Neurorehabilitation for Stroke:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
Definition of Cost Effectiveness:
Equal or less expensive than existing
treatment programmes (Clinical Trials).
✓
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Effectiveness:
Persistent neuro-anatomical and neurophysiological changes that occur during
recovery from stroke (Type 1 research).
✓
✓
✓
✓
✓?
Optimization and Prediction:
Account for direct and indirect health costs
for each component step of intervention and
follow-up healthcare needs (HS research).
Objective:
Use a better model of clinical neuroplasticity
to drive effective treatment (Delivery).
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)
Neurorehabilitation for Stroke - Feasibility:
The Case for Robot-Assisted Therapy of the Upper Limb
Ref
Active
X
Y
NW
S
Robot-mediated reaching can be partnered with state-of-the-art technologies to study mechanisms
responsible for motor learning during healthy development and in clinical populations.
d.l.turner@uel.ac.uk
Turner et al. 2013 Frontiers in Neurology 8:184
Neurorehabilitation for Stroke – Feasibility:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
Definition of Cost Effectiveness:
Equal or less expensive than existing
treatment programmes (Clinical Trials).
✓
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Effectiveness:
Persistent neuro-anatomical and neurophysiological changes that occur during
recovery from stroke (Type 1 research).
✓
✓
✓
✓
✓?
Optimization and Prediction:
Account for direct and indirect health costs
for each component step of intervention and
follow-up healthcare needs (HS research).
Objective:
Use a better model of clinical neuroplasticity
to drive effective treatment (Delivery).
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)
Neurorehabilitation for Stroke - Feasibility:
70
70
60
60
60
50
40
30
20
10
0
MID
30
20
10
MID
*
20
10
0
50
40
30
20
*
10
MID
POST FOL1
20
10
MID
POST FOL1
RM ANOVA F=13.9; P=0.002
60 Values are mean ± SD; N=10
*, Sig. Diff. vs. All Others
50 Bonferroni p=0.016
40
30
20
10
0
PRE
30
70
LOWER ARM FM Score
40
40
PRE
RM ANOVA F=14.3; P=0.001
60
50
50
POST FOL1
70
RM ANOVA F=15.8; P=0.001
RRA0001
RRA0002
RRA0004
RRA0006
RRA0007
RRA0008
RRA0010
RRA0011
RRA0013
RRA0014
0
PRE
UPPER ARM FM Score
TOTAL FM Score
40
POST FOL1
60
30
50
0
PRE
70
LOWER ARM FM Score
70
UPPER ARM FM Score
TOTAL FM Score
Clinical effectiveness: Robot therapy for everyone?
*
0
PRE
MID
POST FOL1
PRE
MID
POST FOL1
Early robot therapy is feasible at the population level, but not for all individuals.
d.l.turner@uel.ac.uk
Turner et al. 2012 Clin Neurophysiol.;123, 183-192
Neurorehabilitation for Stroke - Feasibility:
Clinical effectiveness: Robot Measures
0.06
RRA3 1ST
RRA3 2ND
FM = 11
0.00
ERROR (m)
Y position (m)
0.12
-0.06
Y position (m)
0.06
RRA3 3RD
RRA3 4TH
FM = 54
0.00
-0.06
Y position (m)
0.12
0.06
RRA3 5TH
H S2
FORCE (N)
-0.12
O
0
FM = 61
0.00
O
O
270
90
-0.06
RRA3 1ST
RRA3 5TH
H S2 1ST
H S2 2ND
0.09
0.06
0.03
0.00
0.0
-1
0.12
FORCE RATE (N s )
-0.12
0.12
2.8
40
20
0
-20
-40
8.4
11.2
8.4
11.2
14.0
16.8
14.0
16.8
19.6
22.4
19.6
22.4
19.6
22.4
UP
DOWN
0.0
30
5.6
0
2.8
O
5.6
90
O
180
O
270
O
20
10
0
0.0
2.8
5.6
8.4
11.2
TIME (s)
14.0
16.8
O
-0.12
-0.12
-0.06
0.00
0.06
X position (m)
0.12 -0.12
-0.06
180
0.00
0.06
0.12
X position (m)
Early robot therapy may improve position-holding control after stroke
d.l.turner@uel.ac.uk
Turner et al. 2012 Clin Neurophysiol.;123, 183-192
Neurorehabilitation for Stroke – Group Evidence:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
Definition of Cost Effectiveness:
Equal or less expensive than existing
treatment programmes (Clinical Trials).
✓
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Effectiveness:
Persistent neuro-anatomical and neurophysiological changes that occur during
recovery from stroke (Type 1 research).
✓
✓
✓
✓
✓?
Optimization and Prediction:
Account for direct and indirect health costs
for each component step of intervention and
follow-up healthcare needs (HS research).
Objective:
Use a better model of clinical neuroplasticity
to drive effective treatment (Delivery).
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)
Neurorehabilitation for Stroke – Group Evidence:
Clinical Effectiveness – Functional Outcome (F-M)
Robot-assisted upper limb therapy improves motor impairment
d.l.turner@uel.ac.uk
Norouzi-Gheidari et al. 2012 JRRD, 49,479,-496
Neurorehabilitation for Stroke – Group Evidence:
Clinical Effectiveness: Meta-analysis
Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of
the Stroke Patient: A Scientific Statement From the American Heart Association [Stroke
2010; 41:2402-2448]
Statement regarding ICF: Body function and structure
‘Varied repetitive task practice (e.g. CIMT, robot-assisted therapy) to improve UE motor
coordination in individuals with some voluntary finger extension in outpatient and chronic care
settings is recommended; it is reasonable to do so in inpatient settings. No recommendations are
made for one type of varied repetitive task practice over another.’
Robustness of Useful Impact for function and structure
In-Patient Setting - Class IIa; Level of Evidence A
Out-Patient Setting - Class I; Level of Evidence A
Community Care Setting - Class I; Level of Evidence A
Robotics Can Deliver for Upper Limb Functional Recovery.
d.l.turner@uel.ac.uk
Stroke 2010; 41:2402-2448
Neurorehabilitation for Stroke – Group Evidence:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
Definition of Cost Effectiveness:
Equal or less expensive than existing
treatment programmes (Clinical Trials).
✓
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Effectiveness:
Persistent neuro-anatomical and neurophysiological changes that occur during
recovery from stroke (Type 1 research).
✓
✓
✓
✓
✓?
Optimization and Prediction:
Account for direct and indirect health costs
for each component step of intervention and
follow-up healthcare needs (HS research).
Objective:
Use a better model of clinical neuroplasticity
to drive effective treatment (Delivery).
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)
Neurorehabilitation for Stroke – Group Evidence:
Cost Effectiveness: How much does the therapy cost?
Robot-assisted therapy costs are cheaper than matched intensive
physical therapy for chronic stroke.
d.l.turner@uel.ac.uk
Wagner et al . 2011 Stroke 42, 2630-2632
Neurorehabilitation for Stroke – Group Evidence:
Cost Effectiveness: What are the follow-up costs?
Robot-assisted therapy costs are competitive for chronic stroke
d.l.turner@uel.ac.uk
Wagner et al . 2011 Stroke 42, 2630-2632
Neurorehabilitation for Stroke – RCT Design:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
Definition of Cost Effectiveness:
Equal or less expensive than existing
treatment programmes (Clinical Trials).
✓
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Effectiveness:
Persistent neuro-anatomical and neurophysiological changes that occur during
recovery from stroke (Type 1 research).
✓
✓
✓
✓
✓?
Optimization and Prediction:
Account for direct and indirect health costs
for each component step of intervention and
follow-up healthcare needs (HS research).
Objective:
Use a better model of clinical neuroplasticity
to drive effective treatment (Delivery).
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)
Neurorehabilitation for Stroke – RCT Design:
Pragmatic Testing of Robot-Assisted Therapy - RATULS
Robot therapy comprises a comprehensive programme of adaptive
assisted reaching, wrist movements and grasping over 12 weeks.
d.l.turner@uel.ac.uk
Rodgers et al . 2014-8 funded by NIHR-HTA
Neurorehabilitation for Stroke - Issues:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Neuro-Effectiveness:
Minimal but promising evidence.
✓
Definition of Cost Effectiveness:
Promising in certain healthcare systems.
May save €300m of €64b EU cost per year.
✓
Optimization:
Patient-centred modelling lacking.
✓
✓
✓
✓?
Prediction:
Neural correlates of successful treatment
lacking.
Framework Objective:
Use a better model of clinical
neuroplasticity to drive effective
treatment.
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)
Neurorehabilitation for Stroke - Future:
Reaching for a Metropolitan Robot Therapy Service
NRU-UEL
d.l.turner@uel.ac.uk
cf. Hunter et al PLOS One 2013; 8:e70420; Morris et al BMJ 2014;349:g4757
Neurorehabilitation for Stroke - Drivers:
Embedded in the Greater Context of RAS-UK
d.l.turner@uel.ac.uk
Neurorehabilitation for Stroke:
The Case for Robot-Assisted Therapy of the Upper Limb
✓
✓
?
Definition of Cost Effectiveness:
Equal or less expensive than existing
treatment programmes (Clinical Trials).
✓
✓
Efficacy and Mechanisms:
Animal Models of Neuroplasticity;
Motor Learning and the Brain;
Recovery from Stroke = Motor Learning?;
Clinical Neuroplasticity (Basic Sciences).
Definition of Clinical Effectiveness:
Persistent neuro-anatomical and neurophysiological changes that occur during
recovery from stroke (Type 1 research).
✓
✓
✓
✓
✓?
Optimization and Prediction:
Account for direct and indirect health costs
for each component step of intervention and
follow-up healthcare needs (HS research).
Objective:
Use a better model of clinical neuroplasticity
to drive effective treatment (Delivery).
d.l.turner@uel.ac.uk
from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)