Name: robotic mirror therapy system for functional recovery of hemiplegic arms
Uploaded: 2016-08-15T15:00:00
Description: Watch this Scientific Journal Video about Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms at JoVE.com

This work was supported by the Brain Fusion Program of Seoul National University (800-20120444) and the Interdisciplinary Research Initiatives Program from College of Engineering and College of Medicine, Seoul National University (800-20150090).

&#160;All of the procedures were reviewed and approved by the Institutional Review Board of Seoul National University Hospital.
1. Mirror Therapy Tasks
<ol>
	<li>Examples of 2-dimensional mirror therapy tasks (Figure 3)
	<ol>
		<li>Freely move the healthy arm while looking in the mirror about 5 min for warm-up exercise. 
		NOTE: One may utilize a metronome so that the patient can exercise the motion of the healthy arm in a rhythmic manner.</li>
		<li>On healthy side, dribble and place a sma...

<ol>
	<li>Hamzei, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+plasticity+induced+by+mirror+training:+the+mirror+as+the+element+connecting+both+hands+to+one+hemisphere.">Functional plasticity induced by mirror training: the mirror as the element connecting both hands to one hemisphere.</a> Neurorehabil Neural Repair. 26 (5), 484-496 (2012).</li><li>Thieme, H., Mehrholz, J., Pohl, M., Behrens, J., Dohle, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mirror+therapy+for+improving+motor+function+after+stroke.">Mirror therapy for improving motor function after stroke.</a> Cochrane Database Syst Rev. 3, CD008449 (2012).</li><li>Dohle, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mirror+therapy+promotes+recovery+from+severe+hemiparesis:+a+randomized+controlled+trial.">Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial.</a> Neurorehabil Neural Repair. 23 (3), 209-217 (2009).</li><li>Pervane Vural, S., Nakipoglu Yuzer, G. F., Sezgin Ozcan, D., Demir Ozbudak, S., Ozgirgin, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+Mirror+Therapy+in+Stroke+Patients+With+Complex+Regional+Pain+Syndrome+Type+1:+A+Randomized+Controlled+Study.">Effects of Mirror Therapy in Stroke Patients With Complex Regional Pain Syndrome Type 1: A Randomized Controlled Study.</a> Arch Phys Med Rehabil. 97 (4), 575-581 (2016).</li><li>De Santis, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+training+of+the+kinesthetic+sense:+enhancing+proprioception+after+stroke.">Robot-assisted training of the kinesthetic sense: enhancing proprioception after stroke.</a> Front Hum Neurosci. 8, 1037 (2015).</li><li>Smorenburg, A. R., Ledebt, A., Deconinck, F. J., Savelsbergh, G. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Practicing+a+matching+movement+with+a+mirror+in+individuals+with+spastic+hemiplegia.">Practicing a matching movement with a mirror in individuals with spastic hemiplegia.</a> Res Dev Disabil. 34 (9), 2507-2513 (2013).</li><li>Semrau, J. A., Herter, T. M., Scott, S. H., Dukelow, S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+identification+of+kinesthetic+deficits+after+stroke.">Robotic identification of kinesthetic deficits after stroke.</a> Stroke. 44 (12), 3414-3421 (2013).</li><li>Niku, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chapter+4,+Dynamic+Analysis+and+Forces.">Chapter 4, Dynamic Analysis and Forces.</a> Introduction to Robotics: Analysis, Systems, Applications. , (2001).</li><li>Sanford, J., Moreland, J., Swanson, L. R., Stratford, P. W., Gowland, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+the+Fugl-Meyer+assessment+for+testing+motor+performance+in+patients+following+stroke.">Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke.</a> Phys Ther. 73 (7), 447-454 (1993).</li><li>Bohannon, R. W., Smith, M. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interrater+reliability+of+a+modified+Ashworth+scale+of+muscle+spasticity.">Interrater reliability of a modified Ashworth scale of muscle spasticity.</a> Phys Ther. 67 (2), 206-207 (1987).</li><li>Shah, S., Vanclay, F., Cooper, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improving+the+sensitivity+of+the+Barthel+Index+for+stroke+rehabilitation.">Improving the sensitivity of the Barthel Index for stroke rehabilitation.</a> J Clin Epidemiol. 42 (8), 703-709 (1989).</li><li>Lo, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+therapy+for+long-term+upper-limb+impairment+after+stroke.">Robot-assisted therapy for long-term upper-limb impairment after stroke.</a> N Engl J Med. 362 (19), 1772-1783 (2010).</li><li>Ho, N. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+EMG-driven+exoskeleton+hand+robotic+training+device+on+chronic+stroke+subjects:+task+training+system+for+stroke+rehabilitation.">An EMG-driven exoskeleton hand robotic training device on chronic stroke subjects: task training system for stroke rehabilitation.</a> IEEE Int Conf Rehabil Robot. , 5975340 (2011).</li><li>Hesse, S., Schulte-Tigges, G., Konrad, M., Bardeleben, A., Werner, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+arm+trainer+for+the+passive+and+active+practice+of+bilateral+forearm+and+wrist+movements+in+hemiparetic+subjects.">Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects.</a> Arch Phys Med Rehabil. 84 (6), 915-920 (2003).</li><li>Lum, P. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=MIME+robotic+device+for+upper-limb+neurorehabilitation+in+subacute+stroke+subjects:+A+follow-up+study.">MIME robotic device for upper-limb neurorehabilitation in subacute stroke subjects: A follow-up study.</a> J Rehabil Res Dev. 43 (5), 631-642 (2006).</li><li>Yang, C. L., Lin, K. C., Chen, H. C., Wu, C. Y., Chen, C. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pilot+comparative+study+of+unilateral+and+bilateral+robot-assisted+training+on+upper-extremity+performance+in+patients+with+stroke.">Pilot comparative study of unilateral and bilateral robot-assisted training on upper-extremity performance in patients with stroke.</a> Am J Occup Ther. 66 (2), 198-206 (2012).</li><li>Nef, T., Mihelj, M., Riener, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ARMin:+a+robot+for+patient-cooperative+arm+therapy.">ARMin: a robot for patient-cooperative arm therapy.</a> Med Biol Eng Comput. 45 (9), 887-900 (2007).</li><li>Ozkul, F., Barkana, D. E., Demirbas, S. B., Inal, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+proprioceptive+sense+of+the+elbow+joint+with+RehabRoby.">Evaluation of proprioceptive sense of the elbow joint with RehabRoby.</a> IEEE Int Conf Rehabil Robot. , 5975466 (2011).</li><li>Pehlivan, A. U., Celik, O., O'Malley, M. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mechanical+design+of+a+distal+arm+exoskeleton+for+stroke+and+spinal+cord+injury+rehabilitation.">Mechanical design of a distal arm exoskeleton for stroke and spinal cord injury rehabilitation.</a> IEEE Int Conf Rehabil Robot. , 5975428 (2011).</li><li>Zhang, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Feasibility+studies+of+robot-assisted+stroke+rehabilitation+at+clinic+and+home+settings+using+RUPERT.">Feasibility studies of robot-assisted stroke rehabilitation at clinic and home settings using RUPERT.</a> IEEE Int Conf Rehabil Robot. , 5975440 (2011).</li></ol>

The primary purpose of this study was to develop a real-time mirror robot system for functional recovery of a hemiplegic arm using an automatic control algorithm. The effect of robot-assisted therapy on long-term recovery of upper-limb impairment after stroke was proven beneficial in previous studies12, and various kinds of arm robots have been introduced13-20. However, previous studies of upper extremity robots that realized bilateral arm movement applied mechanical connections without using a mirr...

For patients with stroke, dysfunction of a hemiplegic arm has debilitating effect. The ability to perform bimanual activities is essential for daily life, but functional deficit of a hemiplegic arm often remains even a few years after stroke onset. Among various training programs in the hospital, an exercise to increase the range of motion or passive repetition of simple tasks have little effect on functional recovery of a hemiplegic arm. For this reason, training of meaningful tasks related to activities of daily living (ADLs) has been applied to occupational therapy in hospitals.
The effects of mirror therapy were proven by previous studies in neurorehabilitation1-4. Mirror therapy is conducted by eliciting an illusion through use of a mirror as if the hemiplegic arm is moving in real-time while moving the healthy arm. It can facilitate brain neuroplasticity by activation of the sensorimotor cortex1. Thus, motor power and function of the hemiplegic arm can be improved. However, conventional mirror therapy has a critical limitation in that the hemiplegic arm is not actually moving.
Therefore, we developed a real-time 2-axis mirror robot system as a simple add-on module to conventional mirror therapy, using closed feedback mechanism. This may convey proprioceptive input to the sensory cortex, which is considered important in neuroplasticity and functional recovery of a hemiplegic arm (Figures 1 and 2)5-7.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>LabVIEW</td>
			<td>National Instruments</td>
			<td></td>
			<td>System design software</td>
		</tr>
		<tr>
			<td>24V power supply</td>
			<td>XP Power</td>
			<td>MHP1000PS24 24V</td>
			<td>Any 24V power supply should do</td>
		</tr>
		<tr>
			<td>AHRS sensor receiver</td>
			<td>E2box</td>
			<td>EBRF24GRCV</td>
			<td></td>
		</tr>
		<tr>
			<td>AHRS sensors</td>
			<td>E2box</td>
			<td>EBIMU-9DOFV2</td>
			<td>You will need total 3 sensors. Any AHRS sensors will do</td>
		</tr>
		<tr>
			<td>EC90 flat motor module</td>
			<td>Maxon</td>
			<td>323772 + 223094 + 453231</td>
			<td>Any geared motor with higher than 30Nm should do. (For our custom machined parts, you will need these particular flat motor and gear module, but the gear ratio and encoder may vary)&#160;</td>
		</tr>
		<tr>
			<td>EC45 flat motor module</td>
			<td>Maxon</td>
			<td>397172</td>
			<td>Any geared motor with higher than 10Nm should do (For our custom machined parts, you should use the same gear module but the gear ratio, motor, and encoder may vary)</td>
		</tr>
		<tr>
			<td>EPOS2 70/10 controller</td>
			<td>Maxon</td>
			<td>375711</td>
			<td>This can be replaced with EPOS 24/5 controller</td>
		</tr>
		<tr>
			<td>EPOS2 24/5 controller</td>
			<td>Maxon</td>
			<td>367676</td>
			<td></td>
		</tr>
		<tr>
			<td>Connector and cable set</td>
			<td>Maxon</td>
			<td>381405 + 384915 + 275934 + 354045</td>
			<td>You can also make these cables. Connectors and corresponding wire info can be found in &#34;300583-Hardware-Reference-En.pdf&#34; and &#34;300583-Cable-Starting-Set-En.pdf&#34;</td>
		</tr>
		<tr>
			<td>Coupling- Oldham, Set Screw Type</td>
			<td>Misumi</td>
			<td>MCORK30-10-12</td>
			<td>Type may vary</td>
		</tr>
		<tr>
			<td>Coupling- High Rigidity, Oldham, 
			Set Screw Type</td>
			<td>Misumi</td>
			<td>MCOGRK34-12-12</td>
			<td>Type may vary</td>
		</tr>
		<tr>
			<td>Shaft Collars</td>
			<td>Misumi</td>
			<td>SCWDM10-B &#160;</td>
			<td>You will need 4 sets</td>
		</tr>
		<tr>
			<td>Shaft Collars</td>
			<td>Misumi</td>
			<td>SDBJ10-8</td>
			<td>You will need 2 sets</td>
		</tr>
		<tr>
			<td>Precision Linear Shaft</td>
			<td>Misumi</td>
			<td>&#160;PSSFG10-200</td>
			<td>Any straight 10mm diameter shaft with at least 200mm length should do&#160;</td>
		</tr>
		<tr>
			<td>Bearings with housings</td>
			<td>Misumi</td>
			<td>BGRAB6801ZZ</td>
			<td></td>
		</tr>
		<tr>
			<td>Elbow motor force dispersion shaft&#160;</td>
			<td>custom machined</td>
			<td>3D CAD&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Lower elbow support</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Elbow rooftop frame</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Support wall</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td>You will need 2 frames.</td>
		</tr>
		<tr>
			<td>Elbow coupling hollow cylinder cover&#160;</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Wrist motor force dispersion shaft</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Wrist rooftop frame</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Upper wrist coupling hollow cylinder cover</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Lower wrist coupling hollow cylinder cover</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Joint movement limiter</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Handle</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Upper elbow support</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Friction reduction ring</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Acrylic mirror</td>
			<td>custom laser cutting</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Task table</td>
			<td>custom machined</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Silicone sponge</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>DOF limiter</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>DOF limiter lid</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Healthyarm handle</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Ball rollers - Press fit</td>
			<td>Misumi</td>
			<td>BCHA18</td>
			<td></td>
		</tr>
		<tr>
			<td>Goalpost</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Circle trace</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
		<tr>
			<td>Angled assist</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td>Optional</td>
		</tr>
		<tr>
			<td>Curved assist</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td>Optional</td>
		</tr>
		<tr>
			<td>Plain assist</td>
			<td>3D printed</td>
			<td>Part Drawings</td>
			<td>Optional</td>
		</tr>
		<tr>
			<td>Task board</td>
			<td>custom laser cutting</td>
			<td>Part Drawings</td>
			<td></td>
		</tr>
	</tbody>
</table>

robotic mirror therapy system for functional recovery of hemiplegic arms

Mirror therapy has been performed as effective occupational therapy in a clinical setting for functional recovery of a hemiplegic arm after stroke. It is conducted by eliciting an illusion through use of a mirror as if the hemiplegic arm is moving in real-time while moving the healthy arm. It can facilitate brain neuroplasticity through activation of the sensorimotor cortex. However, conventional mirror therapy has a critical limitation in that the hemiplegic arm is not actually moving. Thus, we developed a real-time 2-axis mirror robot system as a simple add-on module for conventional mirror therapy using a closed feedback mechanism, which enables real-time movement of the hemiplegic arm. We used 3 Attitude and Heading Reference System sensors, 2 brushless DC motors for elbow and wrist joints, and exoskeletal frames. In a feasibility study on 6 healthy subjects, robotic mirror therapy was safe and feasible. We further selected tasks useful for activities of daily living training through feedback from rehabilitation doctors. A chronic stroke patient showed improvement in the Fugl-Meyer assessment scale and elbow flexor spasticity after a 2-week application of the mirror robot system. Robotic mirror therapy may enhance proprioceptive input to the sensory cortex, which is considered to be important in neuroplasticity and functional recovery of hemiplegic arms. The mirror robot system presented herein can be easily developed and utilized effectively to advance occupational therapy.

Six healthy subjects conducted a &#39;pen marking task&#39; (touching the two small boards alternately with a pen attached on the healthy hand as shown in Figure 17) 10 times which took on average 106 sec per subject. No adverse event was observed, and robotic mirror therapy was proven to be feasible.
In addition, a clinical study on rehabilitation doctors was conducted. We requested expert opinions to determine...

Watch this Scientific Journal Video about Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms at JoVE.com

Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms

We developed a real-time mirror robot system for functional recovery of hemiplegic arms using automatic control technology, conducted a clinical study on healthy subjects, and determined tasks through feedback from rehabilitation doctors. This simple mirror robot can be applied effectively to occupational therapy in stroke patients with a hemiplegic arm.

Mirror therapy has been performed as effective occupational therapy in a clinical setting for functional recovery of a hemiplegic arm after stroke. It is ...

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