Facilitating active training after stroke
Workshop ICORR 2011 July 1st, 2011
Dr. GB (Gerdienke) Prange
[email protected] Roessingh Research & Development, Enschede
Stroke rehabilitation • Optimal recovery to achieve functional independence • Exercise therapy: – – – – –
Active movement Functional tasks Intensive training Motivation Feedback
• Similarities with motor skill acquisition • Motor learning theory input for rehab robotics
3
Robotics • Robotic modalities: – Passive – Active-assisted – Resistive
• Comply with key aspects?
Motor learning (healthy)
• Motor adaptation experiment – Distortion of environment – Learning new movement
Van Asseldonk et al. 2009
Visuomotor rotation Real and “projected” handmovement
• Instead of 1-to-1 projection of cursor above hand • Cursor rotated 30 deg. • Learn to correct for this rotation Van Asseldonk et al. 2009
Motor learning (healthy) - modalities
Van Asseldonk et al. 2009
Motor learning (healthy) – methods
Van Asseldonk et al. 2009
Motor learning (healthy) – results • Passive and Hard Guidance hardly any learning effect • Active and Error Enhanced pronounced learning effect
Van Asseldonk et al. 2009
Motor learning (healthy) - conclusion • Active participation crucial to learn • In line with key aspects for stroke rehab • Robotics should encourage active participation!
Active rehabilitation • Ability to learn retained after stroke [Winstein 1999, Scheidt 2007] – Although slower/to smaller extent
• Motor adaptation leads to motor skill acquisition? • Successful therapy: – CIMT – BWS-TT
11
Robotics • Robotic modalities: – Passive – Active-assisted – Resistive
• Comply with key aspects? • Active practice! • How complex?
• Arm support
Arm support • Involuntary coupling of shoulder and elbow (Beer et al. 2000) – Stronger shoulder abduction – Stronger involuntary elbow flexion
• Reduction in workspace (Beer et al. 2004) – Limited elbow extension
• Potential for arm support!
Sukal et al. 2007
Freebal Healthy person 0.30
WITHOUT and WITH arm support
Y-Axis [m]
0.15
0
-0.15
0 X-Axis [m]
Stroke patient
0.3
0.30
0.15
Y-Axis [m]
-0.3
0
-0.15
-0.3
0 X-Axis [m]
0.3
Stienen et al. 2007
Supported reach training • 7 chronic stroke patients – severe, moderate, mild
• Reach training • Arm support + game • Pre- and post-test of unsupported reaching
Furball Hunt (video)
Unsupported reach • Increased reach distance
• Increased E-extension
• Increased muscle activity Prange et al. 2009
Abnormal coupling Change after training
+
0
-
BIC/AD co-contraction
N=2
N=2
N=3
Prange et al. 2009
• Change in abnormal coupling varying between patients • More selective control of muscles in some patients Mostly in more severely affected patients
Fugl-Meyer assessment • Increase in FM score varying between pts • Mean +3.3 points
Prange et al. 2009
Remarkably… Sanchez 2006 Amirabdollahian 2007 Housman 2009 Prange 2009
Prange et al. 2006
• Similar effect of robotics and arm support
In summary • Active initiation and execution crucial in rehab • Arm support training – facilitates activation of agonists – possibly reduces abnormal coupling
• Supported arm training enables active training – relatively cheap & simple device – applicable in rehabilitation setting
Developments Camera
Arm support
Rehab games
• Commercialisation to ArmeoBoom (by Hocoma, Zürich CH) • Implementation study in 7 Dutch rehabilitation centres (ROBAR) (funded by Revalidatie Nederland) Roessingh, Enschede
Beatrixoord, Groningen
Groot Klimmendaal, Arnhem
Rijndam, Rotterdam
St Maartenskliniek, Nijmegen
Reade, Amsterdam
De Hoogstraat, Utrecht
Challenges Development: • Robotics that allow and encourage active practice • Suitable for clinical practice (simple & cheap) Research: • Optimization of robotic guidance paradigms – Minimizing assistance – Maximizing active involvement
All in ways that allow quick and easy use in practice
Thank you for your attention! Bedankt voor jullie aandacht!
