Use of Rehabilitation Robots Combined With Different Functional Training in Stroke Rehabilitation
Dr. & Prof. Keh-chung Lin（台湾大学 林克忠教授） Professor of Occupational Therapy & Director of General Affairs College of Medicine, National Taiwan University, Taipei, Taiwan July 30, 2016 E-mail:
[email protected]
Inhibiting the healthy cortex Immobilization (CIT) Inhibiting NIBS
Stimulation of the injured cortex Constraint-Induced Therapy Robotics Virtual Reality Stimulating NIBS
2
Paradigm Shift in Neurorehabilitation
Contemporary Approaches to Induce Neuroplastic Changes - Constraint-induced therapy (CIT ) - Bilateral arm training (BAT) - Robot-assisted therapy (RT) Traditional Approaches
- Mirror therapy (MT)
(Neurodevelopmental Treatments)
- Combined therapy
- Rood
- Proprioceptive Neuromuscular Facilitation (PNF) - Brunnstrom - NDT/Bobath 3
Radomski & Trombly Latham (2014)
Robot-Assisted Therapy (RT)
Applicability Patients with low- to high- function in subacute to chronic stroke Advantage
High-intensity of motor rehabilitation
Limitations
Focus on limited types of movement and patterns involving specific joints or degrees of freedom, possibly leaving other impaired joint movements untrained. The evidence for RT to improve quality of life (QOL) is insufficient.
Robot-Assisted Therapy (RT) Unilateral Arm Training
Bilateral Arm Training
Proximal Emphasis InMotion 2.0 Interactive Motion Technologies (U.S.)
Distal Emphasis
InMotion 3.0 Interactive Motion Technologies (U.S.)
Bi-Manu-Track Reha-Stim Co. (Germany)
Research Program of Robot-Assisted Therapy After Stroke Robot-Assisted Therapy (RT)
Randomized Controlled Trials (RCT)
DoseResponse Effects of RT
Example 1 Stroke 43: 2729-2734, 2012
Effects on Functional Outcomes and Motion Analysis
Example 2 Clin Rehabil 26:111-120, 2012
Markers Study (e.g., Oxidative and Inflammation Markers) Example 3 Int J Mol Sci 15 (4), 6504-6516, 2014
Comparative Efficacy Research (CER)
Unilateral vs. Bilateral RT Example 4 Am J Occup Ther 66: 198206, 2012 Example 5 J Neuroeng Rehabil 10: 35, 2013
TherapistBased vs. RobotAssisted Therapy Example 6 Phys Ther 92: 1006-1016, 2012
Combined vs. MonoTherapy Example 7 J Neurol 261(5), 1037-45, 2014 Example 8 JNER, 2016 Example 9 J Neuroeng Rehabil 12,96, 2015 Example 10 PM&R, 2016 Example 11 Clin Rehabil, 2016
Unilateral Hybrid Therapy vs. Bilateral Hybrid Therapy
Ongoing Study
Example 7
RT + CIT led to additive effects on motor ability and functional performance relative to RT and CIT.
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The findings support the evidence of using RT combined with therapist-based arm training to enhance treatment efficacy. 7
Example 8
Effects of RT + mCIT on Reaching and Trunk Kinematics
RT + mCIT
RT
20 therapy sessions (90 to 105 min/day, 5 days for 4 weeks) Motor function
shoulder abduction ↓ elbow extension ↑
─
Motor control strategies
trunk compensation ↓
─
Independence of daily functions
IADL↑
─ 8
Example 9
Robot +Electrical Stimulation
PAS system GD-601 (OG GIKEN Co., Ltd. in Japan)
RT + ES RT + sham (n=10) stimulation (n=12)
RT (n=10)
FMA
↑
↑
↑
WMFT-time
↓
↓
↓↓
WMFT-functional ability
↑↑
↑
↑
Muscle tone-wrist flexor
↓↓
↑
-
Daily function
↑
↑
↑
Quality of life
↑
↑
↑
The stimulation intensity was targeted at a muscle contraction level (poor to fair). The electrodes were placed: 1. Wrist extensors 2. The forearm supinator or pronator 9
Example 10
RT + Task-Oriented Practice (RTT) vs. Impairment-Oriented Training (RTI)
PM&R. 2016 Jan 21. pii: S1934-1482(16)00040-X. doi: 10.1016/j.pmrj.2016.01.008.
RT + task-oerinted practice (RTT)
RT + impairment-oriented training (RTI)
vs. 60 min
30 min
60 min
30 min
All participants received 20 sessions (90-100 min/day, 5 days/week for 4 weeks). 10
Example 10
Background: Task-Oriented Training and Impairment-Oriented Training If combined with RT, may produce additive effects on motor function, motor recovery, ADL as well as QOL.
If combined with RT, may intensify motor ability and motor control.
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Example 10
The need for the study The effects of RT were limited to domains of movement
performance and motor control. Task-specific training or impairment-oriented training may be
combined with RT to enhance functional outcomes. There is a need for comparison of the two combinatory regimens. Research purpose: This study is designed to compare the effects of RTT and RTI on motor function, muscle strength, and QOL in patients with chronic stroke.
Hypotheses: − RTT would result in better outcomes in life quality. − RTI may lead to enhanced performance in upper limb movements. 12
Example 10
Methods: A randomized controlled trial Inclusion criteria −
> 6 months after a unilateral stroke
−
An initial score of 20-50 on the FMA-UE
−
A score of MAS ≦ 3 in any joints of the affected upper limb
−
A score on MMSE ≧ 24 and able to follow study instructions
−
No other neurologic, neuromuscular, or orthopedic disease
−
No participation in any experimental intervention within the past 3 months
FMA-UE=Fugl-Meyer Motor Assessment Upper Extremity subscale; MAS=Modified Ashworth Scale; MMSE=Mini-Mental State Examination
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Example 10
Methods 5 min
• normalize muscle tone for the affected arm • RT with the InMotion 3.0 robot
60 min
(Interactive Motion Technologies Inc., Watertown, MA, USA)
• RTT group: task-specific training 30 min • RTI group: impairment-oriented training The InMotion 3.0 involves practice of 2 types of movement patterns: 1. forearm pronation-supination 2. wrist circumduction
Outcome measures Primary outcomes
Fugl-Meyer Motor Assessment Upper Extremity subscale (FMA-UE) Stroke Impact Scale version 3.0 (SIS)
Secondary Medical Research Council (MRC) outcomes
Action Research Arm Test (ARAT) 14
Example 10
Results: Primary Outcomes (FMA-UE & SIS) RTT group
• Improved the overall, proximal, and distal FMA-UE score and the SIS score from pretest to posttest and from pretest to follow-up.
RTI group
• Only improved the overall FMA-UE score from pretest to posttest.
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Example 10
Results: Secondary Outcomes (MRC & ARAT) The RTT led to significantly greater improvements of pinch function on
the ARAT immediately after the intervention, relative to the RTI.
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Example 10
RTT vs. RTI
• RTT may be a more compelling approach to enhance motor function and quality of life for a 3-month follow-up than RTI. Robot-assisted therapy
Task-specific training
repetitive training of single-joint movement motor priming: activate the cortex region that is needed for voluntary movements beforehand
context-related and goal-directed practice link the practice in the therapy room with the environment of daily life to generalize
• RTI may be an opportunity for stroke patients with severe motor impairment or problems of concentration and weakness. 17
Example 11
RT as a Priming Technique to Augment Task-Oriented Practice
• Participants were randomly assigned to two groups (1) The primed group: Bilateral robotic priming + task-oriented approach (2) The unprimed group: Only task-oriented approach
• All participants received a daily 90-minute therapy session, 5 days/week for 4 weeks, for a total of 20 sessions. 18
Example 11
RT + Task-Oriented Practice
1. Bilateral robotic priming before the task-oriented approach may improve selfperceived strength and degrees of disability in patients with subacute stroke. 2. The priming techniques can be used as an adjuvant approach to stroke rehabilitation to promote functional recovery.
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Need for Further Work Adverse effects after intensive therapy
Exoskeleton RT
Neuroplastic change in responders and non-responders
Home-based or remotecontrolled interventios
Markers predictive of treatment outcomes 20
台湾大学-长庚大学 神经康复研究队伍
