion differ in robotic testing of sensory, motor and cognitive function?

Background

KINARM end point robotic testing on a range of tasks evaluating sensory, motor and cognitive function in children/adolescents with no neurologic impairment has been shown to be reliable. The objective of this study was to determine whether differences in baseline performance on multiple robotic tasks could be identified between pediatric/adolescent ice hockey players (age range 10–14) with and without a history of concussion.

Methods

Three hundred and eighty-five pediatric/adolescent ice hockey players (ages 10–14) completed robotic testing (94 with and 292 without a history of concussion). Five robotic tasks characterized sensorimotor and/or cognitive performance with assessment of reaching, position sense, bimanual motor function, visuospatial skills, attention and decision-making. Seventy-six performance parameters are reported across all tasks.

Results

There were no significant differences in performance demonstrated between children with a history of concussion [median number of days since last concussion: 480 (range 8–3330)] and those without across all five tasks. Performance by the children with no history of concussion was used to identify parameter reference ranges that spanned 95 % of the group. All 76 parameter means from the concussion group fell within the normative reference ranges.

Conclusions

There are no differences in sensorimotor and/or cognitive performance across multiple parameters using KINARM end point robotic testing in children/adolescents with or without a history of concussion.