As part of a collection of studies conducted on stroke rehabilitation, VA Maryland Health Care System researchers are exploring robotics to better rehabilitate stroke survivors and to help them achieve functions that are as close to normal as possible.

Tuesday, May 14, 2013

Researchers at the VA Maryland Health Care System have found that an adaptive approach to stroke treatment can help stroke survivors improve gait. Using a specialized ankle robot – Anklebot − researchers can train participants in various ways to improve control of their weakened leg, either by playing videogames from a seated position or during task-oriented locomotor training on a treadmill. This flexibility provides a versatile training tool that permits the researchers to customize therapy to meet the specific needs of participants, and that may offer exciting new options for improving gait and balance in stroke survivors. Initial results from the first participants in a two-year $199,900 VA Rehabilitation Research & Development Merit Pilot funded study suggest that the repetitive practice of walking on a treadmill with the Anklebot may also improve balance and propulsion by improving ankle control at key events during walking. Their preliminary research findings are forthcoming in the Proceedings of the Institute of Electrical and Electronics Engineers (IEEE) International Conference on Robotics and Automation (IEEE-ICRA). The IEEE-ICRA is the most prestigious of all robotics conferences with an average acceptance rate of just under 40 percent. The research team will present their work at this year’s IEEE-ICRA in Karlsruhe, Germany in May.

With more than 800,000 Americans suffering annually from strokes, it is the leading cause of long-term disability in this nation. And with the graying of America, the prevalence of stroke and its debilitating after-effects are expected to increase. The ability to work ranks high among the debilitating post-stroke effects,  affecting individuals to various degrees from  inefficient gait due to asymmetric step lengths and timing, poor propulsion from the affected side, reduced balance control, and  causes a more inconsistent gaits overall.  As part of a collection of studies conducted on stroke rehabilitation, VA Maryland Health Care System researchers are exploring robotics to better rehabilitate stroke survivors and to help them achieve functions that are as close to normal as possible.

“Drop foot is a common impairment after a stroke, caused by the weakness in the dorsiflexors and evertor muscles [muscles used in walking] that lift the foot,” says Larry Forrester, PhD, director of the Baltimore VA Medical Center Human Motor Performance Laboratory and associate professor at the University of Maryland School of Medicine. “A major complication of drop foot is the increased likelihood of dragging the foot on the ground as the leg swings forward during stepping. Lack of control in the weakened ankle also can contribute to slapping of the foot after the heel strike, in addition to excessive inversion (rolling the ankle inward), which is a risk for injury. Using the Anklebot during gait training may help patients practice and learn how to control foot clearance, orientation at contact, and foot slap. This is possible because the device can independently provide supportive forces during the gait cycle to modulate stance, swing and specific sub-tasks within the gait cycle to better address the walking issues that appear post stroke.”

“To address the diversity of walking deficits in those with stroke, we had to invent a novel systems-level control system; one that utilizes the “assist-as-needed” Anklebot in a deficit adjusted manner, to time robotic assistance to key functional deficits. This enables therapists to tailor robotic gait therapy to not only the severity, but also the type of gait deficit,” said Anindo Roy, PhD, chief robotics engineer for the VA Maryland Health Care System’s Exercise & Robotics Center of Excellence and assistant professor at the University of Maryland School of Medicine, the latest paper’s lead author. “Our preliminary findings with this approach indicate that it can yield durable benefits in those with drop foot, weak propulsion and/or poor landing. To our knowledge, this is the first-of-its-kind approach in the field of contemporary lower extremity robotics that enables customizability of gait therapy across survivors with a wide range of deficit profiles,” Roy says.

Just ask Vivian Elaine James. For James, the world changed April 2011 after she suffered a stroke. “I was totally shocked I had a stroke,” says James, who, prior to the stroke, had owned a construction company that kept her physically active. “I did painting, renovating, dry wall installation, and other things,” James says. The stroke, which afflicted her left side, stole her balance and capacity to move with ease, to function and complete many tasks she had taken for granted. “At the time, I had no idea what was happening to me. I thought I was having an anxiety attack, but apparently I had had some mini strokes and didn’t know it before the major one hit me.”

Hope for James came from her participation in the study using the Anklebot, and this 52-year old credits improvements in her ability to walk directly to her experience with the device. “I’ve only participated in the study for three months, but those three months made a major difference in my life,” James says. “I still need to be careful when I’m walking if the surface is not solid, but I don’t need assistance anymore. Using the Anklebot made a big difference in the strength of my left leg.”

Roy, Forrester and the team are conducting an ongoing VA-funded study to compare outcomes of robotic treadmill training to the use of the Anklebot in both seated, computer-video aided interventions and treadmill walking. They are exploring the differences of the effect on ankle strength and walking since each approach targets specific deficiencies. During the seated approach, individuals use their weakened ankles to play a video game three times a week in one-hour long sessions. In the treadmill approach, individuals walk on the treadmill three times a week for up to 40 minutes per session.

“Our earlier work examined the effects of seated Anklebot in chronic stroke and found that 18 sessions over six weeks produced some measureable gains in floor walking speed and the underlying components of the gait cycle. We now need to compare the relative effectiveness of the seated versus the task-oriented approach on the treadmill, to see if they yield similar results. So far the treadmill locomotor approach seems very promising, but it is too early to draw sweeping conclusions,” says Forrester, a principle investigator on the study.

During the treadmill approach, the team employs footswitches embedded in the individual’s shoes to detect the occurrence of key events during walking such as the feet rising and falling within the gait cycle, enabling the Anklebot to time assistance precisely to those events, and, over time, progressively wean robotic assistance so that the individual can move incrementally toward a more normal gait. “The Anklebot is unique in that, it is impedance-controlled allowing it to be programmed to apply more or less support to the effort, depending on the user’s performance and tolerance,” Roy said. “It is also highly ‘backdrivable,’ meaning it can ‘get out of the way’ when appropriate, allowing patients to perform movements on their own.”

For James, it’s simpler: “Anyone who has had a stroke needs the Anklebot,” she says.

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“We’re definitely doing something that’s very interesting with technology. We’re really changing people’s lives.” — Rodolfo Rohr, President and CEO

It’s been 24 years since MIT scientists began looking into using robots to help stroke victims recover motor skills.

Because neuroscience research points to evidence that the brain is not hard-wired — it’s flexible and can recover from ­injury — MIT professors Neville ­Hogan and Hermano I. Krebs at the ­Newman Lab for biomechanics and human ­rehabilitation are using advanced robotic technology to enhance the brain’s ability to recover from neurologic injury.

Through the MIT-Manus project, they led a team to develop robotic devices that help clinicians deliver intensive interactive therapy in an efficient manner. The robots help with the same movements that patients perform with physical therapists’ guidance, but patients can do far more repetitions with the robots. Plus, the robots can objectively measure each patient’s progress.

In 1998, Interactive Motion Technologies (IMT) formed to manufacture the clinical version of the MIT-Manus–InMotion robots for clinical research around the world. Fifteen years later, numerous randomized controlled clinical trials have resulted in objective clinical evidence that, CEO Rohr says, shows the technology used in a clinical setting can improve patient outcomes.

“It’s really what gets us through the tough times,” he says. “We’re making a difference in people’s lives.”

Patients report that the robots have helped them regain hope in living. “It’s not a silver bullet. We’re still at the start of the journey,” Rohr says. “But when people start to regain some movement and gain more control in their lives, you can see the real benefits.”

The InMotion robots are clinical tools to deliver high-intensity, interactive therapy using video games. Clinicians are now able to keep patients continously enagaged with customizable progressive therapy protocols. Patients report that therapy with the robots is fun, and in some cases, they see benefits after the first session. The American Heart ­Association recently recommended that robot-assisted therapy be used for upper-­extremity motor rehabilitation in stroke patients.

Each system consists of a robot, as well as a computer and software developed by IMT, an Acer monitor, and a Seal Shield keyboard and mouse.

Through the clinical trials, IMT has substantially revised the hardware and software it uses, Rohr says. The results of the trials “have allowed us to learn what type of robotic assistance should be used to maximize patient recovery,” he says. “We have learned that a patient must actively attempt to move, and the robot should only assist as needed.”

The team has also evolved its robot into a precise clinical evaluation tool capable of providing results that can be closely correlated with traditional assessment scales.

The InMotion robots have changed in other ways as well. “We’ve improved our products quite a bit over the years,” Rohr says.

Their universal design makes them easy to use and prepare for patients. Even patients in wheelchairs can use the robots, which is fundamental for clinical efficiency and utilization, he says. The robots are also compact and moveable, so they can function in many different hospital settings.

The next step is to develop more affordable devices that patients could purchase or rent on their own, instead of using them solely through clinics.

“We’re definitely doing something that’s very interesting with technology,” Rohr says. “We’re really changing people’s lives.”

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Cardinal Santos Medical Center recently acquired InMotion Robots that provide rehabilitation technology for the therapy of patients with stroke, multiple sclerosis, and other neurological conditions.

A top local hospital is using mobile technology, robotics, and modern medical science to take care of perhaps the human body’s most under-appreciated part — the hand.

Cardinal Santos Medical Center recently launched the CSMC Hand Center, a one-stop-shop for all ailments of the hand, which it defines as from the fingers to the upper extremities, including the palm, wrist, elbow, and shoulder.

The hospital also acquired InMotion Robots — developed through research in medical engineering at the Newman Laboratory for Biomechanics and Human Rehabilitation at the famed Massachusetts Institute of Technology (MIT) — that offer robotic solutions for rehabilitation therapy, which Cardinal Santos says is a first in the country.

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Medica

November 14-17 2012

Dusseldorf, Germany

www.ospedalebambinogesu.it

Pediatric anklebot from InMotion Robots awaits the first research patient at the new Bambino Gesù  Children’s Hospital in Santa Marinella.

Weeks of rigorous rehabilitation at Rancho Los Amigos National Rehabilitation Center in California also were exhausting, until a different kind of therapist paid a visit to the Los Angeles native: a robot named Bandit.

At first glance, Bandit lacks many of the qualities of a good coach or companion. But with its shiny gray metal face, cameras for eyes and a simple wire mouth, it has been using its well-honed social skills to help improve the quality of life of stroke victims.

Designed by researchers at the University of Southern California’s Viterbi School of Engineering, Bandit motivates and corrects patients as they carry out strenuous exercises. It’s one of several efforts nationwide to tap the abilities of robots to provide assistance and social interaction in health care.

Other researchers are developing the use of socially assistive robots in working with patients who have Alzheimer’s disease and children with autism spectrum disorders. Rancho Los Amigos and USC launched a study in mid-June that aims to compare improvements in stroke patients working with robots with those working only with humans.

Patients seem to readily accept their robot companions and trainers — even older adults who might be leery of other new technology take to the “cute” Bandit as if it were a child. And patients often practice strenuous and repetitive exercises for longer periods with the robot, and sometimes even engage in banter.

“It was definitely fun,” says Dimon, 63, who spent three hours “playing” with the robot. “It was like a diversion from the tediousness of rehab.”

Others seem to agree. Instead of putting off rehab, some patients ask to return to spend more time with Bandit, researcher Eric Wade says.

That extra therapy can make all the difference, says Mindy Aisen, chief medical officer at Rancho Los Amigos. “The social robot (is like) the cheerleader that never gets fatigued — and it’s fun to mimic.”

Wade says patients should exercise weakened limbs for at least six months, but many get far less rehabilitation because of the costs. Robots can serve as an additional resource in fields already stretched thin to meet growing demand for services, researchers say.

Though social robots are at least a decade away from market, one study in the works already is looking into how robots can adapt to a home environment. As now designed, robots may malfunction if they have to navigate around new furniture or adapt to new sounds.

The KUKA youBot, a flat, boxy robot that can roll and grab objects, may help cross that hurdle. The Robot Autonomy and Interactive Learning lab at the Worcester (Mass.) Polytechnic Institute put one in a model apartment. Internet users will be able to log on later this summer to teach it tasks such as knocking items off a table, so the team can collect data on how people teach robots, says lab director Sonia Chernova.

The field of socially assistive robotics has grown slowly over 20 years, but it got a boost in April when the National Science Foundation granted $10 million to a Yale-led team of 17 principal investigators at four universities, including USC, to develop a robot that would adapt while working with a preschool-age child for months or even a year.

As the field grows, researchers expect robots to be embraced as a tool for therapy, rehab and even to learn skills such as speaking a second language.

“It may seem counterintuitive to say, ‘Do we want robots in people’s lives?’ says Maja Mataric of USC. “But I think that’s going back to people’s natures. We’re very social creatures.”

Read in USA Today

Matéria_17.05.12 (InMotion)

Listen:

Dr. George Wittenberg

Nearly 700,000 strokes occur in the United States each year, leaving thousands of people with lasting movement problems. Even with rehabilitation therapy, half of stroke survivors will continue to have weakness on one side of their body. However, research is pointing to promising new ways for people to regain at least some of their function.

In this interview, Dr. George Wittenberg, a neurologist at the University of Maryland Medical Center, discusses the latest research in stroke rehabilitation, including the use of robotics, which assist people to perform movements correctly, much like power steering in a car makes it easier to turn the car around.

Researchers are studying whether moving arms or legs correctly, in a repetitive way, will help stroke survivors to regain function and move better. They are also looking at brain images to see if the repetitive movements cause changes in the brain.

In this interview with Sharon Boston, Dr. Wittenberg also discusses other devices such as braces and stimulators that may benefit stroke patients. Dr. Wittenberg is also an assistant professor of neurology at the University of Maryland School of Medicine and a staff physician at the Baltimore VA Medical Center.

http://www.umm.edu/podcasts/2008/stroke_rehabilitation_robotics_research.htm#ixzz2CRHWejGg

Read at University of Maryland Medical Center