TheraDrive in a Robot Gym

Toward Stroke Rehabilitation beyond Inpatient Rehabilitation Settings in USA and

Mexico

Michelle J. Johnson

1-3

, Sandra Montes

and Karla Bustamante

3,4

Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, U.S.A.

Department of Biomedical Engineering, University of Pennsylvania, Philadelphia, PA, U.S.A.

Department of Biomedical Engineering, Marquette University, Milwaukee, WI, U.S.A.

Biomedical Engineering, ITESM, Campus Chihuahua, Heroico Colegio Militar, 4700,Chihuahua, Mexico

Keywords: Game Therapy, Haptics, Motivation, Stroke Rehabilitation, Robotics, Upper Limb.

Abstract: Affordable stroke rehabilitation approaches can maximize the functional independence of stroke survivors

discharged after inpatient and outpatient services and improve access to rehabilitation for low-resource

environments. This paper briefly describes the evolution of the Theradrive system and its novel use in a

robot therapy gym in Mexico, where it was one of 6 devices aimed at improve motor function after stroke.

Results from testing with TheraDrive in Mexico in a robot gym suggest it is an effective affordable solution

for upper limb stroke rehabilitation whether alone or in a suite with other devices.

1 INTRODUCTION

Fifty percent of stroke survivors who are six months

post stroke and post rehabilitation have residual

impairments in their upper and lower limbs. Greater

than 30% are unable to walk without some

assistance and 26% remain dependent in activities of

daily living (Rosamond et al., 2008). Affordable

stroke rehabilitation approaches can maximize the

functional independence of stroke survivors

discharged after inpatient and outpatient services

and improve access to rehabilitation for low-

resource environments (Howitt et al., 2010). New

affordable assistive/robotic devices for home and

outpatient environments are needed for areas staffed

by a few therapists. For example, Colombo and

colleagues (Colombo et al., 2007) and Hesse and

colleagues (Hesse et al., 2005) in separate efforts

developed affordable robot devices for upper limb

therapy and showed that they were motivational and

useful for rehabilitation. Johnson and colleagues

(Johnson et al., 2004); (Johnson et al., 2005);

(Johnson et al., 2007) developed Driver’s SEAT and

Theradrive and later proposed the use of low-cost

devices such as Theradrive in a device suite tied to

Unitherapy, a unifying custom software that allowed

stroke survivors to play therapeutic games (Feng and

Winters, 2009). Recently, Buschfort and colleagues

showed that a suite of four simple robotic devices

(from Reha-STIM) can provide effective seated

‘hands on’ therapy to acute and sub-acute patients

(Arm Studio) inside the Charite’ Rehabilitation

Hospital in Berlin, Germany. Arm Studio can deliver

effective therapy to patients under the supervision of

a single therapist (Buschfort et al., 2010).

This paper briefly describes the evolution of the

Theradrive system and its novel use in a robot

therapy gym in Mexico, where it was one of 6

devices aimed at improving motor function after

stroke. We suggest it is an effective affordable

solution for upper limb stroke rehabilitation whether

alone or in a suite with other devices (Johnson et al.,

2007); (Bustamante and Johnson, 2012).

2 TheraDrive

TheraDrive, initially sponsored by the American

Heart Association, was developed as an affordable

stroke therapy system. It uses commercial force-

feedback wheels mounted on novel height adjustable

frames to provide a therapy environment for the

upper limb (Johnson et al., 2007). Figure 1 shows an

example of the original system. The main

307

J. Johnson M., Montes S. and Bustamante K..

TheraDrive in a Robot Gym - Toward Stroke Rehabilitation beyond Inpatient Rehabilitation Settings in USA and Mexico.

DOI: 10.5220/0004934603070311

In Proceedings of the International Conference on Biomedical Electronics and Devices (TPDULL-2014), pages 307-311

ISBN: 978-989-758-013-0

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

components of the TheraDrive system are a pair of

modified, commercial force-feedback steering

wheels, commercial gaming software as well as a

customized software called Unitherapy (Feng and

Winters, 2009). The system can be utilized in

several training modes; these are unilateral steering

utilizing the Logitech force-feedback wheel in the

front or on the side and bilateral steering utilizing

the two steering wheels mounted in the front in a bus

driving configuration (Paranjape et al., 2006).

TheraDrive can be used with or without an

autonomous mobile robot that can move about the

perimeter. The robot can monitor arm and torso

movements and provide visual feedback on activities

(Johnson et al., 2011). Therapy with Theradrive

consists of subjects playing off-the-shelf driving

games such as Need for Speed or completing custom

tracking tasks such as circle tracking or complex

sine wave tracking. As subjects completed tracking

tasks using the wheel, they experienced spring like

assistive or resistive forces on the wheel; the

magnitude of the force-feedback was proportional to

the tracking error. The proportional gain was pre-

adjusted according to a subject’s tracking ability.

The custom tracking tasks and the force-feedback

experience were created via the Unitherapy program.

Theradrive was used in a pilot study where data

were collected from ten stroke subjects who used the

device in twenty-four, one-hour therapy sessions

(Ruparel et al., 2009). Results showed that the

device was useful for stroke rehabilitation of the

upper limb [no hands], increasing range of motion in

the shoulder and elbow flexion/extension degrees of

freedom. The Theradrive system proved most suited

for subjects with moderate-to-high function. The low

torque output of the commercial wheels and the non-

adaptive force-feedback algorithm applied during

therapy made it difficult for stroke subjects with low

motor function due to severe hemiparesis to

experience a great benefit. The wheels were unable

to apply sufficient assistive forces for these users.

The system’s inability to support very low-

functioning subjects lead to a re-design effort to

improve its usefulness to them. The design efforts

lead to the creation of Haptic Theradrive, a low-cost

robot that is stronger in that it is able support larger

forces. Custom adaptive control algorithms allow

forces to be applied at the wheel that can adapt to a

user’s functional ability. The system also includes a

novel mechanism for creating variable compliance

and torque limits at the wheel; this enables safe use

of the system (Theriault et al., 2014). Figure 2

shows a prototype of the newest Theradrive, Haptic

Theradrive, with the custom crank arm capable of

applying torques stronger than the commercial

force-feedback wheel (45Nm versus 1.5Nm).

Figure 1: Theradrive original in front and side drive.

Figure 2: Haptic Theradrive.

2.1 TheraDrive in Mexico

Simultaneous to the Haptic Theradrive development,

BIODEVICES2014-InternationalConferenceonBiomedicalElectronicsandDevices

308

the original Theradrive was recreated in Mexico by

Co-PI, Karla Bustamante with specifications given

by PI Johnson. As in the USA stroke survivors in

Mexico are discharged from rehabilitation still

having residual disabilities and needing access to

services in the community. Unfortunately, in

developing countries such as Mexico a disproportion

number of the population is without easy access to

rehabilitation services (Lozano-Ascencio et al.,

1996); (Kurland, 1977). Access is very limited by, 1)

economics: rehabilitation services and associated

technologies may not exist outside of major urban

areas and many times are not affordable by low

income patients; 2) training: skilled therapists and

physiatrists are often not available in large numbers

inside or outside of cities; and 3) technology: access

to state of art rehabilitation technologies may be

limited and gaining access may be too costly.

The Mexican version of the Theradrive system

essentially mimicked the original version with

commercial force-feedback steering wheel and a

height adjustable frame (Bustamante and Johnson,

2012). Several custom games were used with the

Mexican system. Figures 3 and 4 show the

Theradrive Mexican version. The Mexican version

of the system maintained the key features of a height

adjustable frame and a variety of mounting positions

for the force-feedback wheel. It improved upon the

seating by creating a rail-mounted seating system

that made adjusting patients easier. The Unitherapy

custom software was also used. Therapy with this

system was similar and consisted of stroke survivors

playing off-the-shelf games and custom tracking

tasks.

Figure 3: Theradrive the version in Mexico.

Figure 4: Mexico Theradrive with user.

2.2 Robot Gym Study

The Mexican Theradrive was deployed in a novel

concept, we develop and called the robot gym

(Bustamante and Johnson, 2012). The robot gym

offered therapy based on circuit training where

patients could rotate to 6 stations under a clinician’s

supervision; each station used a custom or

commercially built robot/mechatronic rehabilitation

technology. On four machines subjects did activities

of daily living (ADLs), cycling, or game-based

visuomotor tracking tasks using the upper limb and

on two machines, cycling and gait training using the

lower limb.

The long-term goal of the robot gym is to

provide therapy for the upper and lower extremities

of stroke patients in an environment where limited

supervision is available. Our main objective in this

pilot study was to determine if the robot gym can

deliver comparable care as standard therapy

administered at CREE, the only low-cost public

rehabilitation healthcare center located in

Chihuahua, Mexico. Seventeen patients with right

hemiparesis due to a stroke were randomized to

either a standard therapy group (Control

Group:N=7) or the robot gym group (Robot

Group:N=10). All patients had 24, 1-hour therapy

sessions for the upper and/or lower limb. Patients in

the standard therapy group experienced 1-on-1

manual therapy. Patients in the robot therapy group

rotated through the six stations with an engineer and

therapist as supervisors that assist with set-up and

use of the devices.

All patients were evaluated pre- and post-

therapy for arm/hand motor impairment using the

Fugl-Meyer (Fugl-Meyer et al., 1975). Their

engagement in the therapy was assessed using the

intrinsic motivation scale (Wilson et al., 1984).

Unpaired t-tests determined significant differences

with p≤0.05 as threshold.

TheraDriveinaRobotGym-TowardStrokeRehabilitationbeyondInpatientRehabilitationSettingsinUSAandMexico

309

3 RESULTS AND DISCUSSION

Both Control Group (CG) and Robot Group (RG)

experienced a mean 4 point change in the Fugl-

Meyer motor control scores (RG: 4.6±1.23 and CG:

4±1.85: p=0.79), representing a more than 20%

increase over baseline (Figure 5). On average both

CG and RG perceived the therapy received as

valuable (RG: 6.83±0.56 and CG: 6.57±1.04:

p=0.14) and engaging (RG: 6.36±1.23 and CG:

5.89±1.6: p=0.27) (Figure 6). The differences in

upper limb outcomes and engagement were not

significant suggesting comparable therapy (Johnson

and Bustamante, 2014). Figures 5 and 6 summarize

the FM and motivation results.

The Mexican study shows that TheraDrive was

effective in concert with the other upper limb

devices. The impact of TheraDrive alone on motor

recovery cannot be separated from the Bioness

device or the Motormed upper limb. However, the

previous pilot data in the USA suggested TheraDrive

main contribution would be in shoulder and elbow

flexion and extension improvements (Ruparel et al.,

2009) and (Johnson et al., 2007).

Our overall goal for the pilot study in Mexico

was to determine if a low-cost system of

robot/computer-driven devices under limited

supervision by clinicians could improve motor

function of stroke survivors. The pilot study

demonstrated that the robot gym was effective and

was just as good as the control group. This is a

successful outcome given our goal and suggest that

we could potentially address issues of access to

rehabilitation services in more rural locations in

Mexico. The results suggest that creating a robot

gym in more rural Mexico where access to

rehabilitation is limited and staffing it with both a

remote supervisor and at least one skilled clinician

could not only provide access to rehabilitation for

stroke survivors in these locations but also given

them ways of further improving their rehabilitation

outcomes.

Figure 5: Fugl-Meyer score.

Figure 6: Motivation scores.

3.1 Lesson Learned

There is a need for appropriate rehabilitation

technologies. Except for one of the machines used,

all other devices were commercial products that

were not developed with Mexico in mind or

developed to be deployed in a resource poor

environment. As a result, when the devices

developed issues, getting technical help was difficult

and getting replacement parts were a challenge.

There is a need for low-cost solutions that are

rugged and simple to use. Problems with the

technology were sometimes complex and greater

than a clinician could troubleshoot and therefore, the

reliance on the engineer for assistance with the use

of the equipment was more than anticipated.

There is a need for reliable metrics that are able

to be administered, analysed and interpreted quickly.

We found that post assessment of changes after

therapy was difficult to obtain quickly. Clinical,

motion, and engineering analyses were done by the

clinician or an engineer and required many hours of

analysis. As a result, meaningful changes in function

were not feedback to patients in a timely manner.

4 CONCLUSIONS

We briefly presented the TheraDrive, its evolution,

and a feasibility study of its use in robot gym with

five low-cost therapy devices. Our overall goal was

to test the concept of affordable technology-

mediated care delivery in Mexico. Since access to

rehabilitation services and associated technologies

may not exist outside of major urban areas and many

times are not affordable to low income patients, our

robot gym is an innovative solution that has the

potential to augment the delivery of rehabilitation

care.

BIODEVICES2014-InternationalConferenceonBiomedicalElectronicsandDevices

310

ACKNOWLEDGEMENTS

This work was supported in part by the American

Heart Association under the grant #0635450Z

entitled “Robot-Assisted Motivating Rehabilitation

after Stroke”, by departmental funds of the Physical

Medicine and Rehabilitation of the Medical College

of Wisconsin, and by the Mexican government

grant# CHIH-2009-C02-127781 entitled “Gimnasio

Robotica”. We would also like to extend our thanks

to all the members of Rehabilitation Robotics

Research and Design Lab in USA and the gait lab in

Mexico. Please direct all correspondence to Dr.

Michelle J. Johnson.

REFERENCES

Buschfort R., Brocke J., Heb A., Werner C., Waldner A.,

Hesse S., 2010. Arm Studio to intensify upper limb

rehabilitation after stroke: Concept, acceptance,

utilization, and preliminary clinical results. J Rehabil

Med 42:310-314.

Bustamante K., Johnson M. J., 2012 Low cost gymnasium

for robotic rehabilitation of stroke survivors. In 7th

International Conference on Appropriate Healthcare

Technologies for Developing Countries, pp.21, UK

Colombo R., Pisano F., Mazzone A. et al., 2007. Design

strategies to improve patient motivation during robot-

aided neuroRehabilitation. J NeuroEngineering and

Rehabil, 4(6): open access

Feng X. and Winters J. M., 2009. A pilot study evaluating

use of a computer-assisted neurorehabilitation

platform for upper extremity stroke assessment.

Journal of NeuroEngineering and Rehabilitation, open

access.

Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind

S. 1975. The post-stroke hemiplegic patient: A method

for evaluation of physical performance. Scand J Rehab

Med 7:13

Hesse S., Werner C., Pohl M., S. Rueckriem, J. Mehrholz,

and M. L. Lingnau. 2005. Computerized arm training

improves the motor control of the severely affected

arm after stroke: A single-blinded randomized trial in

two centers. Stroke. 36:1960-1966

Howitt P., Darzi A., Guang-Zhong Y. et al., 2010.

Technologies for global health, the Lancet, 380:507-

535

Johnson M. J., Bustamante K., 2014. Affordable

technology-mediated rehabilitation of stroke survivors

in a global context. In Unite For Sight 11th Annual

Global Health & Innovation Conference, Yale

University, April 12-13. Abstract. Accepted. In press.

Johnson M. J., Feng X., Johnson L. M., Winters J. M.,

2007. Potential of a suite of robot/computer-assisted

motivating systems for personalized, home-based,

stroke rehabilitation. J NeuroEngineering and Rehabil

Mar 1; 4(6) (open access)

Johnson M. J., Shakya Y., Strachota E., Ahamed S. I.

2011. Low-cost monitoring of patients during

unsupervised robot/computer assisted motivating

stroke rehabilitation. Biomed Tech (Berl). 56(1): 5-9

Johnson M. J., Trickey M., Brauer E., F. Xin, 2004.

TheraDrive: A new stroke therapy concept for home-

based computer-assisted motivating rehabilitation. In

Conf Proc IEEE Eng Med Biol Soc. 2: 4844-47.

Johnson M. J., Van der Loos H. F. M., Burgar C. G., Shor

P., and Leifer L. J., 2005. Experimental results using

force-feedback cueing in robot-assisted stroke therapy.

IEEE Transactions on Neural Systems and

Rehabilitation Engineering. 13(3):335–348.

Kurland L. T., 1977. Twenty five years of

neuroepidemiology in the Americas. Neurol Neurocir

Psychiatr. 18 (2-3): 129-144.

Lozano-Ascencio R., Frenk Mora J., Gonzalez-Block M.

A., 1996. Burden of disease in the aged, México,

1994.

Sal Pub Mex 38 (6): 419-429.

Paranjape R. P., Johnson M. J., Ramachandran B., 2006.

Assessing impaired arm use and learned bias after

stroke using unimanual and bimanual steering tasks. In

Conf Proc IEEE Eng Med Biol Soc. 1:3958-61.

Rosamond W., Flegal K., Furie K. et al. 2008. Heart

Disease and Stroke Statistics_2008 Update: A report

from the American Heart Association statistics

committee and stroke statistics subcommittee,

Circulation 117;e25-e146.

Ruparel R., Johnson M. J., Strachota E., Tchekanov G.,

McGuire J., 2009. Evaluation of the TheraDrive

system for robot/computer assisted motivating

rehabilitation after stroke. In Conf Proc IEEE Eng

Med Biol Soc. 811-4

Theriault, A. R., Nagurka, M. L., Johnson, M. J., 2014.

Design and Development of an Affordable Haptic

Robot with Force-Feedback and Compliant Actuation

to Improve Therapy for Patients with Severe

Hemiparesis. Transactions on Haptics. IEEE

Computer Society In Press.

Wilson D. J., Baker L. L. et al., 1984. Functional test for

the hemiplegic upper extremity. American Journal of

occupational therapy. 38: 159-164.

TheraDriveinaRobotGym-TowardStrokeRehabilitationbeyondInpatientRehabilitationSettingsinUSAandMexico

311