Exoskeletons, Serious Games and Co.: New Technologies in Rehabilitation
Exoskeletons, Serious Games and Co.: New Technologies in Rehabilitation
A stroke, an accident or just because you are aging – there are many reasons to take advantage of physiotherapeutic or rehabilitative measures. More and more new technologies are designed to support patients in this process. They run the gamut from sensor technology and robotics to exergames and virtual reality.
Exercise is vitally important for a person's physical and mental well-being. It helps to prevent or alleviate a number of physical ailments. But what happens if a person is no longer able to move independently, after a stroke for instance? Or when walking becomes increasingly difficult due to advancing age, prompting people to avoid exercise entirely? This is where robotic systems, which are used primarily in rehabilitation and therapy are able to assist.
Goodbye wheelchair, hello exoskeleton – more mobility thanks to exoskeletons
Indego, HAL, Lokomat or ReWalk – different systems that share one common goal: they are all exoskeletons and are designed to support people, who are barely or no longer able to walk, with the help of externally attached limbs. The structures of these robotic systems are all similar: they wrap around the legs and subsequently guide the pelvis, thigh, and foot as if the person walks on his/her own. The differences between these systems are in the control technology as well as the target audience they address.
In the case of the Hybrid Assistive Limb Exoskeleton (HAL) made by the Japanese company Cyberdyne, for example, patients move the exoskeleton of their own volition – using brain signals. HAL measures these signals via EMG electrodes that are attached at the knee and hip area. These signals are subsequently transmitted to tiny electric motors that support the patient's movements. HAL is primarily intended for use in therapy and rehabilitation. Meanwhile, the Phoenix exoskeleton by the American company SuitX is mostly intended to support patients in everyday life. This exoskeleton has just two motors that are positioned on each hip to ensure safety when the wearer is standing. Two walking canes help the patient to move. The device also uses an intuitive interface embedded in the walking canes to let users control standing up, sitting down and walking processes. Unlike other similar exoskeletons, this device features a minimalist design – to keep costs low and make its use as easy as possible.
By now, however, there is an increasing trend toward end-effector-based systems. In this case, the robot simply guides the last link in the human joint chain, for instance, the hand or the foot. "The benefit of this is that patients control their joints autonomously, thus improving motor skills. Patients not only learn motion sequences but are also required to plan and control their own movements," explains Professor Catherine Disselhorst-Klug, Director of the Institute for Rehabilitation and Prevention Research at the RWTH Aachen University. By promoting a patient's own movement, end-effector walking therapy is especially well-suited for stroke patients. This is a finding shared by the German Society of Neurorehabilitation, which subsequently published guidelines for end-effector gait training for stroke patients at the end of 2015.
One aspect all exoskeletons have in common is the fact that they are made of rigid materials and are primarily aimed at wheelchair users, who are no longer able to walk. Meanwhile, the XoSoft project is currently in the process of developing a soft exoskeleton version. "Our XoSoft system is aimed at people, who are still able to walk but in a limited fashion," says Professor Wirz, Director of Research and Development at the Institute of Physiotherapy at the Zurich University of Applied Sciences in an interview with MEDICA-tradefair.com. "This is a new development. This type of exoskeleton is meant to be made of soft materials that stiffen, depending on the application. You might envision this as a type of tights or leggings made of a somewhat thicker material." Depending on the situation, the material uses sensors and actuators to stiffen or soften and become flexible again. The soft exoskeleton’s primary application is to facilitate the private sphere of patients.
Robotic systems as physiotherapist assistants
In the future, robotic systems will gain in importance in rehabilitation, simply because of demographic changes. "There is already a shortage of care for patients with neurological disorders. It's only a question of time before the number of available physiotherapists no longer ensures adequate rehabilitation for these patients," says Professor Disselhorst-Klug. However, that doesn't mean that physiotherapists can be replaced by robotic systems. Quite the contrary. "Physiotherapists will engage patients in 'normal' training without the robot. This training will be recorded and transmitted to the robot. In doing so, the robot continues to receive a new custom exercise routine that is tailored to the patient. This also multiplies the impact of training with physiotherapists, without the need for them to be physically present," Professor Disselhorst-Klug describes the future use of robotic systems in rehabilitation. "The robot becomes the physiotherapist's assistant. On the one hand, in collaboration with the physiotherapist, the robot is able to bear the weight of the patient and physically assist the therapist in his/her job. On the other hand, the robot is also able to assist patients in their individual training. And thirdly, thanks to the data the robot measures and analyses using sensor technology, the training program can be further improved and customized." This is why patients are also benefiting from using a robotic system: improved exercises and more frequent training.
Exergames – play, fun and motivation combined with training and exercise
To ensure the effectiveness of physiotherapy, exercises need to constantly be repeated. But this leads to a lack of motivation in patients, which is a problem because these exercises have to be performed on a regular basis in the patients' homes. This is where exergames can help. The term exergame derives from the words exercise and game. As the name indicates, exergames focus on exercise and movement. This makes them perfect for rehabilitation, prevention, and therapy because playing is an activity people enjoy – even if they have to do it repeatedly.
This is also something Joris Wiersinga, Managing Director of SilverFit, is aware of. The Dutch company develops exergames that target older adults. "For example, required exercises are longer and performed more often without the need to worry about the movements," Wiersinga describes the advantages of exergames in an interview with MEDICA-tradefair.com. "What’s more, there is a high level of motivation, which makes rehabilitation or exercise more intense."
Immediate feedback to boost motivation
Exergames record the movement of players using technical elements like sensors or a 3D camera and are transferred to what happens in the game. Depending on the application and intended purpose, this might be just a body part like the hand, for example, or movement of the whole body. One added benefit is the recording of movements and the chance to analyze them. This makes it possible to measure and visualize therapeutic success – another boost of motivation for patients.
The modular "Armeo" system of the Swiss company Hocoma was specifically designed for patients, whose hand and arm function has been affected due to a neurological disorder. The robotic system includes an arm exoskeleton and software that not only provides treatment plans and documentation options but also a variety of different games. For example, patients are asked to collect coins in an underwater setting or grab specific products in a supermarket. Depending on the exercise, this trains range of motion and coordination, strength or stamina. Patients continuously and immediately receive performance feedback. Treatment progress is being recorded and measured at the same time, allowing for better assessment of the course of treatment thanks to this data. In doing so, patients always perform the appropriate and individually adapted training.
The blessing of these new technologies
The new technologies provide a multitude of benefits for both therapists and patients: a more accurate diagnosis with the help of data collection and analysis, improvement of individual therapies and intensification of the training program. The use of robotics and exergames also increases patient compliance. At any rate, the new technologies have changed the face of physiotherapy. That is why we can look forward to discovering how this technology will advance and how it will impact rehabilitation and physiotherapy..
The article was written by Olga Wart and translated from German by Elena O'Meara. MEDICA-tradefair.com