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Robotic Devices used in Rehabilitation

Original Editor - Deepmala Jadwani Top Contributors - Deepmala Jadwani, Angeliki Chorti, Kim Jackson, Vidya Acharya, Rucha Gadgil and Khloud Shreif

Introduction

Robotic devices have revolutionised rehabilitation by providing innovative solutions to enhance recovery for individuals with various physical impairments. These advanced systems are designed to aid in restoring motor functions, improving mobility, and enhancing the overall quality of life for patients. The integration of robotics into rehabilitation therapy offers several key benefits, including precise control, consistent performance, and the ability to deliver intensive, repetitive training crucial for neuroplasticity and motor recovery. [1]

Rehabilitation robotics is a rapidly evolving field that leverages advanced robotic systems to assist in the recovery and enhancement of motor functions in patients with various impairments. The incorporation of advanced technologies such as robotics has transformed rehabilitation practices, offering promising results for improving motor function and enhancing the quality of life for patients with neurological impairments, including those recovering from stroke and spinal cord injury (SCI).

These robots typically interact with the patient at the end of a robotic arm mechanism, usually at the Hand and Foot, guiding the patient’s limb through specific movements and exercises. Continued research and development are essential to refine these technologies and ensure their widespread clinical adoption. Robotic technology designed for rehabilitation, has the potential to significantly enhance the efficiency and accessibility of therapy. By assisting therapists in delivering consistent training over extended periods and collecting data to monitor progress, these systems can improve therapeutic outcomes. Automation in therapy could allow multiple patients to receive treatment simultaneously and even remotely, from the comfort of their own homes, through telerehabilitation. Recently, many affordable, consumer-grade, off-the-shelf devices have been incorporated into therapy sessions, along with methods to boost patient motivation and engagement.[2]

We will explore various robotic devices currently being utilised in rehabilitation.

  • Exoskeleton Robots
  • Soft Robotics
  • End-Effector Robots
  • Electrical Stimulation with Robotic Therapy/Wearable Devices
  • Robotic Rehabilitation with Virtual Reality

The field of robotic rehabilitation is rapidly evolving, incorporating a variety of innovative technologies to enhance patient outcomes. From Exoskeleton Robots that provide support and mobility to individuals with physical impairments, to Soft Robotics, which is a rapidly growing field of Robotic Research that offer gentle and adaptive assistance, these advancements are transforming therapeutic practices. End-Effector Robots focus on precise movements and targeted therapy, while Electrical Stimulation with Robotic Therapy combines electrical impulses with robotic assistance to stimulate muscle activity and improve motor function. Additionally, Robotic Rehabilitation with Virtual Reality [Artificial Intelligence AI] integrates immersive environments to engage patients in interactive and motivating exercises. Together, these technologies represent a comprehensive approach to modern rehabilitation, aiming to restore and enhance physical capabilities through cutting-edge robotic solutions.

[3]

Exoskeleton Robots

The exoskeleton robots act directly upon specific joints of the user and are often more difficult to design and construct as they must follow the design of the limb that is targeted, be adjustable to accommodate users of different anthropomorphic dimensions, and attach to the limb at multiple points. [4][5]

There are two types of Exoskeleton Devices: Active and Passive

Active Exoskeleton

These exoskeletons are powered by external energy sources such as batteries or motors also called as powered exoskeleton They use actuators (like electric motors, hydraulic systems, or pneumatic systems) to assist or enhance the user’s movements. Equipped with sophisticated control systems that can interpret user intentions through sensors and bioelectric signals. Commonly used in rehabilitation, industrial settings, and military applications to enhance strength, endurance, and mobility. They are basically wearable robotic devices that attach to the user’s body and assist or enhance movement by providing powered support to specific joints. They can be used for both rehabilitation and daily mobility assistance. [6]

Its Examples are: Hybrid Assistive Limb (HAL), ReWalk (This video shows it How works), and Ekso Bionics.(Youtube Video of Ekso Bionics).

Passive Exoskeleton

These exoskeletons do not have an external power source, they rely on mechanical structures and springs, use elastic elements, springs, or other mechanical means to support and assist the user’s movements. Generally simpler in design and lighter in weight compared to active exoskeletons. Often used for support and load distribution in industrial settings, and for light-duty assistive applications. [7][8]

Its example are: Wilmington Robotic Exoskeleton (WREX), NEUROExos

Exoskeleton Devices

The different types of exoskeleton devices are as follows[9]:

  • Wilmington Robotic Exoskeleton (WREX): Its a two-segment, provides 4-degrees of freedom (DOF), passive orthosis. It can be mounted on a wheelchair or body jacket. It uses a linear elastic elements to balance gravity.
  • Hybrid Assistive Limb (HAL): Known as HAL, The Hybrid Assistive Limb (HAL), created by the University of Tsukuba and CYBERDYNE, Inc., is the world’s pioneering cyborg-type robot designed to enhance, support, extend, and restore the physical capabilities of individuals with disabilities caused by aging or diseases. HAL detects subtle bioelectric signals from the skin’s surface, originating from the brain and nervous system, and converts these signals to operate its actuators, thereby aiding the patient’s movements in real time. The medical version of HAL (lower limb type) has been commercialised in the European Union, specifically targeting the treatment of lower-limb paralysis.
  • ARMin III: The ARMin robot is an arm therapy exoskeleton with multiple degrees of freedom, designed to assist with activities of daily living and improve rehabilitation in stroke patients.
  • IntelliArm: The IntelliArm is a whole arm robot, which has eight actuated DOFs and two passive DOFs at the shoulder. Also, the IntelliArm has an additional degrees of freedom (DOF) for hand opening and closing.
  • Cable-Driven Exoskeleton: It is a 7-DOF (degrees of freedom) exoskeleton for the upper arm. It is a cables-driven exoskeleton for which cables were driven by electrical motors.
  • NEUROExos: The NEUROExos is an advanced elbow exoskeleton designed to aid in the rehabilitation of stroke patients. It features a variable impedance-powered system and employs a double shell link structure along with a 4-degree-of-freedom (DOF) passive mechanism. The NEUROExos incorporates an adaptive, passive-compliant actuator, inspired by biological systems, utilising an antagonistic nonlinear elastic actuation method.
  • Robot Interaction (HRI): Exoskeletons are dynamic systems that integrate human movement. For both active and passive exoskeletons, human-robot interaction (HRI) is crucial, as these devices operate in close proximity to the human body. HRI presents challenges throughout all phases of exoskeleton design and development, including design simulation, mechanical engineering, sensing, and actuation. Biomechanical simulation, in particular, enhances our understanding of human motion and sensory mechanisms. Meanwhile, mechatronics design focuses on creating the physical system to achieve the desired HRI.

Soft Robotics

Soft robotics is a subfield of robotics that focuses on creating robots from highly flexible and compliant materials, similar to those found in living organisms. Unlike traditional rigid robots, soft robots are designed to mimic the adaptability and resilience of biological systems. Soft robots are typically made from materials like silicone, rubber, and other elastomers that can stretch and bend without breaking. These materials allow the robots to deform and adapt to their environment, making them ideal for tasks that require gentle interaction with delicate objects or living tissues. Often, soft robots have a modular design, allowing for various configurations and movements. They can be actuated using different methods, such as pneumatic (air pressure), hydraulic (fluid pressure), or shape-memory alloys that change shape in response to temperature changes. Soft robots are used in minimally invasive surgery, rehabilitation, and assistive devices. For example, soft robotic gloves [10] can help stroke patients regain hand function, and soft robotic grippers can handle fragile items like fruits and vegetables without causing damage. These robots can navigate through complex and unpredictable environments, making them suitable for search and rescue missions or underwater exploration. Due to their compliant nature, soft robots are inherently safer for human interaction, reducing the risk of injury. They can easily adapt to different shapes and surfaces, making them versatile for various tasks. Soft robots can replicate the movements and functions of biological organisms, leading to innovative solutions in robotics. However, achieving precise control over soft robots can be challenging due to their flexible nature. The durability and longevity of soft materials under repeated use and stress is an ongoing area of research. [2][11]

Octobot: A fully soft robot inspired by the octopus, capable of autonomous movement using pneumatic actuators

Soft Robotic Glove: Used in rehabilitation to assist patients with hand movements and improve motor function. [12]

Soft Robotic Grippers: Soft robotic grippers can be used in rehabilitation to assist with tasks that require fine motor skills, such as picking up small objects. These devices can be combined with electrotherapy to enhance muscle activation and coordination. [13]

[14]

Integration of Soft Robotics in Electrotherapy

In the context of electrotherapy, soft robotics presents innovative solutions for rehabilitation and therapeutic applications. These devices can integrate electrodes and sensors to deliver electrical stimulation to specific muscles or nerves. [15] Their flexibility allows for precise placement and consistent contact with the skin, enhancing the effectiveness of electrotherapy. Soft robots can adjust their shape and stiffness in response to electrical signals, providing dynamic support and assistance during therapy. This adaptability enables the creation of more personalised and effective rehabilitation programmes. [16]

Examples: Robotic Cuffs and Patches, Wearable Gloves, Grippers.

Integration of Soft Robotics in Telerehabilitation

Research published in Wearable Technologies explores the integration of soft robotics and telerehabilitation for stroke rehabilitation. The study focuses on a soft inflatable robotic glove designed to assist with hand movements, combined with a cloud-connected software interface for remote monitoring and guidance. Key findings indicate that the soft robotic glove is user-friendly and can be effectively used in a home setting. Participants showed significant improvements in hand strength and dexterity, as well as enhanced flexibility and range of motion in the affected hand. [17] Additionally, the system allows for independent therapy sessions, reducing the need for constant supervision by healthcare professionals. [18]

End-Effector Robots

These robots interact with patients at the end of a robotic arm or mechanism, typically at the hand or foot, guiding the limb through specific movements and exercises. End-effector-based systems are robotic systems attached only to the distal segments of the limbs, usually realised by a handle for the hand, a forearm brace, or a footplate. [19] A subgroup of these systems includes cable-driven motion support robots, which use ropes to provide gravitational compensation and motion-promoting forces to a distal limb segment.

Compared to exoskeletons, end-effector-based systems require far less adjustment to individual patients. [20] However, due to the reduced contact between the human and robotic system, only the motion of one body segment is directly measured by the robot. The motion of all adjacent segments must be inferred using mechanical models or additional sensors. For end-effector-based upper limb rehabilitation systems, which directly measure a distal segment, the motion of the upper arm is commonly inferred using the simple assumption of a fixed shoulder position. [21]

Examples:

MIT-Manus: Assists stroke patients in performing reaching movements. [22]

Lokomat: A robotic gait training system that supports the patient’s weight and guides their legs on a treadmill. (Video of gait training with Lokomat.

End-Effector Device Lokomat

Electrical Stimulation with Robotic Therapy/Wearable Devices

The integration of advanced technologies like robotics, telerehabilitation, and electrical stimulation has transformed the rehabilitation field. These innovations provide new opportunities to improve motor function in patients with neurological impairments, such as stroke and spinal cord injury (SCI). This article reviews recent studies and trials that examine the effectiveness and potential of these cutting-edge approaches.

Functional Electrical Stimulation (FES)

One study published in Trials investigates the combined effect of robot-assisted upper limb training and functional electrical stimulation (FES) on stroke patients. [16] This randomised controlled trial aims to compare the neuromuscular rehabilitation outcomes of combined therapy versus robot-assisted training alone. The study involves 60 participants who undergo a six-week intervention. Key outcomes measured include:

  • Improvements in motor skills and coordination
  • Enhanced ability to perform everyday tasks
  • Decrease in pain levels associated with movement
  • Overall improvement in life satisfaction and well-being

The results indicate that the combination of robot-assisted training and FES significantly enhances motor recovery compared to robot-assisted training alone, suggesting a synergistic effect of the two modalities.

Electromyography-triggered neuromuscular electrical stimulation (RT-ENMES)

Electromyography-triggered neuromuscular electrical stimulation (RT-ENMES) is an advanced rehabilitation technique that integrates electromyography (EMG) with neuromuscular electrical stimulation (NMES) to enhance motor recovery, especially in patients with neurological impairments like stroke. [23] This technique leverages the benefits of both EMG and NMES to improve motor function and recovery outcomes. The key components and benefits of RT-ENMES include enhanced motor skills, improved coordination, increased ability to perform daily tasks, reduced pain levels associated with movement, and overall better life satisfaction and well-being.

Electromyography (EMG):

Electromyography (EMG) measures the electrical activity produced by skeletal muscles, detecting the bioelectric signals generated during muscle activation. In RT-ENMES, EMG sensors are placed on the skin over the target muscles to monitor the patient’s voluntary muscle activity. [23]

Neuromuscular Electrical Stimulation (NMES):

Neuromuscular electrical stimulation (NMES) delivers electrical impulses to the muscles through electrodes, causing them to contract. In RT-ENMES, this electrical stimulation is triggered by EMG signals, meaning the stimulation occurs in response to the patient’s own muscle activity. [23] When the patient attempts to move a muscle, the EMG sensors detect the bioelectric signals. These signals then trigger the NMES device to deliver electrical stimulation to the same muscle, enhancing the contraction. [24] This creates a feedback loop where the patient’s voluntary efforts are augmented by the electrical stimulation, promoting more effective muscle activation and motor learning.

Benefits of Robot Assisted Therapy

By integrating voluntary muscle efforts with electrical stimulation, RT-ENMES enhances muscle activation and strength. This method promotes neuroplasticity through repetitive and augmented muscle contractions, aiding the brain in rewiring and improving motor control. The real-time feedback and assistance provided by RT-ENMES boost patient motivation and engagement in the rehabilitation process, leading to better outcomes compared to passive treatments. Studies have shown significant improvements in upper limb function, including better motor control and strength, with RT-ENMES. This technique has been found to increase activation in the cerebral cortex, which is associated with improved motor function. RT-ENMES is commonly used to improve upper limb function in stroke patients, helping them regain the ability to perform daily tasks. It is also beneficial for enhancing motor recovery in patients with spinal cord injuries. [24]

An example study published in Bioengineering investigated the effects of 3-dimensional robotic therapy combined with RT-ENMES on upper limb function in stroke patients. The results showed significant improvements in motor function and cerebral cortex activation compared to traditional therapies. [24]

RT-ENMES represents a promising advancement in rehabilitation technology, offering a synergistic approach to enhance motor recovery through the combination of voluntary muscle efforts and electrical stimulation.

Robotic Rehabilitation with Virtual Reality

Robotic technology designed to assist rehabilitation can significantly increase the efficiency and accessibility of therapy. By assisting therapists in providing consistent training for extended periods and collecting data to assess progress, these systems ensure high-quality care. The automation of therapy allows for the simultaneous treatment of multiple patients, potentially even remotely, through telerehabilitation. [25] In recent years, many consumer-grade, low-cost, and off-the-shelf devices have been adopted for therapy sessions, integrating methods to increase motivation and engagement. [26]

Virtual Reality (VR) has emerged as a powerful tool in the field of rehabilitation, offering immersive and interactive environments that enhance the therapeutic experience. When combined with robotic devices Kinesiological Instrument for Normal and Altered Reaching Movements (KINARM), VR can provide a more engaging and effective rehabilitation process.

Virtual reality (VR) has revolutionised rehabilitation by creating immersive environments that make therapy sessions more engaging and enjoyable for patients. The interactive nature of VR significantly boosts patient motivation and adherence to therapy programmes. VR also allows for the development of personalised rehabilitation exercises tailored to each patient’s specific needs and progress, providing real-time feedback to help patients adjust and improve their movements.[27]

Combining VR with robotic devices enables remote therapy sessions, allowing patients to receive high-quality care from the comfort of their homes. This approach makes rehabilitation more accessible to those who may have difficulty traveling to therapy centers. VR systems can collect detailed data on patient performance, offering valuable insights for therapists to monitor progress and adjust treatment plans. The precise measurements provided by VR and robotic systems ensure accurate assessment of motor functions and improvements. Immersive VR systems have been shown to significantly improve motor function and patient engagement.[25] When combined with wearable sensors and robotic devices, VR can provide detailed analysis of joint movements and enhance therapy outcomes. Research indicates that integrating VR and robotic devices in neuromotor rehabilitation is well-received by both patients and healthcare professionals, promoting physical independence and psychosocial well-being.

Continued research and development are essential to refine these technologies and maximise their potential in clinical settings.

Resources

Emerging Technologies in Rehabilitation for Complex Injuries and Conditions

References

  1. ↑ Laut J, Porfiri M, Raghavan P. The Present and Future of Robotic Technology in Rehabilitation. Curr Phys Med Rehabil Rep. 2016 Dec;4(4):312-319.
  2. ↑ 2.0 2.1 Cunha B, Ferreira R, Sousa ASP. Home-Based Rehabilitation of the Shoulder Using Auxiliary Systems and Artificial Intelligence: An Overview. Sensors. 2023; 23(16):7100.
  3. ↑ Peace Medical Tourism. Advantages of Robotics in Rehabilitation - Robotic physiotherapy. Available from: https://www.youtube.com/watch?v=mGI6TUR1190 [accessed 04/10/2024]
  4. ↑ Association for Advancing Automation Robotics. Exoskeleton Robots. Available from:https://www.automate.org/robotics/service-robots/service-robots-exoskeleton [accessed 04/10/2024]
  5. ↑ Laut J, Porfiri M, Raghavan P. The Present and Future of Robotic Technology in Rehabilitation. Curr Phys Med Rehabil Rep. 2016 Dec;4(4):312-319.
  6. ↑ Tiboni M, Borboni A, Vérité F, Bregoli C, Amici C. Sensors and Actuation Technologies in Exoskeletons: A Review. Sensors (Basel). 2022 Jan 24;22(3):884.
  7. ↑ Rafique S, Rana SM, Bjorsell N, Isaksson M. Evaluating the advantages of passive exoskeletons and recommendations for design improvements. J Rehabil Assist Technol Eng. 2024 Mar 21;11:20556683241239875.
  8. ↑ Lopez-Delis A, Ruiz-Olaya AF, Ferreira da Rocha A. Chapter Eight - Upper and Lower Extremity Exoskeletons. In: Handbook of Biomechatronics; 2019: 283-317.
  9. ↑ Sawicki, G.S., Beck, O.N., Kang, I. et al. The exoskeleton expansion: improving walking and running economy. J NeuroEngineering Rehabil. 2020; 17, 25.
  10. ↑ Polygerinos P, Galloway K, Savage E, Herman M, O’ Donnell K, Walsh C. Soft Robotic Glove for Hand Rehabilitation and Task Specific Training. Available from: https://biodesign.seas.harvard.edu/files/biodesignlab/files/2015_-_polygerinos_-_icra_-_soft_robotic_glove_for_hand_rehabilitation_and_task_specific_training.pdf [accessed 04/10/2024]
  11. ↑ Morris L, Diteesawat RS, Rahman N, Turton A, Cramp M, Rossiter J. The-state-of-the-art of soft robotics to assist mobility: a review of physiotherapist and patient identified limitations of current lower-limb exoskeletons and the potential soft-robotic solutions. J Neuroeng Rehabil. 2023 Jan 30;20(1):18. doi: 10.1186/s12984-022-01122-3. PMID: 36717869; PMCID: PMC9885398.
  12. ↑ Polygerinos P, Wang Z, Galloway K, Wood R, Walsh C.Soft robotic glove for combined assistance and at-home rehabilitation Robotics and Autonomous Systems. 2015; 73: 135-43.
  13. ↑ Zhang L, Xing S, Yin H, et al. Skin-inspired, sensory robots for electronic implants. Nat Commun. 2024; 15: 4777.
  14. ↑ Syrebo, Fine Motor Training of SYREBO Soft Robotic Hand Rehabilitation Training C12, Mar 13, 2023, https://www.youtube.com/watch?v=fzPGii_v0t4&t=62s
  15. ↑ Cardoso L, Bochkezanian V, Forner-Cordero A. et al. Soft robotics and functional electrical stimulation advances for restoring hand function in people with SCI: a narrative review, clinical guidelines and future directions. J NeuroEngineering Rehabil. 2022; 19:66.
  16. ↑ 16.0 16.1 Rikhof C, Leerskov K, Gerdienke B. et al. Combining robotics and functional electrical stimulation for assist-as-needed support of leg movements in stroke patients: A feasibility study. Med Engineer Physics 2024; 130: 104216.
  17. ↑ Proietti T, Nuckols K, Grupper J, et al. Combining soft robotics and telerehabilitation for improving motor function after stroke. Wearable Technologies. 2024;5:e1.
  18. ↑ Rozevink S, van der Sluis C, Garzo A, et al. HoMEcare aRm rehabiLItatioN (MERLIN): telerehabilitation using an unactuated device based on serious games improves the upper limb function in chronic stroke. J NeuroEngineering Rehabil. 2021; 18:48.
  19. ↑ Passon A, Schauer T, Seel T. Inertial-Robotic Motion Tracking in End-Effector-Based Rehabilitation Robots. Front Robot AI. 2020 Nov 27;7:554639.
  20. ↑ Lee SH, Park G, Cho DY, Kim HY, Lee JY, Kim S, Park SB, Shin JH. Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment. Sci Rep. 2020 Feb 4;10(1):1806.
  21. ↑ Scotto di Luzio F, Simonetti D, Cordella F, Miccinilli S, Sterzi S, Draicchio F, Zollo L. Bio-Cooperative Approach for the Human-in-the-Loop Control of an End-Effector Rehabilitation Robot. Front Neurorobot. 2018; 12:67.
  22. ↑ Krebs H, Ferraro M, Buerger S, Newbery MJ, Makiyama A, Sandmann M, Lynch D, Volpe BT, Hogan N. Rehabilitation robotics: pilot trial of a spatial extension for MIT-Manus. J NeuroEngineering Rehabil. 2024; 1:5.
  23. ↑ 23.0 23.1 23.2 Rong W, Li W, Pang M, Hu J, Wei X, Yang B, Wai H, Zheng X, Hu X. A Neuromuscular Electrical Stimulation (NMES) and robot hybrid system for multi-joint coordinated upper limb rehabilitation after stroke. J Neuroeng Rehabil. 2017 Apr 26;14(1):34.
  24. ↑ 24.0 24.1 24.2 Yang SW, Ma SR, Choi JB. Effect of 3-Dimensional Robotic Therapy Combined with Electromyography-Triggered Neuromuscular Electrical Stimulation on Upper Limb Function and Cerebral Cortex Activation in Stroke Patients: A Randomized Controlled Trial. Bioengineering (Basel). 2023 Dec 22;11(1):12.
  25. ↑ 25.0 25.1 Chheang V, Lokesh R, Chaudhari A, Wang Q, Baron L, Kiafar B, Doshi S, Thostenson E, Cashaback J, Barmaki RL. Immersive Virtual Reality and Robotics for Upper Extremity Rehabilitation. SUI 2023.
  26. ↑ Xiong F, Liao X, Xiao J, Bai X, Huang J, Zhang B, Li F, Li P. Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery. Front Aging Neurosci. 2022 Mar 23;14:863379.
  27. ↑ Zanatta F, Giardini A, Pierobon A, D'Addario M, Steca P. A systematic review on the usability of robotic and virtual reality devices in neuromotor rehabilitation: patients' and healthcare professionals' perspective. BMC Health Serv Res. 2022 Apr 20;22(1):523.
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