Upper limb robot-assisted therapy in cerebral palsy

Article Reviews
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Read Full Text: Upper limb robot-assisted therapy in cerebral palsy: A single-blind randomized controlled trial
Journal: Neurorehabilitation and Neural Repair (2017 Impact Factor: 4.711)
Year Published: 2015
Ranked 33rd on our 2014-2019 list of the 50 most influential articles

This article is a great introduction to massed practice and robot-assisted therapy—and, even though this is our first time looking at cerebral palsy, you will find that this article builds on previous discussions we’ve had on motor learning.

This article sought to determine whether high-repetition robot-assisted therapy would help children with cerebral palsy improve upper extremity functioning and ADL status. As with many studies, the intent was to determine if any improvements found alongside conventional therapy were considered more significant than using conventional therapy alone.

The results of this article were that the smoothness of movement in discrete and unidirectional movement improved significantly more in children who underwent robotic therapy (in other words they improved at the movements they were practicing), but that this did not translate to improved ADL status.

This definitely aligns with a motor learning trend we are seeing, which we’ll dive into below.

What have we already looked at, related to massed practice, in the club so far?

Thus far in the Club, we’ve looked at high-repetition and task-specific therapy twice (here and here). Both times were related to stroke rehab, but we did discuss the ripple effect that this kind of research is having into other practice areas—and this week, we actually get to see that happening.

Robot-assisted therapy has also been seen in a systematic review of stroke care, in which it was not recommended as an adjunct to therapy (due to lack of efficacy in current research).

How does this article contribute to the conversation?

This article aligns with motor learning theories that we’ve already discussed, in which massed practice is a great way to see quick gains in the movement that is being practiced. BUT, unfortunately, these gains do not automatically transfer to improved functional status.

For this particular study, 16 patients were recruited from a school for children with physical disabilities in Brussels, Belgium.

They were randomly assigned to a control group or an intervention group.

All children received 45-minute sessions of therapy five days/week over eight weeks.

The control group received a standard protocol of physiotherapy (focused on neurodevelopmental theory) and OT (focused on ADLs).

The intervention group received three days per week of robot-assisted therapy and two days per week of conventional therapy. During the robotic sessions, these children performed, on average, 744 movements/session—which is obviously a lot. During the other two days per week, they received conventional therapy, which was theoretically supposed to help with transferring the motor improvements to functional tasks.

The robot-assisted therapy device was called the REAPlan.

Assessments

I was introduced to a new kind of assessment today, which @Maggie Sheffiled had alluded to in our conversation last week, which is using a robotic device to measure the “kinematics” of the upper extremity.

Kinematics is the mathematical study of motion—or the “geometry of motion.” Basically, robotic and VR devices are able to track the movement of the UE in unprecedented ways, and are therefore able to give us quantitative data on how the UE is functioning. You can see the protocol they used here.

Other assessments included:

Limitations?

No long-term followup

The information I wanted the most after reading this is whether the motor improvement were maintained after therapy ended. Assessments were done before the eight-week session and immediately after, so we really don’t have any data on the long term effect of this type of intervention.

This is especially important because varied practice seems to maintain its impact more than highly repetitive therapy, so I really want to know if that would be the case here.

Red Flags

In reading about the REAPlan, I recognized a name on the website, Julien Sapien, who happens to be co-founder of the company that created the robotic-device. I’m surprised this was not listed as a conflict of interest—unless I’m reading the situation wrong, the author would have a financial stake in finding evidence that favors the use of the REAPlan.

Takeaways for OT Practitioners

(These are my personal takeaways, and were not mentioned in the article.)

“You gain what you train”: The theme continues in the research we are examining.

While you never want to oversimplify something as complex as rehab, the simple statement “you gain what you train” seems to hold true across the research we are looking at.

If you practice specific movements with a robotic device, you will probably get better at those movements. But, what we really want in rehab is for those gains to translate to better function—and that translation piece proves to be very difficult.

I actually think the article puts forth an interesting description of why this translation is difficult:

“The various exercises were designed to stimulate the patients to repeat discrete reaching movements. However ADL involves discrete reaching movements, along with rhythmic reaching movements (eg, washing the upper body), and grasping movements (eg, opening a bag of chips).”

In my opinion, it seems we need research on UE rehab that is more complex and broadly reaching. If we wish to impact the performance of ADLs, which we OTs can appreciate holds way more complexity than simple motions, this type of research is a must.

Robotic therapy seems to be a promising adjunct to therapy for certain subgroups—but conventional OT seems to be what is needed most.

When we are looking at something as complex as ADL performance, to me it still seems that the best tool we can use in rehab is one of the most complex devices known to man—and that is the human mind and its ability for clinical reasoning. At the end of the day, it seems that conventional OT should be your go-to, and robotic therapy should be viewed as a promising tool and possible adjunct to therapy.

Listen to my takeaways in podcast form:

Find other platforms for listening to the OT Potential Podcast here.

What questions/thoughts does this article raise for you?

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I would have liked to have a third group where patients only received the robot-assisted therapy and no conventional therapy at all. Because its hard for me to assess the real benefits of robotic therapy, if conventional therapy its also involved. How do I know any benefits/gains came from the robotic -therapy and not the 2 days of conventional therapy? And I agree with you that the long term gains should be investigated in further studies.

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I also agree with Sarah and Priscilla. This study continues to support the use of conventional therapy as the primary intervention for improving outcomes. If the gains cannot be translated into actual ADL or functional improvements, then it may not be appropriate to recommend for a client.

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I agree @priscilla! I feel like I always wish there were more comparison groups in studies. That being said, I would guess that they didn’t do a solely robotic group, as it seems other studies have failed to capture improvements in functioning from robotic therapy alone. I think that is why they put their eggs in the basket of devoting time to translating the improvements in motor skills!

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I am interested in the practical set up of this treatment. I know this might be an extension of another study, but being in home heatlh peds, I would love to see if something like this could be set up in home. I think I saw some of the images of the computer set up. Most of my families that would potentially qualify for this would not be able to come to a clinic 5 days a week for 8 weeks.
Also, I think that there was not much on transferring this robot motion to functional use (ie) putting on a shirt, or pulling up pants, or making a bed, or meal set up… etc. (maybe I missed it…)
Also, I think the test did consider cognition (able to respond to 1 cue/command), but I do have some kids with CP that can respond to 1-2 cues most of the time, what about the times they are not processing the cues / commands. CP is so complicated.
thanks for sharing more peds articles. :slight_smile:

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Hey @aharrell! I think you’re hitting on the core problem: the cases are so complicated that robotic devices struggle to match the patients needs. I do think they will continue to evolve/improve, and once the tech companies zero in on devices that work better, I can see home models being made- but, we just don’t seem to be there yet.

When I published the article below in 2018, most robotic devices cost around $60,000

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This article reminds me of when I was doing fieldwork; at one site every patient was set up on the nu step then went to the “arm table” where they did the arm bike then either had to reach for the cones or put clothespins on the line. While all of these activities address strengthening and ROM they don’t translate well to ADLs. We, as therapists in that type of setting absolutely should be doing ADLs with the patients at least once a week or until they are competent. Had one lady that was frustrated because all she got to do was the bike and cones. So my first solo day with her I had her attempt to get dressed. She couldn’t!! So started working on dressing every day and actually got scolded by one of the OTAs that I couldn’t be spending therapy time on dressing!!! So yes we need to strengthen and work on ROM but figure out a way to tie it to real world activities. Have them put dishes away, get ingredients out of the frig, wash a table etc.

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I had a similar experience when I stated work with a bike that would help people push through there tone or get them to go in the other direction I asked the man how it helped with function and he was not able to answer any of the questions. Getting people into those functional task and practicing the task that are important to them is so important.

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yes that is what was so frustrating. I try really hard with home health to focus on what the patient needs to return to normal, yes we do exercises too because they need strengthening normally but after I introduce the exercises if there are ADL tasks they need help with to improve function that’s the focus of treatment they can do exercises on their time.

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@dawn2 and @elizabeth1, I wouldn’t have thought to connect robotic devices to something like the nu step or arm bike, but you are right that it similar in that patients are getting high repetitions of the same motion over and over! I actually see the appeal of these devices, because it so easy to track progress and easy for the patients to understand (for example it must be satisfying to do the arm bike for 8 minutes one day and then 10 minutes the next day.) Unfortunately, we know that that this progress just doesn’t translate to broader improvements.

I’m becoming convinced that it needs to be a part of our role to educate patients on motor learning basics: that doing varied ADL practice, may not feel as satisfying as repetitive practice because the metrics wont be as clean and straight forward as on something like the bike, but it seems that the more challenging and varied ADL practice is what actually makes a difference in their functioning.

Here’s some of my favorite catch phrases I’m learning to explain this:

“Repetition is less important than struggle.”
“Breadth of training predicts breadth of transfer.”
and “You gain what you train.”

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I agree with what has been discussed that robotic assisted therapy can be costly and is not a stand alone effective treatment without the traditional therapy. I think it could benefit individuals if it was cost effective for everyone and that it is used long term so that we can study the benefits of it and that it should be used with additional OT therapy. For example, my son had difficulty with his eye convergence and I took him to see a specialist who gave us a practical solution which was an electronic vision program that allowed him to practice this like a video game for over a year. It was cost effective about $100 and I was shown how to add additional eye exercises to assist him with improving. He also received traditional outpatient OT that assisted him with his gross/fine motor skills. Everything was directed towards “occupation” and who he is. He is a teenager who likes to play video games, needs assistance with school, and practical ADL tasks. After over a year, I took my son back to a follow up with the physician and to our surprise, he had improved dramatically with his eye convergence and tracking which helped him with school and reading.

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Wow! @julie! It is so awesome to hear a personal story like this. I agree that this seems like the perfect use of this kind of technology! I love that it was an adjunct to get in extra practice and function-based! I love that it was cost-effective for you too! VR and gaming devices are becoming so affordable, but that’s what stinks about robotic devices is they are still super-expensive.

On a more personal note, I’m curious what game he was using? I recently was diagnosed with a mild eye convergence problem as well! (Which, in retrospect makes total sense in my life!)

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I can’t help but share this new video in this thread as well! This young patient with cerebral palsy is working on bringing a device to market which enables participation in a broad range of activities.

I love it when OTs are part of the process on brining new devices to market, but it is even better when patients themselves spearhead it :slight_smile:

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Yes I am also curious as to what game he was using. I have so many kids on my caseload that have poor visual tracking skills What specialist did you end up going to see?

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Hi Sarah!
I live in the Dallas area and when I was first looking into helping my son, I found that there were a couple of ODs in the area that assist kids with visual deficits. One of them uses the traditional ways to increase eye exercises by using workbooks to scan and track: Dr. Kenneth Lane: https://www.rfwp.com/pages/kenneth-a-lane-o-d/
The other was Dr. Todd Brantley: https://lonestarvision.com/eye-conditions/eye-tracking-problems/
Dr. Brantley assessed my son and programmed a computer program through: Home Therapy System which is a Computerized Home Therapy program that was only specific for my son and his issues after his assessment which was very thorough one. My son had to do this daily and Dr. Brantley could see my son’s progress on his computer in his office and adjust program as needed.
These are just a couple of forms of vision therapy that can be used to assist with eye tracking issues.
We have tried everything it seems to help him with his dyslexia, eye issues and reading! Everything from Bookshare to using IPADs with various apps to assist also.

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After reading the results of the study, this prompted me to question the “top down” approach vs, the “bottom up” approach. This is a summary of these approaches:
Using either a top-down or a bottom-up approach has been introduced to occupational therapy assessment and there has been a long debate about which approach is the most appropriate for contemporary occupational therapy practice (Weinstock-Zlotnick and Hinojosa 2004). Traditionally, bottom-up assessments have been used more frequently in occupational therapy practice and fit within the medical model (Stewart 1999). Bottom-up assessments tend to examine small, separate components of a client’s skills or occupational performance components. They focus primarily on the body structure and function (impairments) level of the International Classification of Functioning, Disability and Health (ICF; World Health Organisation [WHO] 2001). Moreover, bottom-up assessments are frequently administered in contrived, standardised contexts, which may not be meaningful to the client and are often isolated from relevant daily life contexts. One example is the Peabody Developmental Motor Scales, 2nd edition, which evaluates children’s grasping skills by observing them performing several simulated tasks (for example, stacking blocks and placing coins in a small box).

By contrast, top-down assessments take a global perspective and focus on the client’s participation in his or her living contexts to determine what is important and relevant to him or her. This focus is linked more to the activities and participation levels of the ICF (WHO 2001). For example, the Assessment of Motor and Process Skills incorporates a client’s input to determine which tasks are currently meaningful but challenging to his or her life participation and then assesses the client’s occupational performance in real life contexts (Chard 2000). Therefore, the top-down assessment approach can assist occupational therapists to address more realistic and critical occupational issues.

The “top down” is used in medical settings, whereas the “bottom up” is used in more community/home settings. I have begin to assess which approach I use most often, and it is usually the “top down,” Perhaps as OTs we need to further examine our practices, and determine which approach, or a combination best meets the needs of the client. One more question might be is one approach more consistent with evidence-based practice or not?

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Welcome to the Club, @carol2! It is always so great to have new commenters in the threads! I LOVE that you brought up top-down versus bottom-up assessments! I’ve definitely been noticing that in the many studies we’ve looked at that a combination of both types are almost always utilized. Because both give helpful data.

I think it is also important to remember that our current assessments simply aren’t perfect, so I think the other reason it is helpful to do a couple, when possible, is to get a broader understanding of where the patients is at, and avoid the situation where you are relying too heavily on one assessment that maybe isn’t yielding the best data.

I was really influenced in my thinking about assessments by watching this MedBridge course, if anyone else is interested in this topic: https://www.medbridgeeducation.com/courses/details/rehabilitation-research-boot-camp-self-report-and-outcome-measures-ken-learman-physical-therapy

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@julie and @shawna, I think I found the link to the program! I will definitely ask my neuro-ophthalmologist about this next time I see her!
https://visiontherapysolutions.net/hts-inet/

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