Ebook: Advanced Technologies in Rehabilitation

The proportion of the world population over 65 years of age is climbing. Life expectancy in this age group is increasing, and disabling illnesses now occur later in life, so the burden on the working–age population to support health care costs of aging populations continues to increase. These demographic shifts portend progressively greater demands for cost effective health care, including long-term care and rehabilitation. The most influential change in physical rehabilitation practice over the past few decades has been the rapid development of new technologies that enable clinicians to provide more effective therapeutic interventions.

New rehabilitation technologies can provide more responsive treatment tools or augment the therapeutic process. However, the absence of education about technological advancements and apprehensions by clinicians related to the role of technology in the treatment delivery process puts us at risk of losing the benefit of an essential partner in achieving successful outcomes with the physically disabled and aging population. There are two reasons that may explain why rehabilitation practitioners do not play an integral role in the development and evaluation of these new technologies. First, the engineers who develop these technologies do not recognize the value they could derive by consulting with rehabilitation professionals in order to make their machine-user interfaces more efficient, user friendly, and effective for specific disabilities. Second, many rehabilitation professionals are uncomfortable with technology and fear that it may take the place of individualized interactions with patients.

Funding challenges, a lack of public awareness about technology's potential, a shortage of trained experts, and poor collaboration among researchers, clinicians, and users are often the cause for an absence of clinical trials that demonstrate the value of near-term and future rehabilitation applications. If technology transfer is to become successful, we need to establish collaborative interactions in which the goals of each discipline become overlapping with the skills and goals of the other fields of endeavor and of the consumer. The rapid rise of technological development is pushing the market place and it is essential that rehabilitation specialists oversee the quality and validity of these new applications before they reach the consumer.

It is clear from the chapters in this book that improvements in technology depend on interdisciplinary cooperation among neuroscientists, engineers, computer programmers, psychologists, and rehabilitation specialists, and on adoption and widespread application of objective criteria for evaluating alternative methods. The goal of this book is to bring ideas from several different disciplines in order to examine the focus and aims that drive rehabilitation intervention and technology development.

Specifically, the chapters in this book address the questions of what research is currently taking place to further develop rehabilitation applied technology and how we have been able to modify and measure responses in both healthy and clinical populations using these technologies. In the following sections we highlight some of the issues raised about emergent technologies and briefly describe the chapters from this book that are dedicated toward addressing these issues.

1. Does Training with Technology Add to Functional Gains?

Before we can develop a successful intervention, we need to determine what the end goal is. A number of different therapeutic technologies are already available for use in clinics, but their value to the treatment program is not well defined. Developers and clinicians must consider whether a technological device better targets diagnostic or therapeutic interventions. Does it serve as an extension or repetition of conventional therapeutic interventions? Do we want it to perfectly replicate the actions of a therapist or to assist or augment the actions of the therapist? For example, as stated by Reinkensmeyer in his chapter, there has been a rapid increase in the number of robotic devices that are being developed to assist in movement rehabilitation, yet it is still not well understood how these devices enhance movement recovery, and whether they have inherent therapeutic value that can be attributed to their robotic properties. Chapters by Frisoli et al. and Piron et al. present results of clinical trials that demonstrate improvements in functional outcomes on standard clinical scales when compared with more traditional clinical interventions which would suggest value in adding technology to therapeutic interventions.

2. Are there Rules that Govern Recovery of Function?

Are learning rules for recovery similar to those for skill acquisition? In particular, should we be concerned mostly with error reduction or feedback enhancement? If we are concerned with recognition of movement error, do we try to increase or decrease that error for learning? How do we instruct patients to attend not only to the error, but also to their own kinematics? If functional recovery depends on plasticity of the central nervous system, can the use of technology enhance this plasticity? If we are attempting to promote plastic changes in the nervous system, then motor learning principles most likely should be adhered to and rules for learning need to be defined including the optimal length and frequency of the intervention and how much interference plays a role in learning. Cameirao et al. use virtual reality to engage patients in task specific training scenarios that adapt to their performance thereby allowing for an individualized training of graded difficulty and complexity. Deutsch provides an overview of virtual reality gaming based technologies to improve motor and cognitive elements required for ambulation and mobility in different patient populations. Levin et al. and Merians et al. demonstrate how movement retraining can be optimized by combining virtual reality with haptic devices if important motor learning elements such as repetition, varied task practice, performance feedback and motivation are incorporated. Riva et al. discuss development of a new open source system that uses the principles of motor learning within real life context in order to increase generalization of recovered motor and cognitive behaviours. Using a combination of robotics and virtual reality, Sanguineti et al. demonstrated functional gains by tailoring their intervention to the different degrees of impairment and adapting the intervention as performance changed thereby exploiting the nervous system's capacity for sensorimotor adaptation.

3. Using the Body's Own Signals to Augment Therapeutic Gains

Another rapidly advancing area of technology for rehabilitation is the application of the individual's own residual sensory and motor signals to augment function. Although wheelchairs are still the most popular assistive device for patients with spinal cord injuries and disabling neurological conditions, many users encounter difficulties in controlling their powered wheelchairs. The wheelchair represents an assistive device that, in large part, requires the person to adapt to the technology rather than having the technology fit the abilities of the individual. Bonato discusses the emerging use of miniature sensors that can be worn by the patient to measure and transmit information about physiologic and motor functions. Carabalona et al. explore research on brain-computer interfaces and discuss how technologies that are driven by or access the signals initiated by each patient can support activity in their environments.

4. Technology Incorporates Cognition and Action

Clinicians often voice concerns about using technological interventions because they appear to replace the human interaction which is believed to be a prime factor in the success of rehabilitation programs. Rehabilitation clinicians work with patients using a combination of verbal, visual, and physical interaction as well as a variety of treatment tools and techniques. Delivering equivalent interventions to patients through technological devices presents significant obstacles, but also presents numerous opportunities to enhance the quality, consistency, and documentation of care received. Several chapters in this book explore how rehabilitation technology offers the capacity to individualize treatment approaches by monitoring the specificity and frequency of feedback, providing standardization of assessment and training, and presenting treatment within a functional, purposeful and motivating context. Antonietti presents the field of music therapy as a tool of the mind, using cognition and emotion as the avenue towards accomplishing goals for rehabilitation. Gaggioli et al. demonstrate how virtual reality can be successfully used to support motor imagery techniques for mental practice in stroke rehabilitation. Keshner and Kenyon discuss how cognitive processes such as perception and spatial orientation can be accessed through virtual reality for the assessment and rehabilitation of perceptual-motor disorders.

5. Technology Enhances the Impact of Rehabilitation Programs

One of the greatest challenges for healthcare in the coming decade will be accessibility to the increasing numbers of individuals who are unable to travel to rehabilitation facilities or who do not have local rehabilitation facilities that provide the health maintenance and extended care they require. Additionally, most of the responsibility for caring for individuals with physical or psychological disabilities will fall on their family or on health care aides who do not have the training to provide wellness and rehabilitation interventions. The chapters in this book that address improved access to care and extending the reach of medical rehabilitation service delivery all emphasize the importance of human factors and user-centered design in the planning, developing, and implementation of their systems. Brennan et al. present a brief history of tele-rehabilitation and tele-care and offer an overview of the technology used to provide these remote rehabilitation services. Mataric et al. demonstrate how combining the technology of non-contact socially assistive robotics and the clinical science of neurorehabilitation and motor learning can promote home-based rehabilitation programs for stroke and traumatic brain injury. Weiss and Klinger discuss the practical and ethical considerations of using virtual reality for multiple users in co-located settings, single users in remote locations, and multiple users in remote locations.

6. Summary

Although new technologies and applications are rapidly emerging in the area of rehabilitation, there are still issues that must be addressed before these can be used both effectively and economically. First, we need to demonstrate that these devices are effective through clinical trials. Second, we must determine how to build devices cheaply enough for mass use. Lastly, we need sufficiently educated physicians and therapists to drive the technology development and applications. Although considerable engineering knowledge is required to understand the potential capabilities of the various technologies, engineering alone will not determine the usefulness of these systems. The chapters we have included in this book clearly demonstrate that in order to design appropriate system features and successful interventions, developers and the users need to be familiar with the scientific rationale for motor learning and motor control, as well as the motor impairments presented by different clinical populations. Ultimately, the impact of these new technologies will depend very much on mutual communication and collaboration between clinicians, engineers, scientists, and the people with disabilities that the technology will most directly impact.

Emily A. Keshner, Temple University, Philadelphia, PA, USA

W. Zev Rymer, Northwestern University, Chicago, Illinois, USA

Rehabilitation is placing increasing emphasis on the construct of empowerment as the final goal of any treatment approach. This reflects a shift in focus from deficits and dependence to assets and independence. According to this approach, rehabilitation should aim to improve the quality of the life of the individual by means of effective support to his/her activity and interaction. Here we suggest that advanced technologies can play a significant role in this process. By enhancing the experienced level of “Presence” - the non-mediated perception of successfully transforming intentions into action - these emerging technologies can foster optimal experiences (Flow) and support the empowerment process. Finally, we describe the “NeuroVR” system (http://www.neurovr.org) as an example of how advanced technologies can be used to support Presence and Flow in the rehabilitation process.

There has been a rapid increase in the past decade in the number of robotic devices that are being developed to assist in movement rehabilitation of the upper extremity following stroke. Many of these devices have produced positive clinical results. Yet, it is still not well understood how these devices enhance movement recovery, and whether they have inherent therapeutic value that can be attributed to their robotic properties per se. This chapter reviews the history of robotic assistance for upper extremity training after stroke and the current state of the field. Future advances in the field will likely be driven by scientific studies focused on defining the behavioral factors that influence motor plasticity.

This study presents the evaluation results of a clinical trial of robotic-assisted rehabilitation in Virtual Reality performed with the PERCRO L-Exos (Light-Exoskeleton) system, which is a 5-DoF force-feedback exoskeleton for the right arm. The device has demonstrated itself suitable for robotic arm rehabilitation therapy when integrated with a Virtual Reality (VR) system. Three different schemes of therapy in VR were tested in the clinical evaluation trial, which was conducted on a group of nine chronic stroke patients at the Santa Chiara Hospital in Pisa-Italy. The results of this clinical trial, both in terms of patients performance improvements in the proposed exercises and in terms of improvements in the standard clinical scales which were used to monitor patients receovery are reported and discussed. The evaluation both pre and post-therapy was carried out with both clinical and quantitative kinesiologic measurements. Statistically significant improvements were found in terms of Fugl-Meyer scores, Ashworth scale, increments of active and passive ranges of motion of the impaired limb, and quantitative indexes, such as task time and error.

The disability deriving from stroke impacts heavily on the economic and social aspects of western countries because stroke survivors commonly experience various degrees of autonomy reduction in the activities of daily living. Recent developments in neuroscience, neurophysiology and computational science have led to innovative theories about the brain mechanisms of the motor system. Thereafter, innovative, scientifically based therapeutic strategies have initially arisen in the rehabilitation field. Promising results from the application of a virtual reality based technique for arm rehabilitation are reported.

Stroke will become one of the main burdens of disease and loss of quality of life in the near future. However, we still have not found rehabilitation approaches that can scale up so as to face this challenge. Virtual reality based therapy systems are a great promise for directly addressing this challenge. Here we review different approaches that are based on this technology, their assumptions and clinical impact. We will focus on virtual reality based rehabilitation systems that combine hypotheses on the aftermath of stroke and the neuronal mechanisms of recovery that directly aims at addressing this challenge. In particular we will analyze the, so called, Rehabilitation Gaming System (RGS) that proposes the use of non-invasive multi-modal stimulation to activate intact neuronal systems that provide direct stimulation to motor areas affected by brain lesions. The RGS is designed to engage the patients in task specific training scenarios that adapt to their performance, allowing for an individualized training of graded difficulty and complexity. Although RGS stands for a generic rehabilitative approach it has been specifically tested for the rehabilitation of motor deficits of the upper extremities of stroke patients. In this chapter we review the main foundations and properties of the RGS, and report on the major findings extracted from studies with healthy and stroke subjects. We show that the RGS captures qualitative and quantitative data on motor deficits, and that this is transferred between real and VR tasks. Additionally, we show how the RGS uses the detailed assessment of the kinematics and performance of stroke patients to individualize the treatment. Subsequently, we will discuss how real-time physiology can be used to provide additional measures to assess the task difficulty and subject engagement. Finally, we report on preliminary results of an ongoing longitudinal study on acute stroke patients.

Improving walking for individuals with musculoskeletal and neuromuscular conditions is an important aspect of rehabilitation. The capabilities of clinicians who address these rehabilitation issues could be augmented with innovations such as virtual reality gaming based technologies. The chapter provides an overview of virtual reality gaming based technologies currently being developed and tested to improve motor and cognitive elements required for ambulation and mobility in different patient populations. Included as well is a detailed description of a single VR system, consisting of the rationale for development and iterative refinement of the system based on clinical science. These concepts include: neural plasticity, part-task training, whole task training, task specific training, principles of exercise and motor learning, sensorimotor integration, and visual spatial processing.

Impairments in reaching and grasping have been well-documented in patients with post-stroke hemiparesis. Patients have deficits in spatial and temporal coordination and may use excessive trunk displacement to assist arm transport during performance of upper limb tasks. Studies of therapeutic effectiveness have shown that repetitive task-specific practice may improve motor function outcomes. Movement retraining may be optimized when done in virtual reality (VR) environments. Environments created with VR technology can incorporate elements essential to maximize motor learning, such as repetitive and varied task practice, performance feedback and motivation. Haptic technology can also be incorporated into VR environments to enhance the user's sense of presence and to make motor tasks more ecologically relevant to the participant. As a first step in the validation of the use of VR environments for rehabilitation, it is necessary to demonstrate that movements made in virtual environments are similar to those made in equivalent physical environments. This has been verified in a series of studies comparing pointing and reaching/grasping movements in physical and virtual environments. Because of the attributes of VR, rehabilitation of the upper limb using VR environments may lead to better rehabilitation outcomes than conventional approaches.

Stroke patients report hand function as the most disabling motor deficit. Current evidence shows that learning new motor skills is essential for inducing functional neuroplasticity and functional recovery. Adaptive training paradigms that continually and interactively move a motor outcome closer to the targeted skill are important to motor recovery. Computerized virtual reality simulations when interfaced with robots, movement tracking and sensing glove systems, are particularly adaptable, allowing for online and offline modifications of task based activities using the participant's current performance and success rate. We have developed a second generation system that can exercise the hand and the arm together or in isolation and provide for both unilateral and bilateral hand and arm activities in three-dimensional space. We demonstrate that by providing haptic assistance for the hand and arm and adaptive anti-gravity support, the system can accommodate patients with lower level impairments. We hypothesize that combining training in virtual environments (VE) with observation of motor actions can bring additional benefits. We present a proof of concept of a novel system that integrates interactive VE with functional neuroimaging to address this issue. Three components of this system are synchronized, the presentation of the visual display of the virtual hands, the collection of fMRI images and the collection of hand joint angles from the instrumented gloves. We show that interactive VEs can facilitate activation of brain areas during training by providing appropriately modified visual feedback. We predict that visual augmentation can become a tool to facilitate functional neuroplasticity.

Robot therapy seems promising with stroke survivors, but it is unclear which exercises are most effective, and whether other pathologies may benefit from this technique. In general, exercises should exploit the adaptive nature of the nervous system, even in chronic patients. Ideally, exercise should involve multiple sensory modalities and, to promote active subject participation, the level of assistance should be kept to a minimum. Moreover, exercises should be tailored to the different degrees of impairment, and should adapt to changing performance. To this end, we designed three tasks: (i) a hitting task, aimed at improving the ability to perform extension movements; (ii) a tracking task, aimed at improving visuo-motor control; and (iii) a bimanual task, aimed at fostering inter-limb coordination. All exercises are conducted on a planar manipulandum with two degrees of freedom, and involve alternating blocks of exercises performed with and without vision. The degree of assistance is kept to a minimum, and adjusted to the changing subject's performance. All three exercises were tested on chronic stroke survivors with different levels of impairment. During the course of each exercise, movements became faster, smoother, more precise, and required decreasing levels of assistive force. These results point to the potential benefit of that assist-as-needed training with a proprioceptive component in a variety of clinical conditions.

Assessing the impact of rehabilitation interventions on the real life of individuals is a key element of the decision-making process required to choose a rehabilitation strategy. In the past, therapists and physicians inferred the effectiveness of a given rehabilitation approach from observations performed in a clinical setting and self-reports by patients. Recent developments in wearable technology have provided tools to complement the information gathered by rehabilitation personnel via patient's direct observation and via interviews and questionnaires. A new generation of wearable sensors and systems has emerged that allows clinicians to gather measures in the home and community settings that capture patients' activity level and exercise compliance, the effectiveness of pharmacological interventions, and the ability of patients to perform efficiently specific motor tasks. Available unobtrusive sensors allow clinical personnel to monitor patients' movement and physiological data such as heart rate, respiratory rate, and oxygen saturation. Cell phone technology and the widespread access to the Internet provide means to implement systems designed to remotely monitor patients' status and optimize interventions based on individual responses to different rehabilitation approaches. This chapter summarizes recent advances in the field of wearable technology and presents examples of application of this technology in rehabilitation.

A brain-computer interface (BCI) directly uses brain-activity signals to allow users to operate the environment without any muscular activation. Thanks to this feature, BCI systems can be employed not only as assistive devices, but also as neurorehabilitation tools in clinical settings. However, several critical issues need to be addressed before using BCI in neurorehabilitation, issues ranging from signal acquisition and selection of the proper BCI paradigm to the evaluation of the affective state, cognitive load and system acceptability of the users. Here we discuss these issues, illustrating how a rehabilitation program can benefit from BCI sessions, and summarize the results obtained so far in this field. Also provided are experimental data concerning two important topics related to BCI usability in rehabilitation: the possibility of using dry electrodes for EEG acquisition, and the monitoring of psychophysiological effects during BCI tasks.

In this chapter a conceptual foundation of employing music in rehabilitation is highlighted. The basic assumption is that, when a person is involved in performing or listening to music, she has a comprehensive experience in which several mental registers are activated simultaneously. The specific effect of music is to trigger a coordinated action of motor, visuospatial and verbal mechanisms. Thanks to the synergic activation of these mechanisms, music can stimulate, support and driven the mental functions to be rehabilitated.

Motor imagery is the mental simulation of a movement without motor output. In recent years, there has been growing interest towards the application of motor imagery-based training, or “mental practice”, in stroke rehabilitation. We have developed a virtual reality prototype (the VR Mirror) to support patients in performing mental practice. The VR Mirror displays a three-dimensional simulation of the movement to be imagined, using data acquired from the healthy arm. We tested the system with nine post-stroke patients with chronic motor impairment of the upper limb. After eight weeks of training with the VR Mirror, remarkable improvement was noted in three cases, slight improvement in two cases, and no improvement in four cases. All patients showed a good acceptance of the procedure, suggesting that virtual reality technology can be successfully integrated in mental practice interventions.

Orientation in space is a perceptual variable intimately related to postural orientation that relies on visual and vestibular signals to correctly identify our position relative to vertical. We have combined a virtual environment with motion of a posture platform to produce visual-vestibular conditions that allow us to explore how motion of the visual environment may affect perception of vertical and, consequently, affect postural stabilizing responses. In order to involve a higher level perceptual process, we needed to create a visual environment that was immersive. We did this by developing visual scenes that possess contextual information using color, texture, and 3-dimensional structures. Update latency of the visual scene was close to physiological latencies of the vestibulo-ocular reflex. Using this system we found that even when healthy young adults stand and walk on a stable support surface, they are unable to ignore wide field of view visual motion and they adapt their postural orientation to the parameters of the visual motion. Balance training within our environment elicited measurable rehabilitation outcomes. Thus we believe that virtual environments can serve as a clinical tool for evaluation and training of movement in situations that closely reflect conditions found in the physical world.

Telerehabilitation refers to the use of Information and Communication Technologies (ICT) to provide rehabilitation services to people remotely in their homes or other environments. By using ICT, client access to care can be improved and the reach of clinicians can extend beyond the physical walls of a traditional healthcare facility, thus expanding continuity of care to persons with disabling conditions. The concept of telecare, when telerehabilitation is used to deliver services to clients in their homes or other living environments, empowers and enables individuals to take control of the management of their medical needs and interventions by enabling personalized care, choice and personal control. A wide variety of assessment and treatment interventions can be delivered to clients using remote monitoring systems, robotic and virtual reality technologies, and synchronized collaboration with online material. This chapter will present a brief history of telerehabilitation and telecare and offer an overview of the technology used to provide remote rehabilitation services. Emphasis will be given to the importance of human factors and user-centered design in the planning, development, and implementation of telerehabilitation systems and programs. The issue of self-care in rehabilitation and self-management will be discussed along with the rationale for how telerehabilitation can be used to promote client self-care and self-management. Two case studies of real-world telerehabilitation systems will be given, with a focus on how they were planned and implemented so as to maximize their potential benefits. The chapter will close with a discussion of obstacles and challenges facing telerehabilitation and suggestions for ways to promote its growth in use and acceptance.

This paper describes an interdisciplinary research project aimed at developing and evaluating effective and user-friendly non-contact robot-assisted therapy, aimed at in-home use. The approach stems from the emerging field of social cognitive neuroscience that seeks to understand phenomena in terms of interactions between the social, cognitive, and neural levels of analysis. This technology-assisted therapy is designed to be safe and affordable, and relies on novel human-robot interaction methods for accelerated recovery of upper-extremity function after lesion-induced hemiparesis. The work is based on the combined expertise in the science and technology of non-contact socially assistive robotics and the clinical science of neurorehabilitation and motor learning, brought together to study how to best enhance recovery after stroke and mild traumatic brain injury. Our approach is original and promising in that it combines several ingredients that individually have been shown to be important for learning and long-term efficacy in motor neurorehabilitation: (1) intensity of task specific training and (2) engagement and self-management of goal-directed actions. These principles motivate and guide the strategies used to develop novel user activity sensing and provide the rationale for development of socially assistive robotics therapy for monitoring and coaching users toward personalized and optimal rehabilitation programs.

The rapid development of Virtual Reality-based technologies over the past decade is both an asset and a challenge for neuro-rehabilitation. The availability of novel technologies that provide interactive, functional simulations with multimodal feedback enable clinicians to achieve traditional therapeutic goals that would be difficult, if not impossible, to attain via conventional therapy. They also lead to the creation of completely new clinical paradigms which would have been hard to achieve in the past. In applications of rehabilitation for both motor and cognitive deficits the main focus of much of the early exploratory research has been to investigate the use of virtual reality as an assessment tool. To date such environments are primarily: (a) single user (i.e., designed for and used by one clinical client at a time) and (b) used locally within a clinical or educational setting. More recently, researchers have begun the development of new and more complex VR-based approaches according to two dimensions: the number of users and the distance between the users. Driven by a push-pull phenomenon, the original approach has now expanded to three additional avenues: multiple users in co-located settings; single users in remote locations; and multiple users in remote locations. After a presentation of examples that illustrate theses various approaches, we will conclude in addressing questions and ethical considerations raised by this evolution in the use of virtual environments in rehabilitation.