LETTER TO THE EDITOR
ROBOTICS IN NEUROREHABILITATION AND THE INHERITED BORIGINAL SIN[ To the Editor: The attempt to integrate robotics in neurorehabilitation invests for the future. Robotic devices are expected to guarantee high compliance, repeatability, and flexibility unachievable by humans. They should provide support to the residual strength consistent with the motor learning theory and adapt to progress during the treatment.1 The evidence for the superiority of robot-assisted therapy over traditional rehabilitation after stroke is still lacking. The motor function of 127 hemiplegic patients did not improve after 12 wks of robot-assisted rehabilitation, whereas outcomes at 36 wks were comparable with traditional but inferior to intensive treatment in a multicenter randomized controlled trial.2 The 2008 Cochrane database (328 patients; 11 trials) reports improved motor function and increased strength of the paretic arm.3 Both studies2,3 report no significant improvement in the patients’ generic activities of day living. The 2012 Cochrane database on 666 patients (19 trials, including 10 trials of the 2008 overview) reports better outcomes in the patients’ Activities Day Living as well as improved motor function of the impaired upper limb, but no increase in strength.4 The absence of systematic effects is only partly explained by the heterogeneities among studies (eg, duration, intensity, and type of training; patients’ characteristics; and use of scales assessing either motor recovery or the individual strategies of functional adaptation to the disability).5 Contrary to expectation, the costs in time and labor of robot-assisted rehabilitation are estimated to remain higher than in traditional therapy.2,6 Disseminated application of advanced technology has crucial implications (eg, organization of personnel, privacy concerns, or financial issues) that would be decisive in transferring promising systems to a stage of regular operation but today remain largely unresolved.6 Most important, robots have been conceived as technological substitutes for traditional rehabilitation paradigms.7 Detailed knowledge unavailable in the past on the pathophysiological processes involved in spontaneous recovery and rehabilitation remains incomplete today. Residual motor function, improvement during treatment, and outcomes are still estimated by criteria that are based largely on experience rather than on objective measures. In this respect, robotics shares the Boriginal sin[ of traditional rehabilitationVof having developed empirically in the urge to help improve, or compensate for, major motor disabilities. Independent robot-assisted rehabilitation procedures need to be identified and developed within the mainstream of modern medicine. Research in this regard would be seminal and innovative. New robots should be contrived to overcome the patient-robot dichotomy (a replica of traditional patienttherapist dichotomy) by turning neurorehabilitation into a www.ajpmr.com
self-training experience in which patients play an active role under proper guidance. Flexible, highly specialized options to enrich the recovering of motor function (including sensory/ cognitive/emotional interaction with the environment) and adjust to individual changes during treatment should be available to meet the patient_s (real and perceived) individual needs. Not simply advancement in engineering, robotics needs to evolve into a laboratory to devise innovative training procedures based on, and monitored by, objective measures of motor impairment and recovery provided by the robots themselves. The original sin would otherwise limit the development of robotics in neurorehabiliation to its full potential. REFERENCES 1. Crespo LM, Reinkensmeyer DJ: Review of control strategies for robotic movement training after neurologic injury. J Neuroeng Rehabil 2009;6:20 2. Lo AC, Guarino PD, Richards LG, et al: Robot-assisted therapy for long-term upper-limb impairment after stroke. N Engl J Med 2010;362:1772Y83 3. Mehrholz J, Platz T, Kugler J, et al: Electromechanical and robot-assisted arm training for improving arm function and activities of daily living after stroke (Review). Cochrane Database Syst Rev 2008; Issue 4. Art. No.: CD006876. doi:10.1002/ 14651858.CD006876.pub2 4. Mehrholz J, Ha¨drich A, Platz T, et al: Electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev 2012;6:1Y65 5. Kwakkel G, Kollen BJ, Krebs HI: Effects of Robot-assisted therapy on upper limb recovery after stroke: A systematic review. Neurorehabil Neural Repair 2008;22:111Y21 6. Orwat C, Graefe A, Faulwasser T: Towards pervasive computing in health careVA literature review [Review]. BMC Med Inform Decis Mak 2008;8:26 7. Kwakkel G, Kollen B, Lindeman E: Understanding the pattern of functional recovery after stroke: facts and theories. Restor Neurol Neurosci 2004;22:281Y99
Giuliano Dolce, MD Lucia F. Lucca, MD Loris Pignolo, ENG S. Anna Institute and Research in Advanced Neurorehabilitation (RAN) Crotone, Italy
Walter G. Sannita, MD Department of Neuroscience, Ophthalmology and Genetics University of Genova Genova, Italy Department of Psychiatry, State University of New York Stony Brook
DOI: 10.1097/PHM.0000000000000187
Letter to the Editor Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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ROBOTICS IN NEUROREHABILITATION AND THE INHERITED BORIGINAL SIN[ To the Editor: The attempt to integrate robotics in neurorehabilitation invests for the future. Robotic devices are expected to guarantee high compliance, repeatability, and flexibility unachievable by humans. They should provide support to the residual strength consistent with the motor learning theory and adapt to progress during the treatment.1 The evidence for the superiority of robot-assisted therapy over traditional rehabilitation after stroke is still lacking. The motor function of 127 hemiplegic patients did not improve after 12 wks of robot-assisted rehabilitation, whereas outcomes at 36 wks were comparable with traditional but inferior to intensive treatment in a multicenter randomized controlled trial.2 The 2008 Cochrane database (328 patients; 11 trials) reports improved motor function and increased strength of the paretic arm.3 Both studies2,3 report no significant improvement in the patients’ generic activities of day living. The 2012 Cochrane database on 666 patients (19 trials, including 10 trials of the 2008 overview) reports better outcomes in the patients’ Activities Day Living as well as improved motor function of the impaired upper limb, but no increase in strength.4 The absence of systematic effects is only partly explained by the heterogeneities among studies (eg, duration, intensity, and type of training; patients’ characteristics; and use of scales assessing either motor recovery or the individual strategies of functional adaptation to the disability).5 Contrary to expectation, the costs in time and labor of robot-assisted rehabilitation are estimated to remain higher than in traditional therapy.2,6 Disseminated application of advanced technology has crucial implications (eg, organization of personnel, privacy concerns, or financial issues) that would be decisive in transferring promising systems to a stage of regular operation but today remain largely unresolved.6 Most important, robots have been conceived as technological substitutes for traditional rehabilitation paradigms.7 Detailed knowledge unavailable in the past on the pathophysiological processes involved in spontaneous recovery and rehabilitation remains incomplete today. Residual motor function, improvement during treatment, and outcomes are still estimated by criteria that are based largely on experience rather than on objective measures. In this respect, robotics shares the Boriginal sin[ of traditional rehabilitationVof having developed empirically in the urge to help improve, or compensate for, major motor disabilities. Independent robot-assisted rehabilitation procedures need to be identified and developed within the mainstream of modern medicine. Research in this regard would be seminal and innovative. New robots should be contrived to overcome the patient-robot dichotomy (a replica of traditional patienttherapist dichotomy) by turning neurorehabilitation into a www.ajpmr.com
self-training experience in which patients play an active role under proper guidance. Flexible, highly specialized options to enrich the recovering of motor function (including sensory/ cognitive/emotional interaction with the environment) and adjust to individual changes during treatment should be available to meet the patient_s (real and perceived) individual needs. Not simply advancement in engineering, robotics needs to evolve into a laboratory to devise innovative training procedures based on, and monitored by, objective measures of motor impairment and recovery provided by the robots themselves. The original sin would otherwise limit the development of robotics in neurorehabiliation to its full potential. REFERENCES 1. Crespo LM, Reinkensmeyer DJ: Review of control strategies for robotic movement training after neurologic injury. J Neuroeng Rehabil 2009;6:20 2. Lo AC, Guarino PD, Richards LG, et al: Robot-assisted therapy for long-term upper-limb impairment after stroke. N Engl J Med 2010;362:1772Y83 3. Mehrholz J, Platz T, Kugler J, et al: Electromechanical and robot-assisted arm training for improving arm function and activities of daily living after stroke (Review). Cochrane Database Syst Rev 2008; Issue 4. Art. No.: CD006876. doi:10.1002/ 14651858.CD006876.pub2 4. Mehrholz J, Ha¨drich A, Platz T, et al: Electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev 2012;6:1Y65 5. Kwakkel G, Kollen BJ, Krebs HI: Effects of Robot-assisted therapy on upper limb recovery after stroke: A systematic review. Neurorehabil Neural Repair 2008;22:111Y21 6. Orwat C, Graefe A, Faulwasser T: Towards pervasive computing in health careVA literature review [Review]. BMC Med Inform Decis Mak 2008;8:26 7. Kwakkel G, Kollen B, Lindeman E: Understanding the pattern of functional recovery after stroke: facts and theories. Restor Neurol Neurosci 2004;22:281Y99
Giuliano Dolce, MD Lucia F. Lucca, MD Loris Pignolo, ENG S. Anna Institute and Research in Advanced Neurorehabilitation (RAN) Crotone, Italy
Walter G. Sannita, MD Department of Neuroscience, Ophthalmology and Genetics University of Genova Genova, Italy Department of Psychiatry, State University of New York Stony Brook
DOI: 10.1097/PHM.0000000000000187
Letter to the Editor Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
e25
