I got absolutely nothing useful out of this. Lots of words but nothing EXACTLY USEABLE. I'm sure your doctor did nothing with this 10 year old data. Has your stroke hospital implemented ANY STROKE RESEARCH into interventions helping stroke survivors?
Mechatronic Systems Applications, 2010
Stefano Mazzoleni1, Paolo Dario1, Maria Chiara Carrozza1 and Eugenio Guglielmelli21 ARTS Lab, Scuola Superiore Sant’Anna, Pisa, Italy2 Laboratory of Biomedical Robotics & EMC, Campus Bio-Medico University, Rome, Italy
1. Introduction
During the last decades, the potentiality of robotics as a tool for neuroscientific investigations has been demonstrated, thus contributing to increase knowledge on biological systems. On the other hand, a detailed analysis of the potentialities of these systems (Dario et al., 2003) based on recent neuroscientific achievements, in particular about the mechanisms of neurogenesis and cerebral plasticity underlying the motor learning and the functional recovery after cerebral injury, highlights the advisability of using the robotic technologies, as systems able to contribute to a breakthrough in the clinical procedures of neurorehabilitative treatments. Several examples of robotic machines applied to both neuroscience and neurorehabilitation can be found in the literature (Krebs et al., 1998; Colombo et al, 2000). One of the main scientific and technological challenges is represented by the design and development of innovative robotic and mechatronic systems able to i) simplify interaction modalities during assisted motor exercises, ii) enhance adaptability of the machines to the actual patient performance and residual abilities, iii) provide a comprehensive picture of the psycho-physiological status of the patient for assessment purposes, through the integrated use of brain imaging techniques. The basic assumption of this work relies on a human-centred approach applied to the design of robotic and mechatronic devices aimed at carrying out neuroscientific investigations on human sensorimotor behaviour, delivering innovative neurorehabilitation therapies and assessing the functional recovery of disabled patients. Special attention is paid to the issues related to human-machine interaction modalities inspired to human motor mechanisms and the design of machines for the analysis of human motor behaviour and the quantitative assessment of motor performance.
2. Background
In industrialized societies, several factors contribute to a growing need for rehabilitative services, as complement and support to surgical and pharmacological treatments. The main
of them are the increasing longevity of the population, the trend towards reducing the duration of hospitalization, the use of therapies that can treat highly progressive debilitating diseases, the increased incidence of severe and moderate disabilities resulting from the activities at risk of injury and trauma, the use of advanced techniques of resuscitation. The need for appropriate rehabilitative therapies has an increasing importance in many motor disorders of neurological origin: in this case we speak more specifically of neurorehabilitation. Millions of people worldwide suffer from motor disorders associated with neurological problems such as stroke, brain injuries, spinal cord injuries, multiple sclerosis, Parkinson's disease. A brief outlook to the Italian situation can help to understand the impact: each year in Italy about 196,000 strokes occur1 with approximately 20% of affected people who die within the first month following the acute event and 30% of survivors are severely disabled. Of these 196,000, 80% are first episodes, whereas 20% are relapses. Stroke represents the third leading cause of death in industrialized countries, after cardiovascular diseases and cancer and the leading cause of disability with a significant impact at individual, family and social level (Feygin et al., 2003; Murray et al., 1997; Marini et al., 2004). The incidence of stroke progressively increases with age: it reaches the maximum value in people over 85 years old (24.2%) with a male predominance (28.2%) than females (21.8%). The prevalence of stroke in the Italian elderly population (age 65-84 years) is equivalent to 6.5% and is slightly higher in men (7.4%) than in women (5.9%). Stroke affects, although to a lesser extent, young people: every year about 27,000 people in productive age (<65 years) are affected (SPREAD, 2007). In the U.S., the estimated cost of hospitalization due to stroke in 1998 is $68.9 billion (Heart Disease and Stroke Statistics 2009 Update) . The traditional therapy methods present some limits, which is important to focus on. In many of the above mentioned cases, the traditional motor rehabilitative approaches involve manipulation of the paretic upper limb by the therapist. Usually the treatment is planned by assessingex ante the residual abilities of the subject and can last several hours a day: it can be often a long and exhausting exercise for both the patient and the therapist. The therapeutic treatments can be extended for several months after hospitalization, during which patients must travel daily to the clinical facilities and face hard discomforts for themselves and their family. Moreover, for many motor disorders is not yet sufficiently clear what are the therapeutic approaches and clinical protocols that are objectively more effective for a better recovery of motor function; it partly derives from the fact that the residual abilities of the patient are often assessed by using largely subjective methods of measure, and that makes difficult an adequate evaluation of rehabilitation treatment’s effects on the patient. The nature of these treatments, which have to be administered by therapists on a patient at a time, and the lack of methodologies and tools able to compare the different rehabilitative therapies and their effectiveness make the costs associated to rehabilitation services typically high; thus, the ratio between the number of qualified human resources to be used for the rehabilitative services and the number of patients is often higher than one. It is also difficult1Data extrapolated from the population in 2001.Application of robotic and mechatronic systems to neurorehabilitation101to define methods for assessing and improving the cost/effectiveness ratio related to specific rehabilitation programs. The use of robotic machines for neurorehabilitation is inspired by the neurophysiological evidence showing that, starting from the cellular level, synaptic connections undergo continuous changes, in response to physiological events, environmental stimuli (processes of learning and memory) and damages to the Central Nervous System (CNS)2. The topology of the motor and sensory cortex is not fixed, but flexible and adaptable to learning and experience (Donoghue et al., 1996). This characteristic of the motor cortex has important implications for rehabilitation: a) rapid changes in cortical activity can occur, b) the intensive training of cortical area may occur at the surrounding areas’ expense and c) cortical areas can adapt their functions to those changes. Thanks to the brain imaging techniques, such as functional Magnetic Resonance Imaging (fMRI), Positron Emission Tomography (PET), Transcranial Magnetic Stimulation (TMS) associated to Motor Evoked Potentials (MEP) and electrical stimulation, changes in CNS’s excitability and topology can be shown. Through the use of such techniques, it is possible to identify regions that have suffered a damage and apply a specific therapy. The sensorimotor learning is influenced by physical (sensory feedback such as vision, hearing and proprioception), psychological (pleasure/pain, motivation, emotional impulses and desire) and cognitive (decision making, planning, reasoning, concentration and attention, language and understanding, previous experiences) factors. It can be facilitated by the repetition of movements directed to specific targets (goal-oriented movements), the strengthening of muscles and the increase of the range of motion (ROM), the modulation of spasticity, an increased demand of focusing attention on the movement and the increase of sensory stimuli. In recent years different research groups have studied and developed innovative robotic and mechatronic systems able to let the patient perform repetitive and goal-oriented movements. These systems can provide a safe and intensive training3 that can be carried out in association with other types of treatment, appropriate to the different residual motor abilities, potentially able to significantly improve the rehabilitation outcomes, to perform an objective assessment and to improve the planning and use of healthcare resources. In the rehabilitation assisted by a robot, the patient’s role is undoubtedly central: the machine supports, and, if necessary, completes, the movement performed by the patient according to his/her residual motor abilities (“assisted as needed” control strategy).2 The termsneuroplasticity orneural plasticity are used to point out the sequence of changes in chemical (interaction between neurotransmitter and receptor), electrical (long-term depression and long-term potentiation) and molecular (activation of transcription factors and protein synthesis) responses, which lead to a reorganization of connections in the cerebral areas and, consequently, to cognitive changes and stable behaviours.3 During each training session using robotic systems, a high number of movements can be performed: the repetition of motor actions is a factor which can promote the recovery of motor functions.Mechatronic Systems, Applications102People suffering from motor disorders can perform the rehabilitation therapy with the support of a “rehabilitation machine”4. The patient, through the interaction with these systems, receives different sensorimotor and cognitive inputs, such as proprioceptive and visualstimuli, motivational incentives5: by using appropriate sensors, the machine is capable of measuring dynamic variables of clinical interest during the performance of active and passive movements by the patient. Thus, a quantitative assessment of specific physiological mechanisms, of motor recovery and functional skills can be carried out. This type of assessment is much more accurate than those using traditional methods. In addition, the machine may enable the therapist to plan the treatment and let the patient execute a wide sequence of movements, which can be useful for the limb rehabilitation. The application of machines to rehabilitation is sometimes limited by technical and functional factors; their real advantage in clinical applications has been only partially proved. However, there are solid arguments that encourage researchers to design and develop innovative systems for rehabilitation, which derive a direct benefit from the scientific and technological progress in the field of bioengineering, particularly in biomedical robotics and mechatronics. The clinical potential of these machines, however, is clearly significant as they can, on the one hand, assist the therapist in the administration of a patient-specific physical therapy, with the accuracy and repeatability, typical of the robotic systems, and on the other hand, to acquire quantitative information on the patient’s movements. Such information may be useful for the evaluation of both the patient's motor function and the mechanisms of motor recovery. These machines can also enable the patient to perform rehabilitative sessions in a semi-autonomous modality, and, in principle, even at his/her own home, thus reducing the need for the therapist’s continuous commitment6. The technological innovation in robotics and mechatronics has contributed to achieve encouraging results in the knowledge of motor recovery mechanisms and to a real progress in the rehabilitation field, with a potential high impact.4 A “rehabilitation machine” is a mechatronic or robotic system able to support the therapist during the administration of programmable and customized rehabilitation programs. It is composed by a mechanical structure where the following modules are present: 1) actuators, 2) energy supply, 3) proprioceptive and exteroceptive sensors, providing information on the machine status and the interaction between the machine and the environment, respectively, 4) a microcontroller, dedicated to the processing of data from sensors and generation of motor control commands and 5) a human-machine interface (graphical user interface), dedicated to user inputs, data recording and feedback output.5 The patient feels often rewarded by the use of high-tech systems for rehabilitation. Besides, motivational incentives are strongly stimulated by the use of graphical interfaces which provide a feedback on the performed movements, which are linked to the recovery of essential functionalities for his/her daily life.6 This therapy known as “tele-rehabilitation” is based on the integration of high-tech systems (i.e., a robotic system for rehabilitation) and telecommunication infrastructures (i.e., cable connections, optical fibres, wireless networks and satellite systems): it is aimed at enabling the execution of rehabilitation treatments at own home or rehabilitation centre, through the direct remote supervision and monitoring by physicians and therapists.Application of robotic and mechatronic systems to neurorehabilitation103In the wide range of technological applications developed in the context of biomedical robotics, undoubtedly a class of particular importance is represented by the systems for the rehabilitation of patients who have a reduced mobility, following an injury or disease. In the next paragraphs, robotic systems for upper and lower extremities rehabilitation and mechatronic systems for the functional assessment and the movement analysis for this type of patients will be described.
More at link with pictures.
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