Facilitator of the month: Dr. Abhinav Mishra, India ( Neuro-Occupational Therapist)
The following article is an open access article published in the JIMR publications. The link to the article is provided at the end of the post.
Aims and Issues addressed by the article:
This article aims to identify the potential and latest trends in the area of exoskeleton- or robotic-aided therapy in combination with VR, AR, or gamification for the improvement of motor function for post-stroke patients.
The review specifically aims to determine -(1) If such a coupled approach i.e. VR, AR or gamification combined with exoskeleton is helpful in improving the outcomes for the patients. (2)trends and popular configurations across both types of exoskeletons and software mediums; and (3) future challenges in the field of exoskeleton-based human-computer interaction (HCI) therapy.
The article has been chosen for the Journal Club as it gives an overview of the best technologies available and its implication into practices of Occupational Therapy for a better client outcome.
What is the need of this type of intervention? How it affects the society?
Along with conventional treatment, Robotic Rehabilitation is trending in various parts of the world. There have been several studies to support the various forms of the robot aided therapy for both Upper Limb and Lower Limb in various conditions including Stroke. So this is increasingly being recognized as an effective intervention as a part in Occupational Therapist’s toolkit. But with this we as a therapist need to know various types of devices available and their differences to provide the best to our client.
Study design:
Review based study, combining both published and unpublished articles and summarizing the findings.
Methodology
A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct & The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients’ condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients. Studies which fulfilled the inclusion and exclusion were selected. So the process which was followed by the authors was
Identification ,Screening, Eligibility and Inclusion.
What where the results obtained?
There were 30 studies which the author identified based on the inclusion criteria. This included the Randomized control trials and exploratory research papers. The result based on analysis of these articles which included as many as 385 patients shows that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. Also this could fill the gap between hospital to home transition of the patient. The results also categories the various types of therapies devices that were used by various clinical settings, degree of freedom offered by the devices, number of participants included in the literature.
Conclusion and what does it mean for us?
Systematic Review showed that various technologies used in the field of rehabilitation helped the client in a better recovery. One of the study mentions that clients found multiplayer gaming to be appealing as it helped them in socializing and interacting with peers. This could in turn help in a better outcome. But most of the rehabilitation was carried out in a clinical setup and home-based rehabilitation is rarely attempted using the current technologies available. Also as an occupational therapist we should see to it that the technology and the therapy sessions are designed in a way such that patients feel motivated and confident during home-based rehabilitation sessions as well. The review also shows that these exoskeleton devices are rarely available for trials at home, thereby showing a gap in transition of the rehabilitation services from clinical to home based setup. This leaves an open door for future studies to be a successful application of these technologies in home based Rehabilitation.
What is my perspective of this Systematic Review:
The study has covered on multiple dimensions of treatments such as Robotic training, VR, AR and gamification for rehabilitation. The study has a focused research question specified with the aim to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in post-stroke survivors.
Authors of the study have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched for relevant studies: MEDLINE, EMBASE, Science Direct and The Cochrane Library. Although the study has been done taking into consideration the researches from the year 2010 to 2017, with a good reproducible literature search, but the included studies were not sufficient for the question asked as authors did not find any relevant study which combined Exoskeleton robotics and AR technology.
Authors have not clearly stated their basis for inclusion or exclusion of the primary RCTs. Also authors have not specified the type of VR been used by the primary RCTs i.e. immersive, non-immersive or totally immersive.
The SR has taken into account the methodological quality of few studies, though not all. The methodology of few studies has also been mentioned in the discussion section in brief. This helps in better understanding of the various studies included in the review.
The SR combine primary studies appropriately, taking into consideration the studies which had Exoskeleton robotics, VR gaming and AR gaming in the primary studies.
Also the SR clearly stated the number of Upper-limb and Lower-limb cases, type of devices used etc.Also SR has highlighted few studies summarizing their methodology and results.
SR states that there were different types of assessment scale and quality of collected data, which made it difficult to compare the outcomes and results accurately or quantitatively against each other. In addition, some articles could have been missed in the review due to very specific search criteria.
In the conclusion SR highlights that very little work is done to make use of these technologies for rehabilitation of lower limbs when compared to upper limbs, and that there are a wide variety of exoskeleton-based devices currently in use.
Authors have taken great efforts to identify the future implications of their study. There were researches that were done for Upper Extremities and did not have much evidence on lower limb comparatively, except the two studies. A study using the Rehabilitation robotics in home setup is needed, as almost all of the studies were carried out in clinical setup.
I would like to thank the authors of the study to give us the access to the review. The article is open for your views and discussions. Do let us know your views on it in the comment section.
The link for the full article can be found at:
https://rehab.jmir.org/2019/2/e12010/
Dr. Abhinav Mishra, MOTH (Neurosciences), is a Mumbai based Occupational therapist who is currently working with Adult clients with Neurological disorders in an advanced rehab setup, which includes Robotic devices, sensor based gaming devices as well as water based rehabilitation. He can be contacted on drmishra.abhinav@gmail.com
Thankyou for introducing this article. I suppose i've been guessing my way through trial and error with wii games and using the rehacom programmes with and without assitive technology-switches etc. for mainly cognitive retraining. Now i'm involved in a charitable organisation that have purchased an eksobionics suit and interested in exploring upper limb robotics so this journal couldn't have come at a better time. I'm very interested to hear how the home loan/trials work out and would love to know a bit more about the equipment you do loan. I found myself thinking alot about Functional electrical stimulation such as the bioness H200 and introducing a VR/AR component to this instead of practicing domestic tasks but note one of the research papers found improvements even in non-game learning-i suppose its the intention that really counts.
Amazing article and observation. Technology is building it’s relationship with the rehab world. With Covid 19, more and more practitioners are trying to brainstorm ways to make the rehab service available to their clients. The model is shifting from hospital based to community based on a rapid pace. As a OT practitioner, I have always tried to be as creative and as aware of the recent advances in the field. Fortunate enough to apply gaming, metronomes and now wearable technology in my practice. Based on the researches and application outcome, I can confidently say TechRehab is the future..!! All the best..
Nelofar
This is great initiative since conception of gamification into physical and cognitive rehabilitation is at infancy. I am fortunate to have exoskeleton robotic device for upper limb retraining combined with perceptual cognitive rehabilitation. Data gathered at early stages of rehabilitation is not true reflection of improvement in function at later stage as outside assistance from therapist whether it is physical or prompting weaned off as true recovery take hold. Certainly, technology has advantage over traditional paper or wood based activities as they seemed less childish for adult population in terms of mood and motivation. It is nice to have evidence for trending practice in the field.
very apt article for discussion...and well formed observations.
I wanted to ask..In your last point you have mentioned that a study using rehabilitation robotics in home setup is needed .. but how much practically possible is it? Coz almost all the high end robotics device that we use atleast currently in India, I don’t think it’s practically possible to do a whole study in home setup?
What are your views on this?