Robo-physio

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Issue: 02 January 2008
Author: Daloni Carlisle

Is rehab with robots the future for stroke patients? Daloni Carlisle investigates

Articles about robots in physiotherapy are often breathless in their approach. Everything is new and exciting; this is where the future lies and so on.

So research physiotherapist Carol Restighini from the University of East London is quite refreshing with her down-to-earth attitude. 'They're just another tool like a treadmill,' she says. 'Who would have thought 15 years ago that we would be using that as routinely as we do today? I think robots will be the same.'

Using robots in a therapeutic role in neurorehabilitation, particularly for stroke, is based on the premise that repeating limb movements can help to recover motor control. However, stroke is the most common cause of severe disability in the UK, and physiotherapists are in short supply. So if patients can retrain limbs with the aid of a robot but overseen by a professional physio, then more patients can get more out of rehab programmes.

Hermano Krebs is a principal research scientist at Massachusetts Institute of Technology and is one of the leaders in robotics, with a broad research base to his work. It's what pioneers in the UK are building on today and everyone who's anyone in therapeutic robots will at some stage pass through his lab.

'We started here in 1989 back when I was a student at MIT,' he says. 'We introduced a paradigm shift in the use of robots for rehabilitation.' Previously, they had been used as assistive devices: helping people with a spinal cord injury to feed themselves or as a prosthesis. 'Our idea was to introduce a tool to help clinicians increase their productivity and make more efficient use of  their time.'

Initial trials of a robot-assisted arm and shoulder exercises were with sub-acute patients with a localised lesion. Patients who had the added robot therapy showed twice as much improvement as those who  did not.

'It was an important result,' says Dr Krebs. 'We did not expect it because our colleagues, the neurologists, were saying that basically the nurse, physician or therapist is there simply to entertain patients while nature takes its course. They did not believe there was enough plasticity to nurture the outcome.'

The next set of trials looked at the outcome three years down the line and showed patients who had used the robot maintained their improvement, even if they had not had additional therapy in the interim. This research has paved the way for a wide range of projects over the years. 'There's been a huge increase in activity,' says Dr Krebs. 'Everyone is jumping on the bandwagon.'

FUTURE RESEARCH
The Veterans Association (a massive US health insurer) is doing a final phase clinical trial assessing the costs and benefits of robot-assisted rehabilitation for stroke patients. Others are taking robots out of the clinic and into people's homes, linking robots to telehealth systems where physios can monitor patients remotely.

'There are colleagues in one hospital here looking at the use of robots in strength-building exercises,' says Dr Krebs. 'Others are using ideas from motor learning.'

Dr Krebs' group is looking at linking video games with therapeutic robots. 'There is some evidence the benefit from using robots comes because the movement is intention driven,' he explains. So he has designed computer games where patients linked up to the robot must, for example, align a dot with a gap in a line on  the screen.

Here in the UK, a number of research institutes are working on other innovative projects. Jane Burridge, a lecturer at Southampton University and a physiotherapist, is among them. Along with her postgraduate research student Anne-Marie Hughes, another physio, she is using robotics in conjunction with electrical stimulation.

'Recovery of upper arm function following stroke is a real problem. A high proportion of people who have a stroke regain their ability to walk, but only 14 per cent of people who have a problem at three months regain useful function of their arm,' says Dr Burridge. With evidence showing the positive impact of robotics and the efficacy of electrical stimulation, the hope is that by joining the two different treatments there may be  a benefit.

PHYSIO-DRIVEN DESIGN
Importantly, the programme involves collaboration between the engineers and physiotherapists in the robot design. 'Engineers have often never seen a stroke patient,' says Ms Hughes. 'They do not understand motor movement or have any knowledge of which movements might be easier to start on.

'Their views on what you might be able to do are not necessarily feasible. From a practical point of view you cannot design a functional system without a physio.'

For robots to be truly effective, their design needs to be driven by clinical need and developed as a result of engagement with all interested parties: engineers, physiotherapists, clients and their carers. Aids that are too unwieldy to put on without help or too large to  fit into a person's home cannot be effective as self-management tools.

Over at the University of East London, Duncan Turner and his team of four graduate students – three of them physios – is looking at combining brain stimulation  with robotics.

 Although the robots are not in clinical use yet, Professor Turner is developing links with the rehab team at nearby Newham University hospital. To this end,  Ms Restighini, a physio with 10 years' clinical practice under her belt, is starting a PhD investigating whether working on upper limb function can improve balance  in stroke patients.

As well as the need to engage with users in the design of robots, there is another key issue to address. That is: are robots acceptable to patients? And are they acceptable to physiotherapists?

Dr Krebs says yes. Repeated patient questionnaires have found patients like the robots. 'They all wanted to do more exercises and found it was benefiting them in ways they could not have received otherwise.' Furthermore, his studies have shown patients using robotics have less pain and injury.

He has spent years trying to persuade physios robots will never replace them; they are just a tool. It seems to be getting through. At a recent lecture he asked the physios if they would support the use of robots; over 90 per cent said yes. 'Which kind of made my lecture a bit redundant,' he jokes.

Ms Restighini has some thoughts on this too. 'The robot is your technician,' she says. 'The skill is in goal setting and planning. You still have to stick your  neck out and predict function, which is what patients want, and you have to come up with goals that are not so far fetched they will never be reached, while getting the patient wanting to practise. That's the skilled part.

'I think most patients would agree the amount of time and intensity they would like to give to a patient is not available. Robots can fill that gap.' 

Join the network Dr Burridge and Ms Hughes are launching a UK rehabilitation robot network and plan to hold the first workshop in February 2008. Contact jhb1@soton.ac.uk   or ah10@soton.ac.uk

Centres developing robots

The Gentles project at Reading University has had substantial physiotherapy input and is part way through a trial at Royal Berkshire hospital. This is the first work to investigate reach and grasp from a clinical perspective. See www.sse.reading.ac.uk/projects.htm?viewproject&ID=00101

Researchers at Manchester University, in collaboration with those at Leeds University, are looking at the use of robots in stroke rehab. See http://intranet.cs.man.ac.uk/robotics/research/medical/pneumatic.html

Researcher Gusztav Arz is developing the REHAROB therapeutic system for spastic hemiparetic patients at Budapest University. Clinical trials showed patients were not afraid of the robots and physios learnt easily how to work with them. More trials are due this year and researchers are looking for commercial support. http://cordis.europa.eu.ictresults/index.cfm/section/news/tpl/article/BrowsingType/Features/ID/58642/highlights/REHAROB  

 Frontline would like to hear from you What do you think about robots in rehabilitation? Will they ever become a reality or will they remain in the university lab? Would you be prepared to work with robots? Would your patients accept them? Email features editor Catherine Hill with your views at hillc@csp.org.uk stating whether you are happy for your comments to be published.