Neurocognitive Robot-Assisted Rehabilitation of Hand Function
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1 DISS. ETH NO Neurocognitive Robot-Assisted Rehabilitation of Hand Function A thesis submitted to attain the degree of DOCTOR OF SCIENCES of ETH ZURICH (Dr. sc. ETH Zurich) presented by JEAN-CLAUDE MARTIN METZGER MSc ETH in Mechanical Engineering, ETH Zurich born on citizen of Uitikon Waldegg (ZH) accepted on the recommendation of Prof. Dr. Roger Gassert, examiner Dr. med. Fabio M. Conti, co-examiner Prof. Dr. Derek Kamper, co-examiner 2014
2 Abstract Robot-assisted rehabilitation aims to complement conventional therapy after neurologic injury. Over the past two decades robotic devices have been developed and tested for their beneficial effect on the recovery process in stroke survivors. Results from meta-analyses suggest that robot-assisted rehabilitation might be at least as good as dose-matched conventional treatments. However, not all patients respond equally well to this type of therapy. The goal of this thesis was to investigate unexploited potential in robot-assisted rehabilitation, such as the more distally oriented training of hand function, incorporating the training of haptic perception and the use of robotic measures to assess sensorimotor impairments in order to adapt the therapy difficulty level to the abilities/impairments of the individual patient. Neurocognitive therapy a conventional therapy concept requiring patients to solve cognitive problems based on expected and perceived somatic afferent inputs was developed in the 1970s. It was utilized in this study on a new end-effector based, two degrees-of-freedom hand rehabilitation robot, the ReHapticKnob, to train grasping (hand opening/closing) and forearm rotation in stroke survivors. The large renderable impedance range (Z-width) and high-fidelity haptic rendering capabilities of the ReHapticKnob allow a variety of interactions, ranging from passively guided movements, which are essential for completely plegic patients, to the training of fine motor skills in mildly impaired stroke victims. Novel neurocognitive exercises were implemented on the ReHapticKnob customized to the patient s impairment level using robotic assessments conducted at baseline. During therapy progression, an automatic routine adapted exercise difficulty levels in order to track and maintain a challenging and motivating performance level. The novel neurocognitive robotassisted therapy concept was successfully tested through a four-week randomized controlled trial on 15 sub-acute stroke patients. The intervention group received robotic therapy during four 45-minute sessions per week. A dose-matched neurocognitive therapy control group performed exercises without the robot. Both groups additionally participated in the clinic s intensive rehabilitation program. Over the course of the study, average increases of 7.9% (robot group) and 10.5% (control group) could be observed on the Fugl-Meyer Assessment score for the upper extremity. Sensorimotor impairment, which was assessed by the robot, vii
3 Abstract revealed large inter-subject variability. The robot could be effectively used to customize therapy exercises to the individual patient. Subsequently, the desired exercise performance could be tracked throughout the progression of the therapy. Results from stratified patient subgroups reveal that, within the sub-acute recovery phase, a conventional therapy session can be replaced by a robotic one while achieving an equivalent reduction of motor impairment. Furthermore, results from all the patients enrolled in the study suggest that training at the level of the hand assists reducing impairment in both distal and proximal joints of the upper limb. It could be concluded that neurocognitive therapy is a suitable approach for robot-assisted rehabilitation, which integrates not only motor, but also sensory and cognitive modalities while preventing visually guided compensatory strategies as enhanced by a majority of state-of-the-art robot-assisted therapy concepts. viii
4 Zusammenfassung Robotergestützte Rehabilitation beabsichtigt konventionelle Therapie nach einem neurologischen Insult, wie einem Schlaganfall, zu ergänzen. Über die letzten zwei Jahrzehnte wurden neue Rehabilitationsroboter entwickelt und bezüglich ihrem Nutzen zur funktionellen Verbesserung nach einem Schlaganfall getestet. Resultate von Metaanalysen suggerieren, dass robotergestützte Rehabilitation mindestens die gleichen Erholungsresultate wie mit konventioneller Therapie in vergleichbarer Intensität ermöglicht. Diese Studien zeigen jedoch auch auf, dass nicht alle Patienten gleich von dieser Therapieart profitieren. Das Ziel dieser Arbeit war es, bisher nicht ausgenutztes Potential in der roboter-gestützten Rehabilitation zu erforschen. Hierbei sollten neue Methoden für das distale und haptische Trainieren der Handfunktion untersucht werden, und neue Roboter-Assessments zur Bestimmung von sensomotorischen Defiziten genutzt werden, um die robotergestützte Therapie adaptiv auf die Fähigkeiten des einzelnen Patienten anzupassen. Neurokognitive Therapie ein in den siebziger Jahren entwickeltes Therapiekonzept welches den Patienten dazu auffordert, ein kognitives Problem mittels erwarteten und wahrgenommenen somatosensorischen Inputs zu lösen wurde auf einem neuen Endeffektor basierten Handrehabilitationsroboter, namens ReHapticKnob, implementiert. Dieser ermöglicht das Trainieren von zwei Freiheitsgraden: das Greifen (Öffnen und Schliessen der Hand) und die Vorderarmrotation. Der grosse mit dem ReHapticKnob regelbare Impedanzbereich (Z-width) und seine hohe am Endeffektor realisierbare haptische Auflösung ermöglichen das Trainieren diverser Interaktionen, von passiven Bewegungen, welche unabdingbar für vollständig gelähmte Patienten sind, bis hin zur Feinmotorik im Falle von weniger stark betroffenen Schlaganfallpatienten. Neue neurokognitive Aufgaben wurden auf dem ReHapticKnob implementiert und an die Ausgangsfähigkeiten des Patienten angepasst, welche in robotergestützten Assessments vor der Therapie objektiv erfasst wurden. Ein Computeralgorithmus passt während dem Therapieverlauf die Schwierigkeitsstufe der Übungen fortwährend an, um die Leistung des Patienten immer auf einem fordernden und motivierenden Niveau zu halten. Das neue neurokognitive robotergestützte Therapiekonzept wurde in einer vierwöchigen randomisierten kontrollierten Studie mit 15 subakuten Schlaganfallpatienten in der Clinica Hildebrand cenix
5 Zusammenfassung tro di riabilitazione Brissago erfolgreich umgesetzt und evaluiert. Die Interventionsgruppe erhielt vier 45-minütige Roboter Therapiebehandlungen pro Woche und wurde mit einer Kontrollgruppe verglichen, welche gleich intensive neurokognitive Therapie ohne Roboter erhielt. Beide Gruppen nahmen zusätzlich am normalen Therapieprogramm der Klinik teil. Über den Verlauf der Studie wurden mittels Fugl-Meyer Assessment der oberen Extremität durchschnittliche Verbesserungen von 7.9% (Robotergruppe) und 10.5% (Kontrollgruppe) gemessen. Mittels robotergestützten Assessments konnten sensomotorische Defizite gemessen werden und effektiv zur Anpassung der Schwierigkeitsniveaus der Therapieübungen benutzt werden. Während des gesamten Therapieverlaufs konnte die anvisierte Patientenleistung in den Übungen aufrecht erhalten werden. Die Resultate von stratifizierten Patienten-Untergruppen suggerieren, dass in der sub-akuten Phase eine konventionelle Therapiebehandlung mit einer robotergestützten Therapie ersetzt werden kann, während die gleiche Minderung in motorischen Defiziten resultiert. Die Resultate von allen rekrutierten Patienten zeigen auf, dass das Trainieren der Handfunktion sowohl Defizite in distalen wie auch in proximalen Gelenken der ober Extremität verringert. Daraus kann die Schlussfolgerung gezogen werden, dass neurokognitive Therapie eine geeignete Therapieform für die robotergestützte Rehabilitation darstellt, welche sowohl motorische, sowie auch sensorische und kognitive Modalitäten integriert und visuell gesteuerten Kompensationsstrategien, welche durch die meisten anderen aktuell implementierten robotergestützten Therapieformen gefördert werden, entgegenwirkt. x
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