Robot-assisted therapy is a promising innovative rehabilitation technology for patients with motor disorders. As with any other therapy, motivation is key. To be successful, a therapy regimen needs an active contribution, earnest effort and steadfast commitment by the patient. Creating a supporting environment for the patient to produce the right kind of movement goes hand in hand with any rehabilitation practice. Advancements in technology have ushered a new era adding virtual reality, augmented reality and customizable games to rehabilitation therapy. VR, AR and custom-created games can be used separately or combined to help maintain the interest of the patient and provide critical motivation to perform motion exercises.

The benefits of integrating games, VR/ AR and other breakthrough technologies
Traditional rehabilitation therapy is physically and emotionally draining. If patients are exhausted and fail to be stimulated by the therapy their motivation will decrease, leading to a less than optimal result. Trials suggest that robot-assisted therapies have been more successful in retaining patients’ interest and motivation.[1] They are especially effective when combined with VR, AR and customized games. Integrating these technologies into robot-assisted rehabilitation increases engagement and motivation while immersing the patient into rhythmic task-oriented exercises. This ‘gamification’ of the rehabilitation experience can deliver intensive, repetitive movements while sustaining the patients’ interest and lessening the burden on the therapist. Robot-aided therapy also uses wearable devices (from wrist monitors and electrodes to exoskeletons) that can relay real-time feedback. This feedback can be used to refine the therapy while tracking patient’s progress. Rehabilitation robots are ‘smart’ devices built to encourage interaction. They use sensor-based systems to assess movement and positioning, and are able to detect any change in force and motion, no matter how small. Active-assistive robotic technologies are great for storing data, measuring any number of parameters, which is critical for treatment planning and evaluation.

Breakthrough technologies are emerging globally, and rehabilitation therapists and clinical researchers are eager to integrate them in their practices.  Electromyographic biofeedback (EMG-BFB) uses electrodes that are placed on the patient's muscles and these electrodes respond to any muscle activation by generating a feedback signal. Functional electrical stimulation (FES) uses low-energy electrical pulses that artificially produce body movements in individuals affected by paralysis caused by an injury to the central nervous system. Major advancements in VR technology, notably the arrival of the 6th and 7th generation gaming systems (including the Nintendo Wii and the Xbox 360 Kinect) allowed for more realism to be added to VR.

While VR provides a complete immersion experience shutting out the physical world, AR simulation therapies include real world physical objects in the virtual world adding digital elements to a live view and typically allowing for more control in a patient’s interaction with the virtual objects (through the interaction with the real world physical objects).
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Combined with robotic devices, these new technologies will enhance the rehabilitation treatment’s effectiveness while producing massive amounts of data for clinical evaluations that will pave the way for future improvements.
 
Harnessing VR technology
Studies[2] have shown that the vast majority of patients prefer games-assisted therapies since they find them more engrossing and easier to follow. Making the treatment more game-like turns an intensely repetitive task into an engaging challenge, inspiring patients to participate in therapeutic exercises. VR has produced immense benefits, particularly in poststroke rehabilitation.[3] VR allows therapists to create tailor-made training programs that correspond to the patient’s interests. By offering the right incentives retention is increased and the patient is more dedicated to the rehabilitation process. The patients are encouraged to actively interact with the hardware and simulation software, in some cases virtual rehabilitation may even take place in a patient’s home. Telerehabilitation is another interesting new technology offering real-time rehabilitation services over the internet. Patients can have access to professional medical advice from their homes using a VR device.
Coupling the gaming elements with robotic devices will enhance rehabilitation treatments and occupational therapy in two important ways:

1. They will provide the high-dosage levels of therapy that are extremely difficult to achieve using traditional rehabilitation methods; and
2.  They will motivate the patient to be an active and committed participant in the therapeutic exercises, which will lead to better clinical outcomes.   

 
If you wish to read more, here are some fascinating articles that can be accessed online:

• Zheng J, Shi P, Yu H. A Virtual Reality Rehabilitation Training System Based on Upper Limb Exoskeleton Robot. 10th IEEE International Conference on Intelligent Human-Machine Systems and Cybernetics (IHMSC); 2018; Hangzhou, China. 2018.
• Bouteraa Y, Abdallah Ib, Elmogy Am. Training of Hand Rehabilitation Using Low Cost Exoskeleton and Vision-Based Game Interface.
• Colombo R, Pisano Fabrizio, Mazzone Alessandra, Delconte Carmen, Micera Silvestro, Carrozza M Chiara, Dario Paolo, Minuco Giuseppe. Design strategies to improve patient motivation during robot-aided rehabilitation.
• Alankus G, Lazar A, May M, Kelleher C. Towards customizable games for stroke rehabilitation. SIGCHI Conference on Human Factors in Computing Systems.

 Footnotes:

1. Okajima S, Alnajjar F, Yamasaki H, Itkonen M, García AC, Hasegawa Y, Shimoda S. Grasp-training Robot to Activate Neural Control Loop for Reflex and Experimental Verification. IEEE International Conference on Robotics and Automation (ICRA); 2018; Brisbane. 2018. Kwakkel G, Kollen Boudewijn J, Krebs Hermano I. Effects of robot-assisted therapy on upper limb recovery after stroke: a systematic review. Neurorehabil Neural Repair. 2008;22(2):111–21. doi: 10.1177/1545968307305457.
2. Housman S, Scott Kelly M, Reinkensmeyer David J. A randomized controlled trial of gravity-supported, computer-enhanced arm exercise for individuals with severe hemiparesis.
3. Katz N, Ring H, Naveh Y, Kizony R, Feintuch U, Weiss P L. Interactive virtual environment training for safe street crossing of right hemisphere stroke patients with unilateral spatial neglect.

The face of robot-assisted neurorehabilitation has progressively transformed over the last few years. While traditional neurorehabilitation procedures treating the most common neurological conditions such as stroke, spinal cord injury, Parkinson's disease, spasticity, severe brain injury and cognitive disorders may have limited effectiveness, new technologies have reportedly significantly improved the effectiveness of rehabilitation strategies for theses ailments. Robot-assisted training may be supplemented with new and emerging technologies to further increase the improvement of function for patients including the application of virtual and augmented reality and non-invasive brain stimulation (NIBS) or a form of functional electrostimulation. When paired with robot-assisted technologies these tools enhance both the intensity and quality of neurorehabilitation by manipulating brain excitability and plasticity. Other new technologies can further help recover the wellbeing and increase the quality of life of patients during and after rehabilitation therapy including various forms of assistive technology and domotics.

Novel applications of advanced technologies for neurorehabilitation have a beneficial effect on reliable measurements plasticity. The functional MRI, high-density EEG and near infrared spectroscopy are rapidly confirming outcome measures. The creation of translational and back-translational models ensures the formation of a solid neurobiological evaluating current approaches to disorders. New approaches during the acute phase of neurological ailments, most crucially research on the most appropriate timing of the intervention, play an important role in further optimizing neurorehabilitation.

Neurological rehabilitation programs dealing with diseases, injury, or disorders of the nervous system can be performed on an inpatient or outpatient basis, and at times a combination of both. In addition to the neurologist (or neurosurgeon), orthopedist (orthopedic surgeon), physical or occupational therapist and other rehabilitation specialists, a number of skilled professionals can be included in the neurological rehabilitation team; psychologists/psychiatrists, physiatrist and internists, other specialty doctors, registered dietitians, speech and language therapists, audiologists, social workers and case managers, as well as recreational therapists among others.

Complementary activities that may be used in combination with robotic neurorehabilitation therapies include:

• Nutrition counselling
• Stress, anxiety, and depression management
• Assistance with and enabling of daily activities (eating, dressing, bathing, essential housekeeping skills etc.)
• Speech therapy to help assist speaking, reading, and writing including constraint-induced language therapy and other methods to stimulate speech and motor output.

• Activities that enhance movement, gait and balance coordination including:
  • Prism adaptation therapy
  • Therapies using virtual feedback and implicitly integrating 3D motor and perceptual function
  • Constraint-induced movement therapy
  • Other intensive, experience-dependent learning
• Transcranial magnetic stimulation inducing a permissive brain state (improving motor and cognitive recovery in addition to being beneficial for treatments of depression).
• Transcranial direct current stimulation (promoting better rehabilitation outcomes mood and motor and cognitive functions).

Neuro Rehabilitation Disorders:

• Vascular system disorders such as ischemic heart disease, hemorrhagic strokes, and subdural hematoma
• Infections, such as meningitis, encephalitis, polio, and brain abscesses
• Structural or neuromuscular disorders, such as Bell palsy, cervical spondylosis, carpal tunnel syndrome, brain or spinal cord tumors, peripheral neuropathy, muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome
• Degenerative disorders, such as Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), Alzheimer disease, and Huntington chorea
• Functional disorders, such as headache, seizure disorder, dizziness, and neuralgia
• Trauma, such as brain and spinal cord injury

 
While evidence-based medicine was, to a degree, somewhat difficult to apply in the field of neurorehabilitation, there is a renewed interest in data-driven systematic reviews and meta-analyses, and a recent increase in participation and interest in consensus conferences. Furthermore, new randomized controlled trials exploring and evaluating combined drug and physiotherapy treatments are emerging, lending more visibility in the field of neurorehabilitation in general, while improving function and reducing symptoms for the individual patient.