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Neurorehabilitation Research Laboratoryat the Providence VAMCAlthough there has been tremendousprogress in treating neurological injuriesand disorders, there remains ample opportunityto improve recovery and to restorefunction in chronic and progressiveconditions, particularly during the acuteand subacute phases. As our understandingof neuroplasticity has advanced alongwith technology, attention has focused onnovel methods to augment more traditionalprocedures to reverse impairmentand regain function.The field of rehabilitative therapy hasrecently seen an explosion in the developmentof robotic technology for rehabilitation.A MEDLINE search for therapeuticrobotics yields only 15 results prior to1990, but as of September 16, 2009,there were 2095 results. The consequenttechnological and methodological advances1-3 have been particularly exciting.These devices provide high-volume, repetitive,reproducible, safe therapy andalso allow for reliable, instrumented outcomesof motor performance. One of thebest examples of such devices with a largequantity of pilot human data is the MIT-Manus 3 (InMotion Technologies, Inc.,Watertown, MA), which includes modulesfor shoulder, elbow and hand. Otherupper-extremity robotics include theARM Guide, the MIME, the InMotionShoulder-Elbow Robot, and the Bi-Manu-Track. 1,3 There also exist computeraidednon-robotic therapy orthotics suchas the T-WREX 4 , which allows upper-extremitymovement with 5 degrees of freedomand passively eliminates the force ofgravity via a system of elastics and metallinkages. For the lower extremities, thereexist gait training devices such as theLokomat (Hocoma, Zurich, Switzerland),a body weight-supported treadmill withrobotic orthotics which guide the legsthrough an idealized gait cycle. TheLokomat has been used in research interventionsfor neurological disorders suchas spinal cord injury, 5 stroke, 6 and multiplesclerosis. 7,8 As with the upper extremity,there also exist more focused devicesAlbert Lo, MD, PhDfor the lower extremity, such as the MITAnklebot 9 (InMotion Technologies, Inc.,Watertown, MA), which focuses on trainingankle plantar- and dorsiflexion as wellas in- and eversion. The data from randomizedcontrolled trials of robotics willyield further improvements in methodologyand understanding, allowing rehabilitationcenters to provide more efficientand efficacious care. One can imagine aneventual “robotic gym” 1,2 incorporatinghighly specialized robots capable of addressingevery form and degree of physicaland cognitive disability, all run in concertwith talented therapists.Despite the enthusiasm for robot-assistedtherapy, there is not yet full understandingof how, when, and in which patientpopulations these devices should beused. In order to gain the full potentialof this new technology, careful clinical researchis necessary to establish safe, effectiveprotocols and optimal doses, as wellas to eventually understand how these roboticdevices should be combined withconventional pharmacological and rehabilitativemethods. While robots are anew resource for clinicians to delivertherapy and to measure changes in motorperformance, they will likely neverreplace human interaction, but ratherenhance interactions with therapists.The Neurorehabilitation ResearchLaboratory at the Providence VA MedicalCenter, established in the summer of2007, has been conducting severalprojects examining the efficacy of robotictechnology in improving motor functionin individuals with stroke, multiple sclerosis(MS) and Parkinson’s disease. Additionally,our interests have expandedbroadly to other projects dealing moreinclusively with other aspects of neurologicalinjury, repair, and disability, suchas an epidemiological study on MS andanother study to develop and improvemethods for diagnosis and tracking ofcognitive function for mild traumaticbrain injury. A summary of our currentresearch is provided below.ROBOTIC ASSISTED UPPER-LIMBNEUROREHABILITATION IN STROKEPATIENTSA phase II/III multi-center clinicaltrial funded by the Department of VeteransAffairs is now testing the most advancedMIT-Manus system (includingseparate shoulder, elbow, wrist and handmodules) in chronic stroke patients withupper extremity impairment. The studywas initiated in November of 2006, andenrollment has closed with a total of 127participants at the VA Medical Centersin Baltimore MD, Gainesville FL, SeattleWA, and West Haven CT. This is the firstmulticenter randomized-controlled trialto test a robot-assisted rehabilitation devicefor stroke. The baseline characteristicsfor the study were just published; 10final results are expected to be releasedin early 2010.GAIT & MOBILITY IN MULTIPLESCLEROSIS USING ROBOT-ASSISTEDBODY WEIGHT SUPPORTEDTREADMILL TRAININGImpairment in walking is an importantsource of disability and cause for concernfor people with MS. Even at theearliest stages of disease, MS patients haveobservable gait problems which, in themajority of patients, will progressivelyworsen. 11 Body weight-supported treadmilltraining has been identified as apromising gait-specific intervention forMS, 12 and robotic assistance might proveto be a technological enhancement. Theinclusion of robotic assistance, such as onthe Lokomat, has the added advantageof delivering consistent, guided movementto the legs throughout the gaitcycle.Thirteen MS subjects have completeda randomized, cross-over trial comparingbody weight-supported treadmilltraining with and without robotic assistanceon the Lokomat. 8 In that study,participants improved gait velocity andendurance by over 30%. Approximately20 people have participated in our vari-22MEDICINE & HEALTH/RHODE ISLAND
ous research protocols using theLokomat. Additional studies will continueto refine the optimal dose, treatment regimen,and most relevant outcomes; identifythe patients most likely to respond;and explore the characteristics and neurologicalmechanisms of motor recovery.Dr. Elizabeth Triche from the Departmentof Community Health at BrownUniversity has collaborated on thisproject and is closely involved in many ofthe others presented.ROBOT-ASSISTED TRAINING ANDFOOT DROP IN MULTIPLE SCLEROSISOur clinical and research experiencehas suggested that approximately30% of MS patients experience footdrop. Although gait rehabilitation usingthe Lokomat can improve ambulationin MS patients, people with foot dropstill have difficulty translating task-repetitivegait training to normative gaitpatterns over ground. One of the keylimitations of the Lokomat is a lack ofrobotic assistance for the ankle joint.The MIT Anklebot has the potential toaddress that limitation through focusedankle training, but it does not train theknee or hip.The results of a case-series with 2 MSsubjects with foot drop have been published.1 Additional subjects with MS andfoot drop are being recruited to testwhether Anklebot therapy alone or acombination with Lokomat results in bettermobility. The project is currently enrollingpatients. Collaborators includeDr. Hermano Igo Krebs (MIT) and Dr.Jacob Berger (PVAMC, Department ofNeurology; Brown University).ROBOT-ASSISTED GAIT TRAININGAND FREEZING OF GAIT INPARKINSON’S DISEASEParkinson’s disease, the most commonmovement disorder in neurology,can present with a wide range of motormanifestations, such as bradykinesia,tremor and postural abnormalities.Freezing of gait (FOG) is one of the mostdisturbing symptoms, but there are noeffective treatments for FOG. Studieshave shown that uncoordinated, asymmetricalgait and reduced step length arerelated to FOG, 13 but no group has previouslystudied the effect of robot-assistedgait training on FOG.In collaboration with Drs. JosephFriedman and Victoria Chang, 4 participantshave been examined in a pilotstudy. Pilot data have suggested a reductionin episodes of freezing as well as animprovement in quality of life inParkinson’s disease as a result of robot-assistedgait training. A larger study isplanned.RHODE ISLAND MULTIPLESCLEROSIS STUDY (RIMSS)The Rhode Island Multiple SclerosisStudy (RIMSS) is a communitybasedepidemiological study of MS inRhode Island. This project, in collaborationwith Dr. Stephen Buka, BrownUniversity Professor of CommunityHealth (Epidemiology), is being conductedas a part of the Brown UniversityBioBank initiative. An initial groupof neurologists (Drs. Elaine Jones,Stephen Mernoff, William Stone, MerylGoldhaber, Mason Gasper, and SyedRizvi) has generously contributed in apilot collection of data as well as in gaugingpotential patient participation. TheRhode Island Neurological Society andthe Rhode Island Chapter of the NationalMultiple Sclerosis Society have alsoextended enthusiastic support for thisproject.Much of MS epidemiology andclinical course has been derived fromcohort studies collected outside of theUnited States or from short-term pharmaceuticalclinical trials: 14,15 thesesources may have inherent biases thatlimit their usefulness to typical patientsin the United States. The RIMSS studyproposes to establish a prospective population-basedcohort study of MS, collectingrich epidemiologic and clinical datacritical to both scientific understandingand accurate treatment. Overall goalsinclude enumerating and providing accuratedata on incident and prevalentcases of MS, as well as collecting demographicand diagnostic data from medicalrecords. Study data will describe thedistribution of physical and cognitivedisability, symptomatic areas, magneticimaging changes, disease subtypes, durationof disease, quality of life, and treatmentwith disease modifying agents. Thesecond phase is a longitudinal examinationwhich will follow a group of recentlydiagnosed patients with genetic,neuroimaging, clinical and patient-relatedoutcomes. The scope of thismultidisciplinary study provides an opportunityto build a unique MS cohortbased in Rhode Island to capture criticalinformation and thus better understandthe clinical and epidemiologicalcharacteristics of MS in the UnitedStates.NEW RAPID ASSESSMENT OF MILDTRAUMATIC BRAIN INJURYAs Mernoff and Correia report inthis issue, there are no rapid, reliable,valid, and easily administered tests togauge attention and executive cognitivecapabilities following mild traumaticbrain injury (mTBI). Multiple investigatorsat Brown University and the ProvidenceVAMC (Drs. Stephen Correia,Leigh Hochberg, Albert Lo, StephenMernoff, Michael Worden) are currentlydeveloping an easily administered computerizedassessment of attention, cognitionand motor reaction.The aforementioned projects haveattracted the interest of neurology residents,fellows, graduate students, and undergraduates,all of whom sense the excitementand importance of applying thebest technology and methodology towardrestoring function in individuals with severedisability from neurological disorders.In addition to the physicians andscientists with whom we collaborate atBrown and the Providence VAMC, ourlaboratory includes postdoctoral fellowTara Patterson, PhD, as well as full timeresearch assistants and program coordinatorsMilena Gianfrancesco, DouglasBenedicto, and Elizabeth Jackvony,MPH.Neurorehabilitation research is responsiveto the health needs of veterans.The Providence VAMC has supportedthis unique research, and theNeurorehabilitation Research Laboratorylooks forward to completion of the Centerfor Restorative and RegenerativeMedicine which will soon be the new sitefor this research.AcknowledgmentsThis work is supported by the Officeof Research and Development RehabilitationR&D Service, Departmentof Veterans Affairs.VOLUME 93 NO. 1 JANUARY 201023
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