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Euron Winter Meeting in Rehabilitation Robotics March 30th

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Title: Euron Winter Meeting in Rehabilitation Robotics March 30th


1
Euron Winter Meeting in Rehabilitation Robotics
March 30th April 4th 2008
  • Virtual and tele-rehabilitation Rehabilitation
  • William Harwin
  • University of Reading
  • http//www.isrg.reading.ac.uk or
    http//www.reading.ac.uk/shshawin/LN (follow the
    euron2008 link)

2
Abstract
  • The transfer of ideas from haptics, neuroscience
    and clinical medicine into robot mediated
    rehabilitation is considered with examples of
    work done at the University of Reading, Royal
    Berkshire Hospital, and Trinity College, Dublin
    as well as elsewhere

3
Virtual rehabilitation
  • Rehabilitation in a virtual environment, most
    likely using haptic or haptic inspired
    technologies.
  • Biennial International Conference on Virtual
    Reality, Disabilities and Associated
    Technologies. September 2008 Conference in
    Portugal www.icdvrat.reading.ac.uk
  • Virtual rehabilitation conference (IWVR), August
    2008 Vancouver

4
Virtual reality in rehabilitation
  • Lam Tam Man and Weiss (2004)
  • Pilot study on VR to train cognitive skills in
    street survival for post stroke
  • Risso et al (2006)
  • Treating post traumatic stress disorder for Iraq
    veterans
  • Autism assessment
  • Phobias (height, spiders)
  • Nintendo Wii game based rehabilitation (e.g.
    Sister Kenny Rehab Institute)

5
Tele-rehabilitation
  • Tele-manipulation is not a viable way for a
    therapist to deliver rehabilitation
  • Problems
  • Communication delays leads to device instability
  • Lack of information about the remote environment
  • May be possible to use telerobotics principles
  • More mars rovers than moon landers

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8
Experimental system
ADLER
GENTLE/s
Each of the two subjects is seated on a chair and
play tic-tac-toe while connected to either the
Gentle/s (UK) or the ADLER (USA) system. The game
is played across the internet where game/user
interaction is possible via the video feeds of
the game and opponents camera and audio
9
Procedure and outcome measures
  • Used modified Intrinsic Motivation Inventory
  • (E. Deci et. al., University of Rochester, NY,
    USA)
  • 26-item questionnaire
  • 7 point Likert-type scales (level
    sat-dissatisfaction)
  • 1 not true at all
  • 4 somewhat true
  • 7very true
  • Scales
  • Value/usefulness 12, 13, 19, 20
  • Interest/enjoyment 1, 6, 14, 21
  • Perceived competence 2(R), 7, 15, 22
  • Effort/importance 3, 8(R), 16, 23
  • Pressure/tension 4(R), 9(R), 17, 24
  • Relatedness 5(R), 10, 18(R), 25
  • Perceived choice 11, 26(R)
  • Used also rating scales, check-lists and yes-no
    items
  • Robot data (position, force, velocity)

10
Collaboration Conclusions
  • Clear positive trend in favour of CE game.
  • Most participants were receptive, hence motivated
    to play a very simple game because of the
    interaction via CE.
  • In general, subjects found CE more valuable, more
    interesting and enjoyable. spent more time at a
    task.
  • 66 preferred full interactive environment.
  • Caused subjects to work harder in order to
    perform well (significant differences on scale 4
    effort/importance).
  • Longer exercise time, maybe because of presence
    of other player and conversation during play in
    two of three phases.
  • Video observation On the ROBOT phase, the more
    motivated individuals, mediate the motivation of
    the less motivated.
  • Does it mean that it might be beneficial as a RMT
    ?

11
How we move
  • Prefrontal areas of brain (1-2 seconds)
  • Mirror neurons (Mental imagery?)
  • Motor cortex (homonculus) - the artery near by.
  • Cerebellum and modelling
  • Why can't we tickle ourselves
  • Can schizophrenics tickle themselves?
  • Spinal column
  • Reflex neurons
  • Afferent and efferent neurons
  • Vilayanur Ramachandran Reith Lectures 2003,
    www.bbc.co.uk/radio4/reith2003

12
Rothwell motor patterns
  • Two specimens of John Rothwells signature. Top
    was written over 2cm, the bottom over 20cm

13
Homonculus
14
Models of movement
  • Hogan and Flash, minimum jerk
  • Minimum torque
  • Minimum energy
  • Movement efficiency
  • Fitts Law (1964)
  • Minimise Proprioceptive noise variance (Harris
    and Wolpert 1993)
  • Standard deviation of neural command noise
    increases linearly with the absolute value of the
    neural control signal

15
Minimum energy movement
16
Fitts law (1954)
  • MTab log2 (ID)
  • Where
  • ID2A/W

17
Proprioceptive noise proportional to amplitude of
movement (Harris and Wolpert 1993)
18
Machine mediated Stroke rehabilitation
  • Stroke (Cerebral vascular accident CVA)
  • Third leading cause of death
  • 50 of deaths in first hour
  • 30 day mortality for hemorrhagic stroke is
    40-80
  • Risk factors
  • Age
  • Hypertension
  • Anticoagulant therapies
  • History of stroke
  • Cocaine abuse
  • Men have greater risk than women

19
Stroke statistics
  • Prevalence per 100,000 Male Female
  • China (Beijing) 240 (225-255) 169 (157-183)
  • Denmark 177 (158-197) 93 (80-108)
  • Finland 293 (259-329) 124 (103-148)
  • Germany 150 (135-165) 84 (74-94)
  • Italy 121 (112-130) 63 (57-70)
  • Poland 152 (138-168) 76 (67-87)
  • UK, France 125-160
  • Affluent USA 90
  • Incidence is 1.25-1.8 per 1000 people per annum
  • Incidence rates doubles for every 10 years after
    the age of 45.
  • Leading cause of disability.
  • 2/3 patients survive
  • 2/3 survivors have residual disabilities. Third
    leading cause of death
  • 50 of deaths in first hour
  • 30 day mortality for hemorrhagic stroke is
    40-80
  • Survivability for ischemic stroke higher
  • Leading cause of disability

20
Costs
  • UK Hospital costs with stroke is over 3.8 billion
    Euro/annum
  • USA costs 15000 - 25000 per patient.
  • Costs expected to increase 30 by 2030 along with
    age profile of population

21
Motor relearning
  • Evidence for neuroplasticity
  • Reoganisation of visual cortex in people who are
    blind
  • Occurs in mature adults (eg Hypocampus of London
    taxi drivers)
  • Key areas probably surround the areas of cell
    death.
  • Arthur Rubinstein, the pianist, was once asked
  • How do you get to Carnegie Hall? (a famous New
    York performance venue), and is reputed to have
    answered
  • Practice, practice, practice

22
Upper Extremities post stroke
  • 85 of patients show an initial arm deficit
  • Problems remain in 55-75 patients
  • Functional recovery complex i.e. reaching,
    grasping, manipulation, - less complex for Lower
    Extremities
  • Easier to compensate
  • Secondary complications
  • Shoulder subluxation
  • Muscle atrophy
  • Lack of spontaneous stimulation

23
Stroke therapy
  • Early, intensive and challenging physiotherapy
    can improve outcome
  • Therapies must be customised for each patient
    but Essential movement components are the same
  • Can we improve tools for therapy delivery?

24
Stroke Consequences
  • The most common after-effects
  • Weakness or paralysis Hemiplegia (one side)
  • Abnormalities of sensation
  • Difficulties in perception
  • Cognitive problems thinking, learning,
    concentrating, remembering, decision-making,
    reasoning and planning
  • Fatigue tiredness

25
Stroke therapy
  • Early, intensive and challenging physiotherapy
    can improve outcome
  • Therapies must be customised for each patient
    but Essential movement components are the same
  • Can we improve tools for therapy delivery?

26
Problems of NIHCE (NICE) experimental design
27
Noise in measurements
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30
Washout
31
Cross over trial
32
Machine mediated therapy Bead Pathway (Highway)
concept
  • Robot end-effector is connected to the bead(path)
    using a spring damper combination
  • Bead is constrained to move along the wire
    pathway
  • Defines movement pattern and velocity profiles
    using 7th order polynomials
  • Different levels of guidance can be programmed
  • Velocity profile provides the assistance to move
    while SD combination provides error correction.
  • Amirabdollahian et al. (2002)

33
A model for movementsMinimum Jerk theory
  • It is a general mathematical model for movement.
  • Jerk is the rate of change of acceleration with
    respect to time.
  • It is the third derivative of the position.
  • Human reaching movement tends to minimise the
    jerk parameter. (Hogan and Flash, 1985)

34
Polynomial trajectory
Where
Assumptions
  • Start and end point of the movement are clearly
    defined.
  • Start and end velocity is zero
  • Mid velocity is defined
  • Start and end acceleration is zero

35
Coefficients
Other coefficients dependent on a b
To ensure maximum smoothness Mid velocity must
be set to
where
36
Model data vs Real data
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38
Gentle/S our previous workReach-to-touch
exercises
  • Safe
  • Clinical study (ABC, ACB)
  • 31 chronic strokes (mean 2 years PS)
  • Positive effect SS same as RMT
  • Amirabdollahian, F. et al. Analysis of
    the Fugl-Meyer Measures Assessing the
    Effectiveness of the GENTLE/s Rehabilitation
    Robotics System Delivering Upper Limb Therapies.
    J. NeuroEngineering and Rehab. 2007, 44.

39
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41
Gentle/S Conclusion
  • SS should be considered an effective therapy for
    chronic stroke! There is an opportunity for
    therapies based on instrumented SS with visual
    feedback to the user.
  • RMT methods need to be refined. In particular to
    investigate more intensive therapies earlier in
    the cycle with a greater level of user decision
    making.
  • Problems encountered
  • Treatment was relatively short (9hours RMT)
  • Subjects were stable (no further recovery
    expected)
  • Inclusion onto the study had a beneficial effect
    for better functioning subjects
  • Measurements were not blinded

42
Gentle/G robotic system Whole-arm rehabilitation
exercises
Grasp retraining in combination with reaching
movements in a reach-grasp-transfer-release
sequence.
Allows for selective movements to grasp an
object Easy to monitor what hemiplegic side is
doing
Loureiro, R.C.V., and Harwin, W. S. (2007).
Reach Grasp Therapy Design and Control of a
9-DOF Robotic Neuro-rehabilitation System. Proc.
IEEE 10th International Conference on
Rehabilitation Robotics (ICORR 2007)
04/04/2015
R. Loureiro
42
43
Therapy modes
  • PASSIVE
  • Robot moves patients arm/hand
  • ACTIVE-ASSISTED
  • Robot moves arm/hand after patients input
    (movement initialisation)
  • ACTIVE
  • Robot follows patients movement
  • Robots resists movement and corrects if movement
    performed incorrectly
  • FREE
  • Robot follows patients movement (sling
    suspension only)
  • No help provided measurement only of patients
    movement

04/04/2015
R. Loureiro
43
44
The Reach and Grasp Study
  • Up to 16 hemiplegic subjects (4 completed so far)
  • Sub-acute phase of recovery (mean 3 months PS)
  • A-B, B-A blinded cross-over study
  • In addition, an age matched Healthy Control Group
    is used for comparing quality of movement
    (Kinematic and surface EMG data)
  • Phase A subjects receive Robot Mediated Therapy
    (RMT) in addition to their Normal Therapy (NT)
  • Phase B subjects receive only their Normal
    Therapy (NT)
  • Subjects measured (4 set of measurements)
  • Before start of Phase A and B (Week 1)
  • End of each phase (Week 4)
  • End of trial (Week 8)
  • Follow up (Week 12)

02/04/08
R. Loureiro
44
45
Gentle/G Conclusion
  • A positive effect seen for RMT at intervention
    late after stroke.
  • Treatment was relatively short (16 hours RMT)
  • NT and robot phase had twice weekly normal
    therapy
  • Measurements were blinded (single blinded study)
  • Recruitment was from hospital discharge.

46
ICORR 2009
  • 11th International conference on rehabilitation
    robotics
  • 23-26 June 2009
  • Kyoto, Japan
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