Robotics in Physiotherapy

Physiotherapeutic Robotics (PR), the use of mechanical devices for rehabilitation and clinical/functional assessment, is one of the faster growing branches in physiotherapy science. Although we can trace the use of mechanical devices in the health sciences back to Hippocrates’s pulleys and traction machines for bones and muscles, PR is today a much more complex field which includes not only medical mechatronics and related sup-porting technologies, such as cognitive neural prosthetics, but also extends to the high-tech areas of monitoring systems, assistive devices, virtual reality, or the new research frontier of medical nanotechnology. PR is of major importance for physiotherapy both for the improvements it facilitates in motor impairments and for its contribution to the understanding of mechanisms underlying motor recovery after an injury or stroke. The impact of robotics in physiotherapy has not only a clinical dimension, but also legal, ethical and economic aspects which are directly addressed by Health Technology Assessment (HTA), a multidisciplinary research area for policy analysis which systematically addresses the properties and effects of health technology.

Robots are being used extensively in the rehabilitation of stroke, spinal cord injury and multiple sclerosis patients, as well as with children with central gait impairments. Robots automate labor-intensive training techniques providing longer repetitive assistance thus freeing the physiotherapist for a better observation of the recovery evolution, facilitating further assessment and decisions. How-ever, the goal of rehabilitation robotics is to optimize care and augment the potential of individual recovery, not simply to automatize current rehabilitation practices which, for the most part, lack scientific evidential basis, primarily due to the lack of tools to properly assess the practices themselves [Krebs, 2012], a deficiency which the robotic tools can help to overcome by providing more accurate mappings of physiological parameters and the use of more refined conceptual tools for the under-standing of the complex motor functions.

One major issue in PR is the contrasting neuro-mechanical complexity of upper extremity reaching and grasping versus lower extremity locomotion. The complex structure of human hand, which allows us to perform high dexterity and precise tasks, is a hindrance for the development of useful hand exoskeletons. Nonetheless, therapeutic devices for the hand continue to evolve, with new actuators and materials promising even greater gains in the ratio power to weight [Kamper, 2012], allowing a more efficient implementation in clinical and everyday scenarios. 

A major PR field within the rehabilitation area is assistive robotics, whose aim is the production of exoskeletons that have sufficient mechanical control for the performance of everyday activities by the elderly or the physically impaired. However, the exoskeletons produced by assistive robotics face still some major difficulties in relation to their wearability, energy consumption, stability, accessibility for daily use, besides being unnatural in shape, noisy, and slow running [Viteckova et al. 2013]. The interface with these machines is being adapted to the impaired patient needs and ranges from audio control to a wide variety of body gestures, even the wincing of an eye [Chen et al. Web]. The implementation of versatile and flexible inter-faces has led to the development of cognitive neural prosthetics that will allow the severely impaired patient the control over different kinds of assistive robots. Cortical neural prosthetics seek to help paralyzed patients by recording their thoughts directly from the brain and decoding them to control external devices such as computer interfaces, robotic limbs and muscle stimulators [Pesaran, 2006]. By using activity from several different parts of the brain and decoding several cognitive variables, like speech or the emotional centers, a neural prosthetic can provide a patient with the maximum access to the outside world [Andersen et al., 2004].

References

Andersen et al. [2004] Cognitive Neural Prosthetics. Trends in Cognitive Sciences. Vol. No.11. November 2004.

Chen, Tiffany L. et al.Robots for Humanity: A Case Study in Assistive Mobile Manipulation. Georgia Tech Publica-tions. Web. http://www.hsi.gatech.edu/hrl/pdf/rfh_ram_final_compressed.pdf.

Kamper, Derk, G. [2012]Restoration of Hand Function in Stroke or Spinal Cord Injury. In Neurorehabilitation Tech-nology. Dietz, Volker; Nef, Tobias and Zev, Rymer, Wil-liam. Editors. Springer Verlag. London 2012.

Krebs, Hermano Igo et al. [2012] Beyond Human or Robot Administered Treadmill Training. In Neurorehabilitation Technology. Dietz, Volker; Nef, Tobias and Zev, Rymer, William. Editors. Springer Verlag. London 2012.

Pesaran, B.; Musallam, S. and R.A. Andersen, R.A. [2006] Cognitive neural prosthetics. Current Biology Vol 16 No 3. February 2006.

Viteckova, Slavka; Kutilek, Patrik and Jirina, Marcel. [2013]. Wearable lower limb robotics: A review.  Biociber-netics and Biomedical Engineering. Volume 33, 2013, Pages 96–105.

By Oscar E. Muñoz

Music as Anxiety Reliever in Cancer Treatment

A study by Lee-Chen Chen et al. [2013] has shown the positive effects of music therapy in integrative oncology for the treatment of different symptoms, such as pain, mood disturbances and communication issues. The use of music with slow tempos (60-80 beats per minute) and low dynamics decreases trait anxiety levels and systolic blood pressure in pre-radiotherapy settings.

Reference

Lee-Chen, Chen et al. Fifteen-minute music intervention reduces pre-radiotherapy anxiety in oncology patients. European Journal of Oncology Nursing 17 (2013) 436e441.

Musical Physiotherapy

Music therapy has become a very popular evidence-based intervention whose benefits extend over a wide variety of clinical settings. Whether as an aid for patients with chronic pain, children with migraines or cases of psychotic disorders, music has become a very useful tool for non-pharmacological treatment, facilitating movement, creating positive interactions, and improving cognitive and emotional states in the patient.

Music can be used actively or passively. Active music intervention requires the patient, with the help of a therapist, to create music and sometimes bodily movements, which can complement physiotherapeutical protocols in different ways, for music helps to reduce significantly the perception of effort [Seath and Thow, 1995] and makes more enjoyable intensive repetitive rehabilitation. However, the particular choice of music requires careful considerations by the practitioner, for, as it has been known since the Greeks, different musical structures produce different psycho-biological effects.

References

Bernatzky, Guenther et al.  [2011]Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neuroscience and Biobehavioral Reviews 35 (2011) 1989–1999.

Seath Lorna and Thow, Morag. The Effect of Music on the Perception of Effort and Mood During Aerobic Type Exercise. [1995] Physiotherapy. October 1995. Vol 81 no.10.

Physiotechniques: Percutaneous Intratissue Electrolysis (Electrólisis Percutánea Intratisular (EPI®))

This is an invasive physiotherapeutic pioneering technique that targets musculo-skeletal tissue (tendons, muscles, ligaments, etc.). It consists on the introduction of a galvanic current through an acupuncture needle which induces a local inflammatory process in order to activate phagocytosis and healing of the soft tissue involved. It was recently developed by a team of Spanish physiotherapists (José Manuel Sánchez Ibáñez, Francisco Minaya and Fermín Valera). The process requires the aid of echography to guide the specific placing of the needle. The developers affirm that the current is able to induce a healing on the affected tissue, and to activate a new process of collagen proliferation. The modifications of the structure and mecano-biological behavior of soft tissue can be seen immediately. The effectiveness is high compared to other conventional physiotherapy treatments such as: ultrasound, laser, Cyriax, Diacutaneous Fibrolysis, Extracorporeal Shockwave Therapy, etc., or medical treatments such as: pharmachology, infiltrations or surgery. It also has a low frequency of relapse.

The authors explain that these effects have been recently demonstrated in degenerative processes such as tendinosis of the patellar tendon, lateral epicondylitis, athletic pubalgia, and plantar fascitis.

You will find more information in their website at: http://www.mvclinic.es

They have also published a very thorough book called “Fisioterapia Invasiva” (Invasive Physiotherapy) in Spanish by Elsevier.

Bibliography

Sanchez-Ibañez et al., Int J Phys Med Rehabil 2013, 1:2  

EPI® Technique in Patellar Tendinopathy/ Técnica EPI® en Tendinitis Rotuliana

Physiothoughts: The Body Matrix

G. Lorimer Moseley, Alberto Gallace and Charles Spence [2012] have proposed the concept of “body matrix”, not to be mistaken with Melzack’s [2005]concept of a “neuromatrix”, which would allow our body to adapt to different anatomical configurations in our body and would play a major role in the control of homeostasis. They propose a dynamic neural representation that integrates somatotopic and peripersonal sensory data together with body-centred spatial sensory data.

The relevance of such a concept for physiotherapy practice seems enormous for, if the theory is proven, we would count with evidence for the need of an integrated treatment even for the more basic and mechanical pathologies.  

References

Melzack, Ronald, [2012]. Evolution of  the Neuromatrix Theory of Pain. Pain Practice, Volume 5, Issue 2, 2005. 85-94

Moseley, G. Lorimer; Gallace, Alberto and Spence, Charles. [2005] Bodily illusions in health and disease: Physiological and clinical perspectives and the concept of a cortical “body matrix”. Neuroscience and Biobehavioral Reviews 36 (2012) 34-46. Elsevier.

The Pain and Movement Reasoning Model. A useful tool for pain assessment in physiotherapy.

As the scope of physiotherapy widens, we are increasingly faced with new clinical challenges, particularly with those involving neuropathic pain. We are currently receiving in our clinics a higher number of patients with some form of central or peripheral sensitization, thus, we face the task of having to assess, diagnose and treat very difficult conditions. Our professional training did not equip us with any tool that could assist us when dealing with this kind of patients (except for some pain assessment charts like McGill’s and so on), and all we have been able to do is to apply some type of general manual treatments, very softly, use acupuncture if tolerated, and work out some exercise plan that may include hydrotherapy and movement meditation (Tai-Chi, Qi-Gong, etc.) hoping not to cause any more pain. In this situation we find ourselves in the same place as the physician who does not know either how to deal with these patients, and is forced to treat them with anti-depressants and painkillers to the best of his/her abilities. Fortunately, these neuropathies are no longer considered psychosomatic and are gradually being seriously addressed. An increasing amount of research is starting to be directed towards achieving better models for the understanding of these conditions.

Recent developments in pain research have prompted a whole range of theories and explanations which can be put to use in our physiotherapy practice. For instance, our current understanding of the role of neuroplasticity in pain neurophysiology, following the experiments of Ramachandran with phantom limb patients and other neuroscientists, has encouraged physiotherapists to employ mirror therapy, not only to amputees but, for example, to stroke [1] or Complex Regional Pain Syndrome[2] patients, with successful results. Plasticity in pain has also been explored for treatment using spinal manipulative techniques[3] that target sensitization mechanisms. But, despite these improvements, we are still lacking a satisfactory “protocol” for pain assessment and treatment that may target the complex spectrum of neuropathic pain. For this reason, I wanted to highlight by means of this post, the interesting tool developed by a couple of Australian colleagues which I think will definitely be of assistance and will improve our practice.  

Lester E. Jones and Desmond F.P. O’Shaughnessy recently published an article in Physical Therapy (actually the article is still in-press although published on-line and accessible via Science Direct) where they propose an integrative model for the assessment of pain based on the Neuromatrix Theory of Pain (by Melzack) [4] and neuroplasticity called The Pain and Movement Reasoning Model[5]. This humanistic/holistic model combines the physiological, emotional, cognitive and social inputs in the neurophysiological process. In order to integrate these aspects, they propose a triangular structure of three categories: central, regional and local factors, which have to be addressed and explored in order to diagnose and implement treatment. The first category called Central Modulation, is integrated by three sub-categories: the predisposing factors in the patient (general health, past painful experiences, and gene expression), the prolonged afferent input (that is, the prolonged noxious stimuli), and the cognitive-emotional-social state (including thoughts, beliefs and emotions as well as the current social context of the patient). This category, for instance, can give information on how sensitivity is being modulated, and can re-direct treatment towards psycho-neuro-immunological retraining approaches. The second category is called Regional Influences Category and includes three sub-categories: Kinetic chain (bio-mechanics), patho-neuro-dynamics, and convergence (referred pain). This category gives information on where connective tissue, joints or muscles are altered, thus, providing guidance for manual therapy and exercises regionally. The last category is Local Stimulation Category and comprises the sub-categories of chemical stimulation (that is, chemical sequalae associated with tissue damage), and mechanical deformation. By this category, for instance, treatment could be directed towards managing inflammation, rectifying tissue alterations, and addressing local mechanical influences.

These three categories are arranged in a triangular structure which is filled by a grid. The idea is to evaluate the patient and place the results of this threefold structure in some space of the grid. This placing will give information about the location where pain is more relevant and thus re-direct treatment accordingly. Ongoing assessment and diagnosis will alter the position in the grid and further inform about the changes that are taking place and where the pain condition is being re-focalized so as to modulate treatment consequently.

As the purpose of this blog is to reflect on theoretical issues concerning physiotherapy, it would be interesting to review this model further, but in order to do that, I think it is necessary first to think more deeply about the theories in which it is based on, specifically, the Neuromatrix theory of pain, which leads to a reflection about the different models of pain in general. But that will be a matter for another post, for the time being, I just wanted to highlight the interesting work that is being done in trying to protocolize and improve the diagnosis and treatment of neuropathic pain from a physiotherapeutic point of view by using the current advances in neuroscience.     

      

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[1] H. Thiemea, J. Mehrholzc, M. Pohld, J. Behrensb, C. Dohlee. (2013). Mirror therapy for improving motor function after stroke. Journal of the Neurological Sciences. Volume 333, Supplement 1. p. 573.

[2] Samaa Al Sayegha, Tove Filén, Mats Johanssonc, Susanne Sandströmd, Gisela Stiewee, Stephen Butlerf.(2013). Mirror therapy for Complex Regional Pain Syndrome (CRPS)—A literature review and an illustrative case report. Scandinavian Journal of Pain 4. p.p.200–207.

[3] Robert W. Boal and Richard G. Gillette. (2004). Central Neuronal Plasticity, Low Back Pain and Spinal Manipulative Therapy. Journal of Manipulative and Physiological Therapeutics. Volume 27, Number 5. p.p. 314-326.    

[4] The neuromatrix theory of pain proposes that “pain is a multidimensional experience produced by characteristic “neurosignature” patterns of nerve impulses generated by a widely distributed neural network—the “body-self neuromatrix”—in the brain.” (Ronald Melzack. (2005). Evolution of the neuromatrix theory of pain. The Prithvi Raj lecture: presented at the third world congress of world institute of pain, Barcelona 2004. Pain Practice 5. p.85.) As Melzack continues to explain in his paper, the neuromatrix theory “proposes that the output patterns of the body-self neuromatrix activate perceptual, homeostatic, and behavioral programs after injury, pathology, or chronic stress. Pain, then, is produced by the output of a widely distributed neural network in the brain rather than directly by sensory input evoked by injury, inflammation, or other pathology. The neuromatrix, which is genetically determined and modified by sensory experience, is the primary mechanism that generates the neural pattern that produces pain. Its output pattern is determined by multiple influences, of which the somatic sensory input is only a part, that converge on the neuromatrix.” (Ibid.)

[5] Lester E. Jones and Desmond F.P. O’Shaughnessy (2014). The Pain and Movement Reasoning Model: Introduction to a simple tool for integrated pain assessment. Manual Therapy xxx. p.p. 1-7. (in-press)

The need for a theoretical framework in physiotherapy science

Physiotherapy, as an allied health-care profession, has emerged from medical practice and, although it cannot be considered apart from it, in recent years has found its own unique space within the biomedical sciences.

Its situation is manifold since, on the one hand, physiotherapy finds itself still under the domain of medicine in Hospitals and Health Care Clinics that are led by rehabilitation physicians, traumatologists, orthopedists, etc., where the physiotherapist’s task focuses mainly on the application of the treatment as prescribed by the physician. On the other, it has developed as an independent clinical practice in which the physiotherapist represents the entry-level health care practitioner, being thus required to assess, diagnose, plan and implement treatment physiotherapeutically as well as to evaluate the patient for referral to other health care professionals.  

Added to this situation is the fact that physiotherapy is no longer a clinically centered profession alone, for it has also included research within its field of action. With this increasing focus on research and its ever-growing scope, physiotherapy is gradually becoming an independent science and as such is trying to follow the scientific method in the same way as its parent science does. Since the 1990s, medicine, instead of following the traditional model based on expert opinion, intuition or habit, it has turned to evidence-based medicine and clinical decision-making based on evidence.[1] This is changing the way we deal with patient diagnosis and is finally breaching the gap between clinical practice and research.[2] Physiotherapy also is following this new paradigm and, in this sense, is trying to become an evidence-based physiotherapy (The creation of PEDro[3] and the data from WebPT[4] are an example of this pursuit).

This situation although promising and indubitably positive, presents some problems with respect to physiotherapy science.

Firstly, physiotherapy is leaping forward on the wings of new medical models, without neither defining nor establishing a coherent scientific model for itself as a science. The very definition of physiotherapy is not available. What we find are vague, imprecise and ever-changing descriptions of its scope and legal definitions. Whether described by the WCPT[5], APTA[6] or any other physiotherapy association, it does not explain the domain in scientific terms. I recently read in Scott’s Foundations of Physical Therapy[7] that a definition of the term was impossible and that what we had to do as physiotherapists was to find a definition of our own. Each physiotherapist, depending on his/her own practice, country and situation, should have to come up with a satisfactory definition (having then, as many definitions as there are physiotherapists that may be willing to generate one). This situation of not being able to define the term physiotherapy itself shows how precarious physiotherapy is with respect to its scientific desires. In this sense, it needs the infusion of epistemological thinking and systematicity in order to establish its foundations and build its future developments in a stable manner. Perhaps this very lack of a consistent model is part of what makes it so versatile and flexible when acquiring and using any therapy that may benefit a patient, no matter what paradigm it may follow (biomedical, holistic, etc.) But I think that even at the risk of losing some flexibility, physiotherapy would benefit enormously from a solid foundation. Setting its boundaries will give it the tools to progress and experiment more coherently. Physiotherapy needs to formulate fundamental questions, and create definitions of its own terms, as well as specify the ones used from medicine.

Is there a science of physiotherapy as such or is it just a well-intended project? Which are the theoretical and observational statements of physiotherapy? Can we construct a clear definition of physiotherapy? What are the specific differences of physiotherapy? What are its main concepts and how are they defined in physiotherapy (for instance: disease, disorder, dysfunction, etc.)? What are the signs and symptoms specific to physiotherapy and which ones have we merely integrated from medicine? Is it coherent to be following the evidence-based model at the same time that we are following alternative therapies such as acupuncture, osteopathy, etc.? Is it enough the evidence of practice and its success, or do we need to perform Randomized Control Trials (RTCs) as well with these holistic approaches regardless of theoretical inconsistencies? These are some of the questions that arise when thinking physiotherapy as a system.

I think that before advancing further on other issues, it is paramount that we address first these theoretical problems, before entering into any other matters concerning physiotherapy practice.

The objective of this blog is to venture in the fascinating task of constructing the science of physiotherapy, to dare to think scientifically trying to answer these questions and to formulate new ones that may clarify and establish its boundaries, helping us to develop towards directions that now we cannot even imagine.   

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[1] Zawadowicz, Maria, "Scientific Method in Medicine: Bringing Unity to Research and Clinical Decision-Making." (2009). First-Year Writing Contest. http://publications.lakeforest.edu/firstyear_writing_contest/7

[2] Ibid.

[3] Physiotherapy Evidence Database.

[4] Physical Therapy Software.

[5] World Confederacy of Physical Therapy.

[6] American Physical Therapy Association.

[7] Scott, Ron. Foundations of Physical Therapy: A 21^st Century-Focused View. McGraw-Hill. New York. 2002. p.p.3-5.