The Importance of Visuo-Motor Coordination in Upper Limb Rehabilitation After Ischemic Stroke by Robotic Therapy
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The importance of visuo-motor coordination in upper limb rehabilitation after ischemic stroke by robotic therapy Angelo Bulboaca1,2, Ioana Stanescu1,2, Gabriela Dogaru 1,2, Paul-Mihai Boarescu1, Adriana Elena Bulboaca1,2 1 Corresponding author: Paul-Mihai Boarescu , E-mail: [email protected] , Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2019.244 Vol.10, No.2, May 2019 p: 82–89 1. "Iuliu-Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania 2. Clinical Rehabilitation Hospital, Cluj-Napoca, Romania Abstract Stroke is an acute hypoperfusion of cerebral parenchyma that most often leads to outstanding motor deficits that can last for the rest of the patient’s life. The purpose of the neurorehabilitation process is to limit, as far is possible for the motor deficits and to bring the patient to an independent life. A modern method consists in robotic neurorehabilitation which is more and more used, associated with functional electrical stimulation (FES). At the lower limb, the use of robotic rehabilitation associated with FES is already considered a success due to relatively stereotypical movements of the lower limb. In opposition, the upper limb is more difficult to rehabilitate due to its more complex movements. Therefore, eye-hand coordination (EHC) constitutes an important factor that is conditioning the rehabilitation progress. The eye-hand coordination can be brutally disturbed by stroke with critical consequences on motor-executive component. The EHC development depends on the interaction between a feedback complex and the prediction of the upper limb motility in the space, and requires the association between visual system, oculomotor system and hand motor system. We analyzed the stroke impact on this sensorial-motor functional integration and looked for a possible solution for the interruption of coordination between eyes and the movements of the superior limb. We consider that our study can contribute to a better understanding and to a faster rehabilitation of the motor deficit in the upper limb after stroke. Key words: stroke, rehabilitation, eye-hand coordination, robotic neurorehabilitation, Introduction Stroke is defined as a rapid onset of neurological focal efficiency of motor deficiency recovery therapies. It deficit, symptoms caused by a vascular lesion of the is currently one of essential therapeutic tools for cerebral parenchyma. The syndromes resulting are restorative therapy of lost functions and return to various and greatly depending on aetiology, severity, functional independence in order to improve day by prognosis and recovery possibilities. Over the past 20 day activity for stroke survivors who experience years an important changes in the early diagnosis, limitation of mobility and communication (9). The treatment and rehabilitation techniques were made (1- results of a systematic review of studies that 4). Stroke is the fourth killer and the first cause of investigated the outcome after rehabilitation assisted adult long term disability in United States (US) (5). by robotic therapy after stroke, compared with The worldwide impact of stroke seems to be more classical physical therapy was presented by Kwakkel higher than it is in US (6). The rehabilitation interval et al (10). This study reveals a moderate but has a window when the neuroplasticity is maximum, statistically significant better upper limb motor during which, the brain ability for rehabilitation is rehabilitation results for patients where robotic enhanced (5). In this context, robotic rehabilitation assisted therapy was used, compared with (RR), one of the most modern technique is intensively conventional therapy. In addition, computer assisted studied in this century along with using devices for regaining upper limb function can mechanotronics technologies and computer software optimize the required movement pattern (10). By this development (7, 8). RR can facilitate and increase the technology, more personalized therapy, specific for 82 each patient needs, can be assigned better by robotics training, because patient’s satisfaction can increase than by conventional rehabilitation methods. There the efficiency of rehabilitation therapy. are still more studies needed in order to differentiate The aim of this paper is focused on analyzing the the mechanism of rehabilitation in robotic assisted robotic rehabilitation therapy (type II technology), therapy, where is a recovery based on neuronal repair, dedicated to upper limb rehabilitation, in order to and where is a recovery based on compensation improve its motor performances. The vault key of RR strategies (11). that offer flexibility to “human-robotic arm” interface The functional outcome in stroke rehabilitation is represented by biomimetics. We intend to create a strategies has two targets: one dedicated to upper limb basic framework and offer a new perspective, more motor recovery, and one dedicated to lower limb advanced on human –technology integration, motor recovery. Differentiation in applied hopefully for improving therapeutic efficiency in rehabilitation strategies must take into account the stroke rehabilitation strategies. spatial complexity of the upper limb movement, compared to the relatively stereotypic lower limb Human-robotic interface – role in stroke movement into environment. For the upper limb, rehabilitation movements are automatic or voluntary, goal oriented. For the lower limb there are rhythmic movements for the locomotion and gait (12). These differences are Engineering systems became more and more reflected in speed, amplitude and directions of sophisticated and “intelligent”. For a good movements for each part of the body, in a particular functioning and respect for biomimetic principle, a pattern, that can be controlled by robotic assisted robotic system must present three components: therapy (12). stimulating component, the possibility of recording From a functional point of view, the robotic technique the action potential and integration of the information can be dedicated to mobilizing a limb with no (18). The training has to be gradual in amplitude and function (type I) or mobilizing a limb with a partially force in order to protect the joints (18). The Fugl- lost function and still possessing a variable grade of Meyer (FM) score at time of admission can be muscle strength (13). Adding feed-back mechanisms important for timing the rehabilitation procedures, can have a complementary role in improving shorter robotic training periods being helpful for rehabilitation, especially in prosthetic upper limb patients with lower admission (FM) scores and rehabilitation, due to empowering the users to correct greater upper extremity impairment, followed by their movements in order to get better results (14). longer training periods that can bring new Most of the clinical studies refer to the grasping force improvements. Some of the patients can also improve as a variable that can be controlled by feed-back when their rehabilitation performances after the ending the the patient vision is not able to evaluate it (15). Recent robotic training (18). studies reported that it is possible to improve the Rehabilitation efficiency can be controlled by efficiency of the feedback mechanism by introducing imagistic methods that can assess the progression of a somatosensory feedback and transferring the recovery of lost functions. Integration of robotic stimulus (without translation) directly to the technology with brain imaging, especially those that peripheral nerve endings which are directly are able to visualize the function of the brain could stimulated by this functional loop (16). An important bring a real contribution to understand the conclusion regarding the sensiomotor assisted rehabilitation process. One of the most used imaging prosthesis with feedback function consists in ability technique is represented by positron emission of the patient to grade them the force of contraction, tomography (PET) of the brain, that is able to in order to execute a movement to a target, after the visualise brain activity in different tasks that imply device is removed and after a proper training and a different brain areas functioning. For an adult subject consistent quantitative acquisition of muscular force (right handed) there are early learning process and was made (17). The force generated after the device late learning process each of these processes is removed is about 30-50% from the force generated involving different cortical areas (13). Due to with prosthesis (17). This aspect is important for self- continued advancement of radioligands and due to recent integration of PET and magnetic resonance 83 imaging (MRI) a new window for exploration of can be diminished by choosing a proper stimulation brain function was opened. MRI having a better parameters, by using of an appropriate electrodes and spatial and temporal resolution can substantial by the the correct choice of stimulation (10, 23). contribute to functional assessment of the brain The recording of action potentials, for the robotic arm during rehabilitation process, through functional MRI device, is also an important component of robotic exploration variant (19). Both of techniques are able rehabilitation process. The coordinated movement to capture a designed activity of the brain during involves a two ways shifts (nervous command from learning process of manipulating objects by robotic the central nervous system to the muscles and a feed- devices and to observe the brain