Robot-assisted therapy is an effective adjunct to conventional upper limb rehabilitation after stroke. Robotic devices can provide intensive, repetitive, interactive therapy and allow accurate assessment of motor control and strength. Well-designed robots optimize rehabilitation by addressing complex sensory and motor requirements through varied, motivating activities and feedback. When combined with therapists, robots may improve outcomes, increase therapy intensity and efficiency, and help address workforce shortages in rehabilitation clinics.

1. ADVANCED TECHNOLOGY
IN UPPER LIMB REHABILITATION
Mr Vaikunthan Rajaratnam
MBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),MIDT Dist(OUM),FICS(USA),MBA(USA),
Dip Hand Surgery(Eur),Dip MedEd(Dundee),FHEA(UK),FFST(Ed),FAcadMEd(UK).
Senior Consultant Hand Surgeon
KTPH NHG Healthcare Group, SINGAPORE

2. Technology is Changing Medicine
digital innovations is revolutionizing
healthcare
• 3D printing
• Big data
• Accelerated experimentation
• Mobile apps
• Remote monitoring
• Improved communication

3. Functional Assessment and Evaluation
• Sensory/Motor Evaluation
• Assessing function –
ADL/Work/Recreation/Special
• Rapid
• Valid
• Reliable
• Consistent
• Wearable devices
Treatment Programs
• Sensory/Motor re education –
bionic/acoustic glove
• Cortical plasticity
• Neural Prosthesis and biofeedback
• Work Place assessment **

4. Brain– computer interfacing (BCI). These BCIs can record movement-related neural command signals directly from the
brain, via intracortically with microelectrode arrays implanted in the motor areas of the brain or extracortically

5. 3D Printing of splints
• Water resistance that improves personal hygiene.
• Cost reduction – material PLA (polylactic acid)
• Recyclable product
• Lightness
• Pleasant and novel aesthetics
• Allows visual control of the skin
• A biocompatible splint,
• No irritation of skin
• Ventilation of the skin.
Blaya, F., Pedro, P.S., Silva, J.L. et al. J Med Syst (2018) 42: 54

7. Therapy robot
“a reprogrammable and multifunctional manipulator designed
to perform different rehabilitation tasks through various
programmed motions”
2 therapy robot model
• distal joint and
• proximal joint treatment
Types
1. motor-driven passive mobilization
2. active-assisted exercises for severe and moderate impairments
3. feedback from sensor-based devices

8. Computer/robot-assisted
rehabilitation
Optimizing rehabilitation
• complex physiologic and
anatomic sensory motor
requirement
• Robotic and sensor-based
neurologic rehabilitation

9. Concept matrix
Robotic devices with built-in motors and sensors address patients with severe disability and those who need assistance.
PM&R, Volume: 10, Issue: 9S2, Pages: S189-S197, First published: 27 September 2018, DOI: (10.1016/j.pmrj.2018.07.011)

10. How Therapy Robots Can Be Used
• Train grasping movement
• Targeted finger extension training
• biofeedback and assist‐as‐needed interactions
• Varied robot‐assisted grasping movements
providing intensive stimulation to the brain
• Isometric force, range of motion, or surface
electromyography trigger signals
• Vibration and continuous passive movement
for spasticity
AMADEO

11. Robot therapy in practice
• Range of motion assessment
• Force assessment
• Spasticity assessment & treatment
• Movement therapies – CPM Plus
• Passive, assistive and active
• Sensitivity testing & training
• Gaming in one- and two-
dimensional movements
• Surface Electromyography
• EMG-based training
Arm shoulder robots
DIEGO arm robot
Pablo Upper Extremity

14. Task-oriented rehabilitation
bridging exercises and ADL
Sensor‐based digital surface
• real objects (e.g., coin, cup, or
handle)
• force (push and pull) and
• touch.
• Trains
• gross-motor skills
• fine-motor-skills
• rotation movement
• hand-eye coordination
• motoric coordination
MYRO

15. • wearable systems
• monitoring and provision
of feedback
• on posture and upper
extremity movements
• in stroke rehabilitation.
• accelerometers and
inertial measurement
units (IMUs) - most
frequently used sensors,
Journal of NeuroEngineering and Rehabilitation (2017) 14:20

16. Commercial low cost
assistive technology
• FMA using Kinect is a valid way to assess
upper extremity function and can provide
additional results for movement quality in
stroke patients. This may be useful in the
setting of unsupervised homebased
rehabilitation.
Kim W-S, Cho S, Baek D, Bang H, Paik N-J (2016) Upper Extremity. PLoS ONE 11(7): e0158640
Tsekleves, E., et.al, C. (2016). Development and preliminary evaluation of a
novel low cost VR-based upper limb stroke rehabilitation platform using Wii
technology. Disability and Rehabilitation. Assistive Technology, 11(5), 413–
422.

17. Telerehab

18. Anti Tremor Glove
• Washable
• It’s washer and dryer friendly
• Battery-Free
• No charging. No hassle. Just wear it and go.
• Responsive
• Adapts to any tremor level
• Lightweight
• Wear it as you please

19. Clinical Effectiveness
and Efficiency
• Expensive
• Optimizing human resources
• 1 therapist can oversee several patients at the same time
• Significant improvement
• disability (Barthel Index)
• and upper limb function (Fugl‐Meyer score),
• greater improvements in the robotic group
• robotic group therapy costs less than half per
session
• greater positive effect than conventional
therapies
Giovanni Morone, Grazia Fernanda Spitoni, Daniela De Bartolo, Sheida Ghanbari Ghooshchy, Fulvia Di Iulio, Stefano Paolucci, Pierluigi Zoccolotti & Marco
Iosa (2019) Rehabilitative devices for a top-down approach, Expert Review of Medical Devices, 16:3,187-195

20. Robotic Usability
• Short setup and closure times (2-5 mins)
• group therapy, -severity mix and clinical
characteristics
• Accessibility: wheelchair access and device
adjustment
• Assessment: technology enabled unbiased
objective assessment
• Motivation: meaningful software enhanced
engaged
• Automated reporting and documentation:
• Staff training time: learn a common software

21. Effects of Robot-Assisted Therapy for
the Upper Limb After Stroke:
A Systematic Review and Meta-analysis
• Significant but small improvements in motor
control (~2 points FMA arm) and muscle strength of
the paretic arm and a negative effect on muscle
tone
• No effects were found for upper limb capacity and
basic ADL
• PROXIMAL - significant effects on motor control
and muscle strength DISTAL - small but significant
effects on motor control
• Increase the number of repetitions
• Increase intensity of practice
Veerbeek, J. M., Langbroek-Amersfoort, A. C., van Wegen, E. E. H., Meskers, C. G. M., & Kwakkel, G. (2017).
Effects of Robot-Assisted Therapy for the Upper Limb After Stroke: A Systematic Review and Meta-analysis.
Neurorehabilitation and Neural Repair, 31(2), 107–121.

22. OT perspective of Robot
therapy
• Simple handling
• Adaptable to the patient
• Therapies and assessments
• Objectification by
measurements
• High efficiency - Saves time
and energy
Andrew Stephenson & John Stephens (2017): An exploration of physiotherapists’ experiences of robotic therapy in upper limb rehabilitation within a stroke
rehabilitation centre, Disability and Rehabilitation: Assistive Technology

23. Robots in rehabilitation
clinics - replace OT?
• in combination with therapists
• more job vacancies than candidates
• increasing patient loads
• promoting new rehabilitation techniques and
protocols
• robots decreases this imbalance between OT
and patients
Jakob, I., Kollreider, A., Germanotta, M., Benetti, F., Cruciani, A., Padua,
L., & Aprile, I. (2018). Robotic and Sensor Technology for Upper Limb
Rehabilitation. PM&R, 10(9S2), S189–S197.

24. • valued the use of RT as an adjunct to
conventional therapy,
• barriers to successful implementation
seemed to dominate the views of some
• Resource management and skill mix
crucial

25. Reconstruction and Rehabilitating the injured upper limb
J Neurosurg 127:1163–1171, 2017

26. Electromyogram pattern recognition for control of powered upper-limb prostheses: State of the art and challenges for
clinical use. Erik Scheme, MSc, PEng; Kevin Englehart, PhD, PEng*
Institute of Biomedical Engineering, University of New Brunswick, Fredericton, Canada
JRRD Volume 48, Number 6, 2011 Pages 643–660

28. The DEKA Arm
Participants had
• less perceived disability and
• more engagement of the prosthesis
• although activity performance was
slower
After home use experience, activity performance was improved
and activity speed equivalent to using conventional prostheses

29. AMPUTEES
• stronger focus on the neural and
behavioural changes
• better appreciation of the time-
scale of changes which may
significantly affect
• device adaptation,
• functional device utility, and
• motor learning implemented in
rehabilitation environments.