2614-Article Text-4893-1-10-20151202 PDF
2614-Article Text-4893-1-10-20151202 PDF
2614-Article Text-4893-1-10-20151202 PDF
n Rehabilitation robots physically sup- s robotics moved from industrial to service applica-
port and guide a patient’s limb during
motor therapy, but require sophisticated
control algorithms and artificial intelli-
gence to do so. This article provides an
A tions, engineers began looking for new tasks that could
be automated with robots. Industrial tasks had been a
perfect candidate for automation since they are physically
exhausting and require high precision. Motor rehabilitation
overview of the state of the art in this
area. It begins with the dominant para- seemed like a similarly appropriate robotics application. In
digm of assistive control, from imped- the course of rehabilitation, the patient must exercise by per-
ance-based cooperative controller forming limb motions thousands of times, and the therapist
through electromyography and inten- must physically support and guide the patient’s limb during
tion estimation. It then covers chal- these motions. Since therapists inevitably get exhausted, a
lenge-based algorithms, which provide
rehabilitation robot could support and guide the limb
more difficult and complex tasks for the
patient to perform through resistive con-
instead.
trol and error augmentation. Further- Numerous rehabilitation robots have been designed for
more, it describes exercise adaptation both the upper (figure 1) and lower limbs (figure 2). The two
algorithms that change the overall exer- most famous arm rehabilitation robots are the MIT-MANUS,
cise intensity based on the patient’s per- now sold as the InMotion ARM (Interactive Motion Tech-
formance or physiological responses, as nologies, USA) and the ARMin, now sold as the ArmeoPower
well as socially assistive robots that pro-
vide only verbal and visual guidance.
The article concludes with a discussion
of the current challenges in rehabilita-
tion robot software: evaluating existing
control strategies in a clinical setting as
well as increasing the robot‘s autonomy
using entirely new artificial intelligence
techniques.
Copyright © 2015, Association for the Advancement of Artificial Intelligence. All rights reserved. ISSN 0738-4602 WINTER 2015 23
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(Hocoma AG, Switzerland). The most famous leg complete a motion within a desired time while cor-
rehabilitation robot is the commercially available recting any major errors (such as large deviations
Lokomat (Hocoma AG, Switzerland), with another from an optimal trajectory). The main characteristic
notable example being the Gait Trainer (Reha-Stim, of modern assistive controllers is that they only help
Germany). All of these, and many other robots, were as much as it is necessary for the patient to complete
developed in order to support and guide the patient’s a motion, an approach called patient-cooperative
limbs. However, appropriate hardware is not enough; control (Riener et al. 2005). This is similar to the work
both therapists and robots need to intelligently adapt of therapists in rehabilitation: they manually move
their support to ensure proper exercise. Mistakes the patient’s limb to accomplish a desired motion,
should be corrected, but the patient should exercise but let the patient move on his or her own whenev-
actively and intensely, so the support should not be er possible.
excessive. As summarized by Marchal-Crespo and Reinkens-
The first rehabilitation robot controllers did not meyer (2009), many rationales have been given for
adapt their support to the patient at all. They were such assistive controllers. Aside from allowing
very stiff, and essentially guided the patient’s limbs patients to perform more movements in a shorter
along a predefined trajectory with little care for what amount of time, they interleave active effort by the
the patient was doing or wanted to do. Clinical tests participant with stretching of the muscles and con-
found that patients put significantly less effort into nective tissue, they provide novel somatosensory
robot-aided exercise with such controllers than into stimulation that helps induce brain plasticity, and
therapist-aided exercise, and frequently just let the they may help teach patients to perform demon-
robot move their passive limbs without actively par- strated patterns. Although most of these rationales
ticipating in the motion (Israel et al. 2006, Ziherl et have not been extensively clinically verified (Mar-
al. 2010). This ”slacking“ process leads to slower neu- chal-Crespo and Reinkensmeyer 2009), assistive con-
romotor recovery (Casadio and Sanguineti 2012). To trol algorithms remain dominant, particularly
avoid it, the robot needs to adopt a control strategy impedance-based control.
that assists the patient only as needed: a cooperative
control strategy. Impedance-Based Assistance
The cooperative principle of impedance-based con-
Help Me Help You: Cooperative trollers is as follows: while a patient is moving along
a desired trajectory, the robot does not intervene, but
Assistive Control it corrects deviations from this trajectory by applying
Assistive controllers are the dominant control para- a force to the patient’s limb. This correcting force is
digm in rehabilitation robotics, and are used in the generated with a mechanical impedance. The first,
majority of commercial systems. They operate on the simplest controllers provided proportional position
level of the individual motion, helping the patient feedback: as the patient’s limb moves farther from the
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desired trajectory, the robot applies a proportionally patient. Several algorithms have been developed to
stronger force to the limb. Such force feedback is adapt reference trajectories automatically (Jezernik,
often combined with visual feedback that informs Colombo, and Morari 2004) or to make the trajecto-
the patient how he/she should move instead. This ries of certain limb joints more compliant than those
generally also requires a deadband around the trajec- of other joints (Stauffer et al. 2009). Furthermore,
tory so that the patient can make small deviations alternative impedance-generation techniques have
without being disturbed. The end effect feels some- been investigated, such as virtual objects (Ekke-
lenkamp et al. 2007). These are shapes generated by
what like a tunnel that the patient needs to follow.
the robot’s haptic interface; if the patient attempts to
An additional assistive force, sometimes dubbed a
move a limb into the physical space where the virtu-
“moving wall” or “flow force,” can push the patient
al object is, the haptic interface will push the limb
along the trajectory if he/she is too slow (relative to back, creating the illusion of an object. Such virtual
a desired velocity profile), providing another type of objects can thus physically support the patient in
assist-as-needed control. An example of such assist- reaching a goal.
as-needed control is shown in figure 3 for arm reha- Movements in rehabilitation should also be self-
bilitation. initiated for better motor learning (Lotze et al. 2003).
A major problem with such reference trajectories is Many impedance controllers, therefore, employ trig-
that they are difficult to adapt to an individual gered assistance: the robot is entirely passive until the
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kg
bt
kt basket basket
Figure 3. The Virtual Tunnel and Moving Wall in an Arm Reaching Task.
A spring-damper system prevents the patient from deviating from the reference trajectory (left) while a second spring-
damper system (right) leads the patient along the trajectory (adapted from Mihelj et al. [2012]).
patient has started moving the limb. Once a motion robot apply torque to a joint proportionally to the
has begun, the robot uses an assistive force and push- EMG of the muscle used to control the corresponding
es the patient’s limb toward the desired position, but joint of the human limb (Song et al. 2008, Stein et al.
only if the patient is not moving sufficiently quickly 2007). This avoids the problem of reference trajecto-
or smoothly on his/her own. If the patient’s own ries, which are difficult to adapt to an individual
movement is adequate, the robot becomes passive patient and may thus constrain him/her: since EMG-
again. A more complex possibility is the assist-as- based assistance augments the patient’s own move-
needed paradigm where the assistance parameters ments, it does not provide any constraints.
(for example, robot stiffness, assistive force gain) are This lack of constraints, however, presents a differ-
adapted over a continuous interval based on recent ent weakness. Patients in motor rehabilitation do not
motor performance (Wolbrecht et al. 2008). When only exhibit voluntary motions, but also pathologi-
performance is high, assistance is gradually decreased cal movements such as tremor and spasms. Patho-
due to a forgetting factor in the control algorithm. logical EMG is not easily separated from voluntary
Such assist-as-needed control has been found to sig- EMG, leading to potential augmentation of patho-
nificantly improve motor recovery compared to clas- logical motions. For this reason, some authors have
sic impedance-based control (Cai et al. 2006) or con- suggested that EMG may not be a suitable control sig-
ventional therapy (Reinkensmeyer et al. 2012). nal with patient populations such as stroke (Cesqui et
al. 2013). Other studies, however, have demonstrated
Electromyography-Based Assistance significant benefits of training with EMG-controlled
Surface electromyography (EMG) is the measurement robots (Song et al. 2013). It is likely that the use of
of a muscle’s electrical activity from the surface of the EMG in rehabilitation is appropriate for some
limb. By measuring the activation of different mus- pathologies and muscles but not others, and this
cles, a robot could provide precise assistance to dif- should be investigated further.
ferent parts of the limb. The first implementation
was EMG-triggered assistance, where the robot begins Assistance Based on Other Information
providing assistance once sufficient EMG activity is Impedance-based controllers provide assistive forces
detected (Krebs et al. 2003). A more advanced coop- based on motion of the impaired limb while EMG-
erative control approach is to augment the activity of based controllers provide them based on muscle
individual muscles: for example, have an exoskeletal activity on the impaired limb. However, assistance
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can also be provided based on information from oth- cyclic process, it should be possible to predict the
er parts of the body: the motion of the unimpaired motion of one leg based on the motion of the other
limb, the eyes, and even brain activity related to leg. If only one leg is impaired due to hemiparesis,
movement. The exploitation of this information is the healthy motion pattern for the impaired leg
sometimes referred to as intention detection, though could also be extracted from the motion of the
the term remains contested. It remains largely exper- unimpaired leg, and a rehabilitation robot can then
imental, but has great potential for future rehabilita- provide impedance-based assistance based on this
tion robots. estimated healthy pattern.
Complementary Limb Motion Estimation In principle, since the entire body is coordinated
Complementary limb motion estimation (Vallery et during gait, the motion of the rest of the body can
al. 2009) is an approach mainly used for the lower also be used to more accurately generate a motion
limbs. Essentially, since human gait is a coordinated pattern for the impaired leg. A recent study has thus
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used sensors embedded in a walking cane to control 4), the motion again becomes coordinated. In such
a mobile leg exoskeleton with such complementary bimanual training, it is then possible to apply coop-
motion estimation (Hassan et al. 2014). erative control by measuring the forces applied to the
Bimanual Training object by the unimpaired arm and replicating them
The motion of both arms is generally not as coordi- on the impaired side using a rehabilitation robot
nated as the motion of the legs during gait, so com- (Lum et al. 2006). The gains achieved in such biman-
plementary limb motion estimation cannot be ual training have been shown to transfer to other,
directly transferred to the arms. However, if both unimanual motions, though at least some motion of
arms are used to manipulate the same object (for the impaired arm is necessary for training (Trlep,
example, lift a box or turn a steering wheel — figure Mihelj, and Munih 2012).
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dard feature of the next generation of commercial The use of such measurements in rehabilitation
rehabilitation robots. robotics is known as biocooperative control.
Physiological responses can be directly fed into a
controller that adapts exercise parameters to, for
On a Higher Level: example, keep heart rate close to a desired value
Exercise Adaptation (Koenig, Omlin, et al. 2011). Alternatively, machine-
learning algorithms, such as neural networks or dis-
The controllers in the Cooperative Assistive Control
criminant analysis, can be used to infer workload
and the Challenge-Based Control sections work on
from multiple physiological responses and adapt the
the level of each individual motion, changing their
exercise difficulty accordingly. Such analysis of phys-
assistance or challenges during the motion based on
iological responses has been shown to effectively
how well the patient is performing at that moment.
complement performance measurements in both
But we can go a step farther and adapt the difficulty
upper (Guerrero et al. 2013, Novak et al. 2011) and
of the overall exercise depending on how well the
lower (Koenig, Novak, et al. 2011) extremity rehabil-
patient has been doing over the course of the exer-
itation robots, though it is still unclear whether phys-
cise.
iological measurements provide enough additional
Performance-Based Adaptation information to offset the sensor costs and additional
preparation time.
The principle of performance-based exercise adapta-
tion is simple: if the patient is performing well with
respect to a certain performance criterion, make the Socially Assistive
exercise harder to perform by increasing the motion
complexity, required range of motion, required
Rehabilitation Robots
velocity, and so on. Conversely, if the patient is large- Finally, an entirely different type of rehabilitation
ly unsuccessful at achieving motions, make the exer- robot should be mentioned: those that do not phys-
cise easier by decreasing the above parameters. This ically support the patient, but instead demonstrate
should ideally ensure an appropriate moderate chal- motions to be performed and provide simultaneous
lenge for patients and increase their motivation to verbal guidance, acting as an exercise coach. These
exercise. An early implementation was demonstrated are relatively rare in motor rehabilitation and have
by Colombo et al. (2007), and increasingly more mainly been studied by the group of Maja Mataric for
complex strategies were proposed later (Cameirão et healthy older adults (Fasola and Mataric 2012). They
al. 2010; Chemuturi, Amirabdollahian, and Dauten- utilize artificial intelligence techniques that allow
hahn 2013). However, most of these strategies have them to deliver appropriate verbal instructions at the
only been tested over a single session; for the great- right time as well as, for example, switch between dif-
est benefit, they should be able to guide the patient ferent personalities — one patient may prefer caring
over multiple sessions, gradually shaping therapy. gentle guidance while another may prefer a military
A new, interesting challenge for performance- drill instructor robot that brooks no argument
based exercise adaptation has recently arisen in the (Tapus, Tapus, and Mataric 2008).
form of multipatient exercise games where patients While socially assistive robots are unlikely to see
compete or cooperate with each other in order to broad use with populations such as stroke or spinal
achieve a goal (Novak et al. 2014). The exercise cord injury, where physical support is crucial, they
parameters must then be adapted to suit each exer- have provided several lessons that also apply to
cising patient even though different patients may motor rehabilitation robots, such as patients’ subjec-
have different needs. Several adaptation algorithms tive preferences for different types of guidance and
have been suggested for such games (Caurin et al. encouragement. Researchers have now begun adapt-
2011, Maier et al. 2014), but are so far relatively basic ing elements of socially assistive robots for classic
and have seen very little testing with patients. rehabilitation robots, creating robots that give verbal
instructions as they provide impedance-based assis-
Blood, Sweat, and Tears: tance (Mihelj et al. 2012).
Biocooperative Control
Just because a patient is successfully performing the
exercise does not mean that exercise difficulty should
Discussion
be increased; he/she may be already overloaded and Large multicenter clinical studies of rehabilitation
struggling just to keep up. Alternatively, a patient robots have shown that robots can deliver effective
who is failing at the exercise may be enjoying the rehabilitation with several advantages over manually
challenge and could get annoyed if difficulty were assisted therapy (Klamroth-Marganska et al. 2014, Lo
decreased. To obtain additional subject-specific infor- et al. 2010). However, the biggest studies focused
mation, we can measure the patient’s physiological only on impedance-based assistance; other control
responses such as heart rate and skin conductance, strategies such as error augmentation have gained
which reflect both physical and mental workload. limited clinical acceptance and are rarely seen in
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commercial robots. One major challenge will be to home or group settings. In the future, this combina-
determine how different control strategies can be tion of new artificial intelligence methods and better
combined over the course of rehabilitation. For knowledge of existing control strategies will increase
example, it may be beneficial for patients to progress the therapeutic advantage of rehabilitation robots
from assistive control to resistive control and error and lead to their widespread adoption in many dif-
augmentation as their motor skills improve. As ferent settings.
another example, some patients might benefit from
EEG- or EMG-based assistance while others should
avoid it entirely. However, these two examples Acknowledgments
remain educated guesses at the moment. A major This work was supported by the Swiss National Sci-
step forward would be to create a set of guidelines ence Foundation through the National Centre of
(based on clinical evidence) for how different control Competence in Research (NCCR) Robotics and by
strategies should be combined in order to achieve the Clinical Research Priority Program “NeuroRe-
optimal rehabilitation outcome. hab,” University of Zurich.
These guidelines may not be only used by thera-
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