OVERVIEW AND DESCRIPTION
Robotics and virtual reality are technologies utilized in the field of rehabilitation medicine to facilitate and complement conventional rehabilitation strategies.
A robot can be defined as “a machine that performs various complex acts of a human being” and “automatically performs complicated, often repetitive, tasks.”1 Current robotic systems include therapeutic robots, such as large stationary exercise robots or wearable exoskeletal robots (powered braces). There are also functional robots such as assistant robots for activities of daily living (ADL), and companion robots.2
Virtual reality (VR) is defined as a human-computer interface that allows a user to interact with a computer-generated environment, using multiple sensory channels.3,4 The virtual environment (VE) can provide users with visual, auditory, or tactile feedback. Current systems vary in size, scope and level of immersion, from cave automatic virtual environments , which are room-sized installations containing three-dimensional visual and auditory systems, to head-mounted visual displays (HMD)33, as well as commercially available interactive gaming consoles (e.g., Nintendo’s Wii, or Microsoft’s Xbox Kinect).
Augmented reality (AR) adds digital elements to a live view through a device usually a cell phone, tablet or wearable lenses. Examples include projector-based representation of limbs for amputees and multidimensional maps with superimposed labels and information. Unlike VR which creates a separate environment, AR adds a digital layer to reality. Different types of AR exist on a continuum from unaltered reality to a fully virtual environment. A variety of motion tracking sensors or cameras have been developed in order to incorporate user movement and position. New virtual reality applications now use smartphones as both an interactive visual environment and also a data recording device, allowing measurements of movement and function to be collected in the virtual environment, making the technology more versatile and accessible .30
Types of Augmented Reality
|Marker-based||Device scans for a pattern in the environment. When found content is superimposed over that marker||QR codes as markers|
|Markerless||Uses a separate overlying grid or system to target as a key to superimpose content||GPS as a way to show a user where a restaurant is|
|Projection-based||Physical model or object has additional content projected onto it||Projection of realistic features onto a neutrally colored prosthesis for amputees|
|Superimposition-based||Adds content to the environment based on recognition of space dimensions or adjacent objects||Home design software to model an empty room with potential furniture options|
In the field of rehabilitation medicine, robotics and VR systems have the potential to measure abilities, as well as to serve as therapeutic tools. These systems can be used to assess and measure motor abilities, posture and limb position, strength, gait, and balance. Real-time feedback regarding performance can be provided to patients and clinicians. Reports can also be generated to provide objective data regarding patient progress in comparison to themselves or other users. Therapeutically, they provide users with repetitive, contextualized, task-specific training in a stimulating and entertaining manner. These types of exercises are fundamental in neurorehabilitation as they aid in promoting neuroplasticity and recovery.5Additionally, the engaging presentation of the otherwise repetitive or mundane task with game-like interfaces can assist with compliance with therapy programs over time.
Furthermore, robotic systems can facilitate or assist movement of paretic limbs in performing functional movements and actions, enabling patients to increase social engagement and increase autonomy and independence. VR systems can provide cognitive exercises and measures as well as simulation of real-world activities in a safe context (e.g., driving simulation or street crossing).6 By combining robotics and VR systems, the benefits of both technologies can be achieved to provide precise, repetitive training in engaging and safe virtual environments.
Robotic and VR systems have primarily been studied for use in patients with motor and sensory disorders of the central nervous system (CNS), including stroke, traumatic brain injury (TBI), multiple sclerosis (MS), spinal cord injury (SCI), and cerebral palsy (CP).
Robotic systems are uniquely suited to provide functional assistance with mobility and activities of daily living. For example, robotic exoskeletons can allow paraplegic individuals with SCI to walk independently. Brain-computer interfaces, where computers analyze brain signals and use them to control robotic devices are being studied for patients with neuromuscular disorders such as amyotrophic lateral sclerosis.7 Robotic systems can also serve as companions with social, psychological and physiological benefits.8
VR systems are also being used in the field of orthopedics and sports medicine in order to provide an engaging, structured environment for performing strengthening, stretching, cardiovascular exercise, and for prosthetic training. Additionally, VR systems have been used to treat cognitive disorders resulting from CNS disorders.
An emerging area of literature and research is the use of VR for acute and chronic pain both in adults and children. VR can provide distraction while a patient experiences a painful stimulus, decreasing the patient’s perception of the pain and hopefully reducing the need for medication. VR is also being used in conjunction with desensitization therapy in patients with fibromyalgia with the goal of altering the pain processing system and central sensitization. VR is also being used for psychiatric disorders, such as post-traumatic stress disorder, that may affect patients needing rehabilitation. In terms of AR, some surgeons are using superimposed AR to demonstrate surgical procedures as an educational tool prior to surgery. Robots assist and increase precision in surgery in a variety of applications in recent years (DaVinci® robot in general and gynecologic surgery, Mako robot for orthopedics). AR may be implemented as an educational and simulation tool for patients in therapy both in inpatient, outpatient and home settings.
RELEVANCE TO CLINICAL PRACTICE
Clinical Justification for Use
Repetitive, high intensity task-specific training has been shown to spur neuroplasticity and functional recovery after stroke. Typically this type of therapy is achieved by team of physicians and therapists. This approach is both time intensive and expensive in terms of resources and skilled clinicians. Theoretically VR and robotics can automate portions of this process, making it more reproducible, data-driven and cost effective.
Robotics and VR can be utilized at any point in the process of rehabilitation, from the acute to chronic stages. These technologies may be used to supplement conventional therapy to achieve the relevant goals at each stage of recovery and rehabilitation. Evidence regarding robotics and VR is still too limited to provide definitive clinical practice recommendations, and it remains unclear whether incorporation is more beneficial at one stage of rehabilitation than others.
Robotic and VR modalities offer options for both the inpatient and outpatient settings, or portable devices that patients may use in the community. Workstation robotics/gait trainers are stationary robots (due to their large bulky nature) that are used to provide therapeutic exercise, generally in a clinical setting, such as a physical therapy gym. One study for upper extremity robotic systems for shoulder and elbow rehabilitation in stroke patients in acute rehabilitation facilities showed benefits lasting three years.9 Another study showed improvements in both subacute and chronic population.10 For the lower extremities, robot-delivered body weight-supported treadmill training has been used for gait training. There is some evidence for use of robot-assisted gait training in patients with stroke, Parkinson’s disease (PD), CP, and possibly SCI.11
Wearable powered orthoses can serve both functional and therapeutic goals by compensating for a patient’s neurological deficits while training muscles and coordination. Stroke patients using an electromyogram (EMG)-controlled exoskeletal upper limb-powered orthosis showed improvement in function and spasticity.12 A randomized controlled multisite trial of post-stroke patients with a chronic paretic arm examined task oriented training with the use of an exoskeleton robot and showed improvement in upper extremity function that was superior to conventional treatment28. In a study of powered exoskeletal robots for the lower extremities in patients with motor complete SCI, exoskeletal robots were shown to be safe and well tolerated, and participants were able to walk independently for periods of five to ten minutes with reported physical and psychological benefits.13 Exoskeletons can also be used for individuals with movement disorders such as tremors, to help monitor, diagnose and dampen tremors. A study of five subjects showed statistically significant decreases in all subjects with the use of an exoskeleton.14
Functional, independent robots can perform activities of daily living, supervisory tasks, or function as a companion. These robots are still in development and limited in function. Other robots that help primarily with function include single point-of-contact, end effectors that aid with ADL performance. These can be difficult to master in terms of proprioceptive feedback, especially given that the weight of the device can affect positioning and control of actions.15
In VR systems, the largest amount of research has investigated its use for patients with motor impairments due to stroke.16,17,18 A 2011 Cochrane review found that VR was more effective than conventional therapy in retraining upper limb function and with improving ADL function; however, no statistically significant increase in grip strength or gait speed was found.18 A 2018 Cochrane review of electromechanical and robotic arm training following stroke showed improved arm function and ADL scores compared to usual care, though the clinical impact of these differences is unclear. Though meta-analyses can be helpful in collating the available data on a topic they suffer from heterogeneity among studies and small sample sizes that can obscure statistical and clinical significance. In an effort to address these drawbacks, a multi-site randomized controlled clinical trial (RATULS) was performed in the UK to compare robotic therapy, enhanced upper extremity limb therapy and usual care. Despite rigorous design and large sample size, this study did not find improvement in upper extremity motor impairments nor improved ability to perform ADLs with the use of robotics. Limitations of this study include a relatively chronic population (mean duration > 6 months), and relatively severe motor impairments. Also, the use of a particular robotic system, the MIT-MANUS system, may not reflect the potential for benefit from other robotic devices.
Recently additional randomized controlled trials have examined the benefit of VR following a stroke. The efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST) trial in 2016 failed to show improvement of upper extremity motor abilities or functional/ADL differences when VR was used as an add-on therapy to standard task-oriented recreational activities.31
Virtual reality training for upper extremity in subacute stroke (VIRTUES) trial, a multicenter RCT, showed improvement in upper extremity motor function in both the VR and standard therapy groups but no differences between the groups.32 The two groups were in subacute phase of stroke approximately a month after their stroke and received equivalent total treatment time of therapy.
In addition to the motor and sensory training, VR can also be used to assess and perform cognitive exercises to work on executive function, memory, attention, planning, and visuospatial processing.19 The technology also has been studied in multiple simulation settings with virtual offices, kitchens and driving environments.19 Within the pediatric population, VR has been used among children with CP, and was found to be effective in improving engagement and motor function, proximal stability, postural tone and range of motion.20,21
Factors that Influence Clinical Application
Historically, robotics and VR systems have often been relatively inaccessible for routine clinical use because of the high cost of these technologies. However, with advances in technology, prices continue to steadily decline. In VR, commercial gaming consoles provide a cost-effective means of accessing many of the advantages of this technology conveniently from home. Additional advances in technology include decreasing bulk, weight, ease of donning and doffing, improvement of aesthetics, and portability and reliability of power sources. While robotic therapy and VR have been shown to be superior to “usual care” in a number of studies, there is little convincing evidence that they are superior to dose-matched conventional rehabilitation therapy.22,15 While this technology has the potential to provide labor savings and potentially financial savings, these benefits remain difficult to achieve with existing technologies.
Potential Disadvantages and Adverse Effects
A general limitation to some technological systems is that a population with cognitive, visual, perceptual impairments may find them difficult to use.11Safety issues are also critical to consider, especially given that primary user groups have functional deficits that may make them vulnerable to technological malfunctioning, especially if unsupervised. Several safety mechanisms have been employed in robotics in order to prevent injury. For instance, some systems allow for deviation of force or movement by the user, preventing the patient from being forced into dangerous positions by the machine. Padding is also utilized to decrease pressure and potential for skin injury. There have also been concerns for increased risk of fracture while using adjustable exoskeletons and gait training apparatus such as the Lokomat® in patients with impaired bone quality. While there are case reports of fractures due to weight bearing in this context, insufficient data exist to confidently predict the risk to individual patients.34 Overall, rehabilitation robots have had a very impressive safety record, and no serious injuries have been reported from their use.
With regard to VR, few adverse events are reported in literature and VR appears to be an inherently safe therapeutic modality. The most common adverse effect is transient visually-induced motion sickness, known as cyber sickness or simulation sickness. Symptoms are similar to motion sickness, but generally less severe, and include dizziness, headache, sweating and nausea.18,19 Cyber sickness occurs more frequently with immersive VR systems, such as HMD, compared with less immersive systems, such as projected VE. Occasionally, patient may also complain of transient eye strain.16 There are no explicit contraindications for VR identified in the literature. However, caution is warranted with patients who have communication disorders, such as aphasia, which may prevent one from identifying discomfort during the intervention; or with patients who have certain psychiatric disorders, for instance delusional conditions with symptoms that could be potentiated by the VR experience.
CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
Both robotics and virtual reality, individually or in combination, can potentially provide a wide range of therapies in an engaging and cost-effective manner. In countries with an aging population, such as Japan, emphasis is being placed on robot technology to fill the gap created by an insufficient number of caregivers.23 Additionally there are an expanding number of virtual rehabilitation programs that are delivered to patients at home in a telehealth model. At this point these programs are primarily targeted towards patients with orthopedic diagnoses, such as after joint arthroplasty surgery. The VERITAS (Virtual Exercise Rehabilitation In-home Therapy: A Research Study) showed similar clinical outcomes in patients after total knee replacement who received virtual therapy, with a cost savings of nearly $3,000 per patient compared with traditional clinic physical therapy. As more evidence suggests cost-savings with similar clinical outcomes and patient satisfaction in specific populations, this model is likely to expand to other areas of rehabilitation. Emerging issues involve concerns for accessibility, cost, patient autonomy, and privacy, as well as the potential use/misuse of these technologies to replace rather than supplement the skilled practitioner. Compassionate care is an invaluable component of the rehabilitation process, and one that is unlikely to be automated in the near future.
GAPS IN KNOWLEDGE/EVIDENCE BASE
Additional research is required to further investigate robotic and VR systems in order to determine which designs are most efficacious, the appropriate dosing and timing of intervention, as well as motivation and adherence to therapeutic programs. Methodologically, current research efforts in the field of robotics and VR are limited by heterogeneity among interventional approaches, outcome measures, and control groups, limiting the ability to pool and compare studies.24 Additionally, these studies generally utilize small sample sizes, and few studies have examined whether effects are sustained. One review of clinical trials of robot rehabilitation showed that most studies were suboptimally designed, contributing to the dearth of phase II and III clinical trials.25 Also, there is often limited funding in the area of rehabilitation research, and treatment using robotics is currently not well reimbursed.26 Compounding the challenges of clinical research in robotic rehabilitation is the constant and rapid advancement of technology. Alternative pathways for evaluation of novel robotic systems may need to be considered so that patients can benefit from up-to-date technological advances while ensuring patient safety.
- Dautenhahn K. Socially intelligent robots: dimensions of human-robot interaction.Philos Trans R Soc.2007;362(1480):679-704.
- Schultheis MT, Himelstein J, Rizzo AA. Virtual reality and neuropsychology: upgrading the current tools.J. Head Trauma Rehabil.2002;17(5):378-394.
- Burdea GC. Virtual rehabilitation–benefits and challenges.Methods Inf. Med. 2003;42(5):519-523.
- Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review.Lancet Neurol. 2009;8(8):741-754.
- Katz N, Ring H, Naveh Y, Kizony R, Feintuch U, Weiss PL. Interactive virtual environment training for safe street crossing of right hemisphere stroke patients with unilateral spatial neglect.Disabil. Rehabil. 2005;27(20):1235-1243.
- Shih JJ, Krusienski DJ, Wolpaw JR. Brain-computer interfaces in medicine.Mayo Clin Proc. 2012;87(3):268-279.
- Bemelmans R, Gelderblom GJ, Jonker P, de Witte L. Socially assistive robots in elderly care: a systematic review into effects and effectiveness. [Review].J Am Med Dir Assoc.2012;13(2):114-120.
- Volpe BT, Krebs HI, Hogan N, Edelsteinn L, Diels CM, Aisen ML. Robot training enhanced motor outcome in patients with stroke maintained over 3 years.Neurology. 1999;53(8):1874-1874.
- Mazzoleni S, Sale P, Tiboni M, Franceschini M, Carrozza MC, Posteraro F. Upper limb robot-assisted therapy in chronic and subacute stroke patients: a kinematic analysis.Am J Phys Med Rehabil.2013;92:e26-37.
- Stein J, Harvey RL, Macko R, Winstein C, Zorowitz R, eds.Stroke Recovery and Rehabilitation. New York, NY: Demos Medical Publishing; 2009.
- Stein J, Narendran K, McBean J, Krebs K, Hughes R. Electromyography-controlled exoskeletal upper-limb-powered orthosis for exercise training after stroke.Am J Phys Med Rehabil. 2007:255-261.
- Esquenazi A, Talaty M, Packel A, Saulino M. The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury.Am J Phys Med Rehabil. 2012;91:911-921.
- Rocon E, Belda-Lois JM, Ruiz a F, Manto M, Moreno JC, Pons JL. Design and validation of a rehabilitation robotic exoskeleton for tremor assessment and suppression.IEEE Trans Neural Syst Rehabil Eng. 2007;15(3):367-378.
- Lo HS, Xie SQ. Exoskeleton robots for upper-limb rehabilitation: State of the art and future prospects.Med Eng Phys. 2012;34:261-268.
- Crosbie JH, Lennon S, Basford JR, McDonough SM. Virtual reality in stroke rehabilitation: still more virtual than real.Disabil. Rehabil. 2007;29(14):1139-1146.
- Saposnik G, Levin M. Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians.Stroke. 2011;42(5):1380-1386.
- Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation.Cochrane Database Syst. Rev. 2011;(9):CD008349.
- Schultheis MT, Himelstein J, Rizzo AA. Virtual reality and neuropsychology: upgrading the current tools.J. Head Trauma Rehabil. 2002;17(5):378-394.
- Chen Y, Fanchiang HD, Howard A. Effectiveness of virtual reality in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials. Physical therapy. 2018 Jan 1;98(1):63-77.
- Parsons TD, Rizzo AA, Rogers S, York P. Virtual reality in paediatric rehabilitation: a review.Dev. Neurorehabil. 2009;12(4):224-238.
- Bryanton C, Bossé J, Brien M, McLean J, McCormick A, Sveistrup H. Feasibility, motivation, and selective motor control: virtual reality compared to conventional home exercise in children with cerebral palsy.Cyberpsychol. Behav. 2006;9(2):123-128.
- Fujie M. Application of advanced engineering technologies to medical and rehabilitation fields.Japanese J Cancer Chemother. 2012;39(7):1044-1048.
- Kluding PM, Dunning K, O’Dell MW, et al. Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes.Stroke. 2013;44(6):1660-1669.
- Lo AC. Clinical designs of recent robot rehabilitation trials.Am J Phys Med Rehabil. 2012;91(11 Suppl 3):S204-216.
- Stein J. Robotics in rehabilitation: technology as destiny.Am J Phys Med Rehabil. 2012;91(11 Suppl 3):S199-203.
- Rodgers H, Bosomworth H, Krebs H et al. Robot assisted training for the upper limb after stroke (RATULS): a multicenter randomized controlled trial. The Lancet. 2019; 394(10192):51-62.
- Klammoth-Marganska V, Blanco J, Campen K, et al. Three-dimensional, task-specific robot therapy of the arm after stroke: a multicenter, parallel-group randomised trial. Lancet Neurology 2014; 13:159-66.
- Bettger, Janet Prvu Chokshi, Anang et al. Virtual Exercise Rehabilitation In-Home Therapy: A Randomized Study (VERITAS). Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 12, e217 – e218
- Chang KV, Wu WT, Chen MC et al. Smartphone Application with Virtual Reality Goggles for the Reliable and Valid Measurement of Active Craniocervical Range of Motion. Diagnostics (Basel). 2019 Jul 10;9(3). pii: E71. doi: 10.3390/diagnostics9030071.
- Saposnik G, Cohen LG, Mamdani M et al. Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial. NEJM JW Neurol Sep 2016 and Lancet Neurol 2016; 15:1019
- Brunner I et al. Virtual reality training for upper extremity in subacute stroke (VIRTUES): A multicenter RCT. Neurology 2017 Dec 12; 89:2413. (https://doi.org/10.1212/WNL.0000000000004744)
- Weber LM, Nilsen DM, Gillen G, Yoon J, Stein J. Immersive virtual reality mirror therapy for upper limb recovery following stroke: A pilot study. 2019. Am J PM&R (publish ahead of print), doi: 10.1097/PHM.0000000000001190
- Filippo TR, De Carvalho LB, de Souza DR. Proximal tibia fracture in a patient with incomplete spinal cord injury associated with robotic treadmill training. 2015. Spinal Cord. 53(12):875-6. doi: 10.1038/sc.2015.27
Original Version of the Topic
Joel Stein, MD, Hannah Aura Shoval, MD, Ethan Rand, MD. Virtual reality-robotic applications in rehabilitation. 9/20/2014
Joel Stein, MD
Research grant from Neurolutions, Inc., Principal investigator
Katherine Rief, MD
Nothing to Disclose