SpinalCure Australia is pleased to announce that $20,000 has been granted to Dr Camila Quel De Oliveira, Lecturer of Physiotherapy at UTS, to conduct a feasibility study into a robotic-assisted game-based rehabilitation program for arm and hand function in people with SCI.
“Not having arm and hand function is very limiting for people with SCI – for their independence and participation in the community…it affects their everyday activities such as pushing their wheelchair, feeding independently, dressing or having a shower,” said Dr Quel De Oliveira.
“For people with tetraplegia, reduced hand function and arm function is one of the most common impairments, and today, besides rehabilitation efforts, the recovery of arm and hand function is limited”.
“I believe that robotics has the potential to improve outcomes in arm and hand function for people with SCI.”
Robotics and gaming combined
Camila Quel De Oliveira’s study will be using robotics and gaming combined.
While robotics allows for a large number of repetitions, the gaming component adds a motivational element to the training.
“The combination of robotics and gaming could help therapists to improve motor function and provide better patient outcomes. The reason why is that robotics allows us to perform a greater number of repetitions compared to what you would get in a conventional physiotherapy session. And the gaming component can enhances the motivation during training. When you are playing a game, you do not pay attention to each movement you perform – you do not realise how many repetitions you are doing. Hence, having a game component to training makes it more engaging and stimulating”.
“If you ask someone who is playing a video game, ‘how many times have you moved your thumb’? The person may have moved their thumb hundreds of times without even realising, so the whole idea is to instead of asking the patient, ‘Can you do 20 repetitions of this movement’, is that they do it in a fun, engaging, motivating way,” she added.
Real-time feedback important for recovery
The ability to give patients real-time feedback will be an important aspect of the study.
“Besides the motivational component, the devices allow us to provide real time feedback to let the patient know if they are doing the movement correctly or incorrectly, which is an important element for recovery”.
Motivation, repetition and feedback are three essential components to lead to changes in the nervous system and promote neuroplasticity, Dr Quel De Oliveira explained.
Study to begin recruiting patients in August
Dr Quel De Oliveira is planning to start recruiting 15 patients around August 2019 and to have the entire project completed by September 2020.
The training protocol will consist of 10 sessions per person, three times per week.
“In the past, it was believed that people [with SCI] could not respond to activities that stimulate the paralysed areas, but there is new body of evidence that shows that the spinal cord responds to exercise in the paralysed areas. This had been largely investigated with interventions targeted to the lower limbs involving standing and walking but there is still not enough evidence to show that we can have similar results when training the affected arm and hand. It is possible that if we apply exercises at a high dosage (task specific exercises which we can do with robotics) we can achieve improvements in function”.
The ultimate goal of the study
Dr Quel De Oliveira’s goal is to collect pilot data for a larger clinical study to be performed.
“[If this study is successful], the next step would be to do a larger study and compare this exercise program through robotics with conventional therapies … and assess if one is superior to the other”.
Dr Quel De Oliveira says that they will be looking at the level of independence of the patients and their ability to move their arms before and after the treatment.
“The outcomes we are interested in are: independence – can people use their arms/hands during activities of daily living? the amount of arm and hand movement; and the possible impact on their quality of life.
“But at this stage, our main aim is to know the participants’ opinion about using robotics for training their arm and hand.
“We will ask the participants ‘How much did you enjoy robotic training?’; ‘Did you think it was beneficial?’”.
“Participants opinions and perceptions are essential when implementing new therapies and technologies. There is no point in testing or implementing new therapies and technologies if people (the consumer) do not see the benefit.
“We will evaluate patients’ opinions via a numerical questionnaire and focus group discussions.
The training protocol will consist of 10 sessions per person, three times per week for 15 patients.
The other step will be to check cost effectiveness.
“It has been shown in the stroke population, that robotics is cost-effective as it reduces the need of constant supervision from a therapist. The robotics devices are quite expensive, but on the other hand allow for less hands-on assistance from a therapist.
“So, if this pilot study can show that robotics is feasible and is accepted by the patients, then the future step would be to investigate its cost-effectiveness when treating people with SCI before trying to implement this therapy on a broader scale,” she added.
Research in this field
Robotics have been proven successful in helping rehabilitate people with stroke.
“It has been shown in people with a stroke that using robotics to train arm and hand function is effective and allows for an increased number of repetitions and increased training intensity”.
Robotics have also been investigated before as a treatment for the arm and hand in people with SCI.
“However, we have not come across any studies that used robotics for people with SCI as a training program targeting the UL joints individually. This study aims to investigate the feasibility of an exercise protocol involving three different game-based robotic devices”.
“Furthermore, although robotics have been investigated before in research settings, it is not commonly found in community-based or inpatient clinics for people with SCI, hence the novel component [of the study], said Dr Quel De Oliveira.
‘Very grateful to SCA’
Dr Quel De Oliveira says getting the funding for this study has not been easy.
“It has been hard to find funding because [people with] spinal cord injury in Australia make up a small group, therefore the funding available is limited.
“I am very grateful to SCA for the trust that they put in my work,” Dr Quel De Oliveira says.
The grant will cover costs for the entire study — for research assistants, advertising and some of the consumables for the machines. The machines were purchased by UTS.
The technology that will be used
Three machines will be used in the study, all produced by the Austrian company Tyromotion.
A machine called DIEGO reduces arm weight to facilitate muscle movement in the shoulders. If the patient has even just a little bit of muscle contraction, the machine will help them to complete the movement.
A machine called Amadeo helps with finger and hand exercises. It assists the patient to make a fist, open the hand and helps with individual finger movement.
“If a patient has a little bit of movement, the machine will finish it for them, but if they have some active hand control, the machine can resist the movement to make it hard and strengthen the muscles. We can adjust the training according to the level of ability of each patient,” said Dr Quel De Oliveira.
“If a patient has even just a little bit of movement, the machine will assist them through the movement, but if they have active hand control, we can add resistance to make it harder, so it adjusts to the level of each patient,” said Dr Quel De Oliveira.
‘We need to expand the way we treat people with SCI’
The relationship between SpinalCure Australia and Dr Quel De Oliveira goes all the way back to 2011 when SpinalCure Australia and Spinal Cord Injuries Australia jointly funded her PhD scholarship to investigate the benefits of the NeuroMoves exercise program in Australia.
And Dr Quel De Oliveira’s motivation to help people with SCI remains strong.
“I believe that there is more that we can do for people with SCI,” said Dr Quel De Oliveira.
“I believe that now that we have stem cells and epidural stimulation, we need to change the way that we see spinal cord injuries and the way that we rehabilitate it. We can no longer limit our rehabilitation strategies according to the severity and level of injury. Those new technologies increase the possibilities for recovery and rehabilitation strategies will have to follow and adapt.
“It is a changing environment so we are going to have to expand the way that we see and we treat people with SCI.”
If you are interested in taking part in the pilot, you can email Camila at [email protected]
Please see below for previous research that guided the development of this protocol.
– Cheung EYY, Ng TKW, Yu KKK, Kwan RLC, Cheing GLY. Robot-Assisted Training for People With Spinal Cord Injury: A Meta-Analysis. Arch Phys Med Rehabil. 2017;98(11):2320-31.
– Singh H, Unger J, Zariffa J, Pakosh M, Jaglal S, Craven BC, et al. Robot-assisted upper extremity rehabilitation for cervical spinal cord injuries: a systematic scoping review. Disabil Rehabil-Assist Technol. 2018;13(7):704-15.
– Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a Robotic Rehabilitation Device on Upper Limb Function in a Sub-Acute Cervical Spinal Cord Injury Population. 2011 Ieee International Conference on Rehabilitation Robotics. International Conference on Rehabilitation Robotics ICORR2011.SpinalCure Australia funds program to help rehabilitate hand and arm function for people with SCI