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A Little Help From Technology

Therapy With Robots Help Stroke Victims Regain Movement

New York (Jul 21, 2010)

Male patient with e100 robotic device on his arm eats with a fork
A patient uses the e100 robotic arm
(photo courtesy of Myomo)

Every year, three quarters of a million Americans suffer a stroke. Half of those who survive end up with partial paralysis in one or more limbs and most need intensive rehabilitation to restore a significant level of function. The loss of arm function, in particular, poses a daunting challenge to performing simple daily tasks like eating, washing, brushing teeth, and loading the dishwasher. But technology may be easing the way as several promising devices are coming into use.

One such tool is the Myomo e100 NeuroRobotic System™, a robotic arm brace designed by a team of Massachusetts Institute of Technology (MIT) engineers, that straps on to the arm and elbow. Through a technique known as electromyography, surface electrodes on the skin read electrical signals created by the flexor or extensor muscles around the elbow. The muscles signal impulses that control the machine. If, for example, the bicep tenses to lift the forearm, the electrodes sense that impulse and the device begins to lift the arm.

Everyone, Everything Chips In

It is important to note that the Myomo does not do all the work. It senses and begins the movement, and the person completes the motion. "I liken the Myomo's function to that of power steering in a car," says Joel Stein, M.D., Director of the Rehabilitation Medicine Service and Physiatrist-in-Chief at NewYork-Presbyterian. "It offers proportional assistance, but it does not complete the job on its own."

Joel Stein, M.D.
Joel Stein, M.D.

The intention, in fact, is for the body to re-learn its own motor skills. Explains Dr. Stein, "The brain is quite capable of what is known as cerebral plasticity; that is, it can rewire itself to learn new motor skills. After enough repetition, the body will be able to function on its own, without the device." In a pilot study of this device that he conducted, Dr. Stein has seen as much as a 23% improvement in arm movement.

To be a candidate for the Myomo device, a patient must have preserved passive range of motion at the elbow, at least a trace amount of muscle activation in the bicep or tricep muscle, and cannot have excessive muscle stiffness. For now, patients must use the device with a trained therapist in a hospital or clinic, although that may evolve into programs for home use for approved and trained patients, according to Lisa Finnen, Supervisor of Occupational Therapy at NewYork-Presbyterian.

Michael O'Dell, M.D.
Michael O'Dell, M.D.

While the Myomo device is specifically designed for the arm, other robotic devices are being tested for different stroke-affected areas. NewYork Presbyterian's Columbia campus is currently enrolling participants in a study of Tyromotion's Amadeo device, a hand robot meant to improve finger movement. Clinicians are also seeking participants for a clinical trial of a battery-powered robotic knee device developed by Tibion, which is being studied as a means of helping stroke survivors walk and climb stairs more easily.

Wide Appeal But Still Determining How Much is Enough

One remarkable feature of these devices is their seeming effectiveness even in people whose strokes may have occurred years earlier. "It is often thought that a stroke survivor has a relatively short window of opportunity to improve function - a matter of months. But we are seeing some improvement in control even in the chronic phase," says Dr. Stein. Lisa Finnen concurs. She observes, "We see faster gains with patients who have experienced more recent impairment, but this therapy may offer hope to some people in the chronic stage who have reached a plateau with their prior therapy."

Lisa Finnen, O.T.R/L
Lisa Finnen, O.T.R/L

Researchers are still grappling with how much therapy is enough. Lisa Finnen sees Myomo patients two to three times a week for a half hour session for a period of two to three months. But she would recommend using the device for a few hours a day where feasible, preferably while performing other tasks. Michael W. O'Dell, M.D., Chief of Clinical Services, Rehabilitation Medicine and Medical Director of the Inpatient Rehabilitation Unit at NewYork-Presbyterian/Weill Cornell Medical Center, has seen patients dramatically improve through the use of Constraint-Induced Movement Therapy (CIMT), a non-robotic therapy. CIMT is a very intense approach in which the stronger arm is temporarily restricted and the weak arm is forced to exercise. The classic CIMT regimen lasts six hours a day for two weeks. "Two factors are at work," he says, "repetition and task-specific activity. By focusing on those two goals, therapists can achieve quite a bit in a relatively short-time." The drawback to CIMT is that it is very labor intensive, for both the patient and the clinical staff, and thus quite expensive. A modified CIMT program, more manageable for patients, is now offered at both campuses of NewYork-Presbyterian.

Dr. O'Dell believes strongly in the benefits of functional electrical stimulation, a technique that uses a low-level electrical current to activate nerves. This summer, NewYork-Presbyterian will begin testing a new, non-robotic technology known as the Bioness L300™, a device that provides electrical stimulation to the nerves in the leg and aims to help stroke survivors improve their walking ability. The testing is part of a major clinical trial known as the FASTEST Study that is taking place at NewYork-Presbyterian and nine other sites. "I have found this device helpful for individual patients, and I am hopeful that proof of efficacy will lead to broader insurance coverage of this device," says Dr. O'Dell.

"Robotic technology is in its juvenile phase," notes Dr. Stein. "Recovery is achievable through a variety of techniques and no single tool is the perfect answer." While Dr. Stein can't predict which particular devices will succeed, he is certain that the non-invasive, non-pharmaceutical nature of robotic interventions will propel them into widespread use within a few years.

Contributing faculty for this article:

Joel Stein, M.D. is the Director of the Rehabilitation Medicine Service and Physiatrist-in-Chief at NewYork-Presbyterian Hospital. He is also a Professor of Clinical Rehabilitation Medicine at Weill Cornell Medical College.

Michael W. O'Dell, M.D. is the Chief of Clinical Services, Rehabilitation Medicine and Medical Director of the Inpatient Rehabilitation Unit at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. He is also a Professor of Clinical Rehabilitation Medicine at Weill Cornell Medical College.

Lisa Finnen, O.T.R/L is Supervisor of Occupational Therapy at NewYork-Presbyterian Hospital.

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