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Rehabilitation Robotics Rehabilitation Robotics Technology and Application Edited by Roberto Colombo Vittorio Sanguineti Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1800, San Diego, CA 92101-4495, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom © 2018 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-0-12-811995-2 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals Publisher: Mara Conner Acquisition Editor: Fiona Geraghty Editorial Project Manager: Jennifer Pierce Production Project Manager: Anitha Sivaraj Designer: Mark Rogers Typeset by SPi Global, India Contributors Dino Accoto Università Campus Bio-medico di Roma, Rome, Italy Angelo Basteris Nanyang Technological University, Singapore David T. Bundy University of Kansas Medical Center, Kansas City, KS, United States Etienne Burdet Imperial College of Science, Technology, and Medicine, London, United Kingdom; Nanyang Technological University, Singapore Andrew J. Butler Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA, United States Domenico Campolo Nanyang Technological University, Singapore Maura Casadio University of Genova; Italian Institute of Technology, Genova, Italy Karen Sui-Geok Chua Tan Tock Seng Hospital, Singapore Roberto Colombo IRCCS Istituti Clinici Scientifici Maugeri Spa SB, Pavia, Italy Sara Contu Nanyang Technological University, Singapore Martina Coscia Wyss Center for Bio- and Neuroengineering, Geneva; École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland Kevin C. Elliott University of Kansas Medical Center, Kansas City, KS, United States Peter Feys Hasselt University, Hasselt, Belgium Joana Figueiredo University of Minho, Guimarães, Portugal Kathleen Fitzgerald Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA, United States Antonio Frisoli Scuola Superiore Sant'Anna Via Alamanni, Pisa, Italy xv xvi Contributors Roger Gassert ETH Zurich, Zurich, Switzerland David J. Guggenmos University of Kansas Medical Center, Kansas City, KS, United States Eugenio Guglielmelli Università Campus Bio-medico di Roma, Rome, Italy Stephen N. Housley Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA, United States Asif Hussain Nanyang Technological University, Singapore Riccardo Iandolo University of Genova; Italian Institute of Technology, Genova, Italy Nathanaël Jarrassé Sorbonne University, UPMC, Paris, France Simone Kager Nanyang Technological University, Singapore Dinh Binh Khanh Nanyang Technological University, Singapore Verena Klamroth-Marganska ETH Zurich, Zürich; University of Zurich, Zurich, Switzerland Hermano Igo Krebs Massachusetts Institute of Technology, Cambridge, MA; University of Maryland School of Medicine, Baltimore, MD, United States; Fujita Health University School of Medicine, Nagoya, Japan; Newcastle University, Newcastle Upon Tyne, United Kingdom; Osaka University, Osaka, Japan; Loughborough University, Loughborough, United Kingdom Olivier Lambercy ETH Zurich, Zurich, Switzerland Ilse Lamers Hasselt University, Hasselt; Rehabilitation and MS center, Overpelt, Belgium Yanan Li Imperial College of Science, Technology, and Medicine, London; University of Sussex, Brighton, United Kingdom Laura Marchal-Crespo Institute of Robotics and Intelligent Systems (IRIS), ETH; University of Zurich, Zurich; University of Bern, Bern, Switzerland Francesca Marini Italian Institute of Technology, Genova, Italy Lorenzo Masia Nanyang Technological University, Singapore Contributors xvii Silvestro Micera École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy Matja Mihelj ž University of Ljubljana, Faculty of Electrical Engineering, Ljubljana, Slovenia Vito Monaco The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa; IRCSS Don Carlo Gnocchi Foundation, Firenze, Italy Pietro Morasso Italian Institute of Technology, Genova, Italy Juan C. Moreno Cajal Institute, Madrid, Spain Marko Munih University of Ljubljana, Faculty of Electrical Engineering, Ljubljana, Slovenia Sara Nataletti University of Genova; Italian Institute of Technology, Genova, Italy Domen Novak University of Wyoming, Laramie, WY, United States Randolph J. Nudo University of Kansas Medical Center, Kansas City, KS, United States Sandra W. Petersen The University of Texas at Tyler, Tyler, TX, United States Valentina Ponassi University of Genova, Genova, Italy José L. Pons Cajal Institute, Madrid, Spain Dejan B. Popovi ć Serbian Academy of Sciences and Arts, Belgrade, Serbia; Aalborg University, Aalborg, Denmark Raffaele Ranzani ETH Zurich, Zurich, Switzerland Robert Riener Institute of Robotics and Intelligent Systems (IRIS), ETH; University of Zurich, Zurich, Switzerland Agnès Roby-Brami Sorbonne University, UPMC, Paris, France Vittorio Sanguineti University of Genova, Genova, Italy Robert A. Scheidt Marquette University, Milwaukee, WI, United States xviii Contributors Giulia Sedda University of Genova, Genova, Italy Davide Simonetti Università Campus Bio-medico di Roma, Rome, Italy Susanna Summa Bambino Gesù Children's Hospital IRCCS, Rome, Italy Eva Swinnen Vrije Universiteit Brussel, Brussel, Belgium Nevio L. Tagliamonte Università Campus Bio-medico di Roma; S. Lucia Foundation, Rome, Italy Peppino Tropea The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa; Casa Cura Policlinico, Milano, Italy Andrea Turolla IRCCS San Camillo Hospital Foundation, Venice, Italy Antuvan Chris Wilson Nanyang Technological University, Singapore Michele Xiloyannis Nanyang Technological University, Singapore Kim Giovanni Yongtae Nanyang Technological University, Singapore Loredana Zollo Università Campus Bio-medico di Roma, Rome, Italy Rehabilitation Robotics: Technology and Applications The last decades have seen major advances in interventions for neuromotor rehabilitation. Forms of treatment based on repetitive exercise of coordinated motor activi- ties have been proved effective in improving gait and arm functions and ultimately the patients' quality of life. Exercise-based treatments constitute a significant burden for therapists and are heavy consumers of health-care resources. Technologies such as robotics and virtual reality can make them more affordable. Rehabilitation robotics specifically focuses on systems—devices, exercise sce- narios, and control strategies—aimed at facilitating the recovery of impaired sensory, motor, and cognitive skills. The field has a relatively long history, dating back to the early 1990s. Early attempts were part of the general trend toward automating heavy tasks by using “intelligent” machines, with minimal human intervention. The notion of “artificial therapist” was common in early scientific papers and patent applications. However, the most distinctive feature of these devices is not their ability to “automate” treatment but, rather, that of precisely quantifying sensorimotor performance during exercise, in terms of movement kinematics and exchanged forces. This resulted in a gradual shift toward more evidence-based and data-driven forms of treatment. Present- generation rehabilitation robots are designed as complements, rather than substitutes, of the therapist's work. They support the recovery of functions by efficiently exploiting structure and adaptive properties of the human sensorimotor systems and provide rich information on sensorimotor performance and their evolution. Their design, implementation, and modalities of intervention incorporate findings from behavioral studies on sensorimotor adaptation and motor skill learning and their neural substrates. Rehabilitation robotics is therefore characterized by highly specific design ap- proaches and technical solutions, with roots in both engineering and neurophysiology. This book addresses both technology and application aspects of Rehabilitation Robotics. Part I focuses on the state of the art and representative advancements in the design, control, analysis, and implementation of rehabilitation robots and the underlying neurophysiological principles. Part II addresses the existing applications and the clinical validation of these systems, with a special emphasis on therapy robots, which support exercise-based treatments aimed at recovering sensorimotor or cognitive functions. PART I: BACKGROUND AND TECHNOLOGY NEUROPHYSIOLOGY Planning and execution of movements results from the coordinated activity of mul- tiple interconnected sensory and motor areas in the cerebral cortex. When an area in this specialized motor network is damaged—for example, through a traumatic brain xix xx Rehabilitation robotics: Technology and applications injury or an ischemic event—the activity of the motor networks can be disrupted, thus leading to functional deficits. How the surviving motor networks reorganize to compensate for the injury depends on the location and extent of the lesion but may be affected by sensorimotor exercise. Chapter 1 summarizes how neuroplasticity modifies motor networks in response to injury, by focusing on the changes after a cerebrovascular accident in the primary motor cortex. Neuroanatomical and neurophysiological evidence in animal models and human stroke survivors is reviewed to demonstrate how injuries functionally impair motor networks, how motor networks compensate for the lesion to improve motor function, and how selected therapies may facilitate recovery. Chapter 2 focuses on the hierarchical architecture and synergistic functioning of the motor system. These aspects are crucial for the development of successful robotics applications with rehabilitation purposes. The same framework is used to discuss the mechanisms underlying rehabilitation interventions with a potential to facilitate the recovery process. TECHNOLOGY AND DESIGN CONCEPTS Devices for rehabilitation benefit from advances in robot technologies, including sensors and actuators, mechanical architectures, and the corresponding control architectures. These devices are characterized by a continuous interaction with the human body, which poses specific design constraints. Chapter 3 summarizes the notion of “biomechatronic” design for systems for robot-mediated rehabilitation, encompassing robot structure, musculoskeletal bio- mechanics, and neural control. Robots for rehabilitation are typically conceived to constantly work in constrained motion with the human body, which represents a challenge for designers. This requires a top-down design approach, in which a model of the human agent guides a concurrent, iterative design cycle of the robot's mechanical, electronic, and multilayered control subsystems. Criteria for the identification of functional and technical specifications and the selection of key components of the robotic system are also derived. Two design case studies demonstrate how these design principles are translated into practice. Chapter 4 addresses how actuators play a critical role in defining the charac- teristics of the robot-patient interaction. The different options for actuating and controlling a rehabilitation device are discussed, considering the complex flow of information between the user and the robot during a rehabilitation task. Strategies for both high- and low-level control are presented. Impedance and admittance control modalities are discussed as means of decoding human intention and/or modulating the assistive forces delivered by the robot. Mathematical tools for model-based compensation of nonlinear phenomena (backlash and friction) are also presented. The way robots are used to facilitate training is crucial for their application to therapy and has important implications for their mechanical and control design. Intensity and frequency of practice are major determinants of the recovery process,