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Disability and Rehabilitation: Assistive Technology
ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: https://www.tandfonline.com/loi/iidt20
A motor learning therapeutic intervention for a
child with cerebral palsy through a social assistive
robot
Jaime Alberto Buitrago, Ana Marcela Bolaños & Eduardo Caicedo Bravo
To cite this article: Jaime Alberto Buitrago, Ana Marcela Bolaños & Eduardo Caicedo
Bravo (2019): A motor learning therapeutic intervention for a child with cerebral palsy
through a social assistive robot, Disability and Rehabilitation: Assistive Technology, DOI:
10.1080/17483107.2019.1578999
To link to this article: https://doi.org/10.1080/17483107.2019.1578999
Published online: 26 Feb 2019.
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A motor learning therapeutic intervention for a child with cerebral palsy through
a social assistive robot
Jaime Alberto Buitrago
a
, Ana Marcela Bola~
nos
b
and Eduardo Caicedo Bravo
c
a
Faculty of Engineering, University of Quind
ıo, Armenia, Colombia;
b
School of Human Rehabilitation, University of Valle, Cali, Colombia;
c
School
of Electrical and Electronic Engineering, University of Valle, Cali, Colombia
ABSTRACT
Background: Children with cerebral palsy have difficulty to sit, stand, walk, run and jump independently.
Therapy is an important factor in improving these aspects, and if applied in early intervention treatments,
when the child is growing, it could have many benefits. These therapies require intensive and extended
sessions, which in turn demand dedication and effort. New strategies that provide interesting and moti-
vating interventions are often incorporated to improve the participation and performance of the children
in the therapies. Therapies using social assistive robots can be alternative and complementary methods
to promote the participation and motivation of children with cerebral palsy.
Methods: The objective of this work is to validate the effectiveness of a 16-session physical therapy pro-
gram to improve the participation and fulfillment of therapeutic objectives on an 8 year-old boy with dys-
kinetic cerebral palsy for motor learning to walk using a social assistive robot. The therapy program was
carried out through a methodological proposal that uses SMART objectives (Specific, Measurable,
Achievable, Realistic and Timed), Goal-Directed Therapy (GDT) and its evaluation through Goal Attainment
Scaling (GAS). Results: A NAO robot was used as a social assistive robot to support a physical therapy for
a child with cerebral palsy. In this work, it was observed that the motivation generated by the interaction
with the social assistive robot facilitated the persistence in the walking and the fulfillment of the objec-
tives. Conclusion: Using humanoid robots as social assistive robots may benefit therapeutic processes on
children with motor disabilities. The methodology developed provides a formal way to achieve objectives
in therapeutic processes for children with cerebral palsy.
äIMPLICATIONS FOR REHABILITATION
It requires researchers to conduct more studies to validate the potential of the useof social robots in
therapeutic interventions that promote development inchildren with motor disabilities, such as cere-
bral palsy.
Promoting the use of new technologies in therapeutic processes such as humanoid robots allows us
to create new strategies to know the impact of this technology in the area of rehabilitation.
The use of formal methodologies focused on the patient, along with multidisciplinary teams, could
increase the possibilities of using social robots to improve cognitive and motor outcomes in children
with cerebral palsy.
The formulation of SMART objectives and their quantification through the GAS scale can be used as
recommendations to improve the formulation of goals in therapeutic interventions for children with
cerebral palsy.
ARTICLE HISTORY
Received 10 September 2018
Accepted 2 February 2019
KEYWORDS
Children; cerebral palsy;
therapy; social
assistive robots
Introduction
Cerebral palsy
Cerebral palsy describes a group of permanent disorders in the
development of movement and posture that cause activity limita-
tion. These disorders are attributed to non-progressive disturbances
that occurred in the developing foetal or infant brain [1].
Conventional treatment for children with cerebral palsy consists of
sections of physical, occupational and language therapy, in addition
to adaptive equipment, such as orthoses, wheelchairs or walkers.
Therapies focus on improving functional movement and cognitive
skills; in the same way, they prevent secondary complications and
improve the quality of life, promoting functionality, personal care
and independence. In some cases, the development of secondary
complications contributes to loss of function, gait disturbances,
fatigue, activity limitations and participation restriction [2].
Therapeutic processes for children with cerebral palsy differ
from adult therapy in that children usually cannot (or may not be
willing to) follow direct instructions required in a therapy routine
[3]. Similarly, treatments for children with cerebral palsy require
intensive and extended rehabilitation sessions, which in turn
demand dedication and effort from the patient, the family and
the therapist [4]. Therefore, new strategies that provide interesting
and motivating interventions are often incorporated to improve
the participation and performance of the child in the rehabilita-
tion process.
CONTACT Jaime Alberto Buitrago jalbertob@uniquindio.edu.co Faculty of Engineering, University of Quind
ıo, Carrera 15 Calle 12 Norte Armenia,
Quind
ıo, Colombia
ß2019 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2019.1578999
Motor learning is defined as a series of internal processes asso-
ciated with practice and experience, which in the context of
acquiring a specific skills, will produce relatively permanent
changes in how motor activity is induced. Motor learning also
refers to the acquisition, application and maintenance of motor
skills. Therapeutic interventions have been the foundation and
the reason for the development of different theories of motor
control. Theories of motor control explain the cause and nature of
movement and physiotherapists establish working models and
use coherent rehabilitation techniques that allow the learning or
re-learning of motor skills.
To achieve the acquisition of a new motor skill, progressive
challenge, intensity, problem solving, sufficient motivation, and
focussed attention are required, especially in the early stages of
learning. It is also known that skill-based learning implies active
participation and requires a certain degree of voluntary neuromo-
tor capacity [5].
Social assistive robot
Assistive robotics is a technology widely used in rehabilitation [6].
The assistance in rehabilitation using robots is generally well
received by patients and has proved to be a motivating comple-
ment in therapies for people suffering from motor impair-
ments [7,8].
The field of Human-Robot Interaction (HRI) is presenting new
applications in rehabilitation. More specifically, there is a new
interest in the use of social robots as assistants for rehabilitation
processes. One of the objectives of Socially assistive robotics
(SAR) is to provide assistance to human users through social inter-
action [9]. Beyond the basic capabilities of moving and acting
autonomously, SAR has focussed on the use of the physical com-
ponent of the robot to communicate and interact with users in a
social and attractive way [10]. In addition to creating close and
effective interaction with a human user to provide assistance and
achieve progress in rehabilitation, social assistive robots are being
designed to take advantage of their physical, social and affective
attributes to maintain commitment. Additionally, they are being
created to motivate, train, supervise, educate or facilitate commu-
nication in the assistance or rehabilitation processes to obtain
better results [9].
Currently, the development of humanoid robots and their high
movement capacities in their joints (degrees of freedom), have
favoured the use of therapies to perform tasks of motivation and
participation in physical exercises. The robots have been designed
to interact with children in an interactive way to teach and
encourage them to continue with their therapy exercises [11],
being an effective way to capture children’s attention and create
a pleasant environment.
Some studies have used humanoid robots as a tool to achieve
educational goals in typically developing children through social
interaction with the robot [12,13]. These robots have also been
used in interventions on children with autism [14–16]. Both chil-
dren showed that humanoid robots are a useful tool to generate
levels of attention in children, likewise as mediator in teaching-
learning processes.
For children with cerebral palsy there are studies where
humanoid robots have been used in therapeutic interventions.
The THERAPIST project (An autonomous and socially interactive
robot for motor and neurorehabilitation therapies) [17] is a con-
sortium of Spanish institutions that have developed a robot in the
shape of a bear, called URSUS for carrying out repetitive exercises
[4]. They are also using the NAO robot for rehabilitation exercises
in upper limbs [18,19]. In the same way, at the Ariel University
Center developed the project "Robotics Agent Coacher for CP
motor Function" to help children with cerebral palsy to improve
motor function in activities of daily life using the NAO humanoid
robot [20].
In the Center for Humanoid Robots and Bio-Sensing (HuRoBs)
of the Technological University of MARA (Universiti Teknologi
MARA (UiTM)) the NAO robot is also used to improve motor learn-
ing in children with cerebral palsy [21]. These researchers
reported the use of this humanoid robot as a tool for learning
through imitation with exercises in the upper extremities of chil-
dren with cerebral palsy. [22,23]. In addition, they presented scen-
arios to interact between the robot and the child with cerebral
palsy [24,22,25]. In these interactive scenarios, the children dem-
onstrated attention and participation in the sessions.
New strategies are needed to help promote, maintain, and
rehabilitate functional capacity and thereby diminish the dedica-
tion and assistance required for the patient, caregivers and family
[26]. Therapies using social assistive robots can be alternative and
Figure 1. Methodology diagram [36].
2 J. BUITRAGO ET AL.
complementary methods to promote the participation and motiv-
ation of children with cerebral palsy.
This single-case study presents the use of a NAO robot as a
social assistive robot in a therapeutic intervention for a child with
cerebral palsy, who attends their scheduled physical therapy. The
objective of this work is to validate the effectiveness of a physical
therapy programme to improve the participation and fulfilment of
therapeutic objectives for motor learning to walk using a social
assistive robot to increase the number of steps of the child with-
out falling. The intervention was carried out through a methodo-
logical proposal that uses SMART therapeutic objectives (Specific,
Measurable, Achievable, Realistic and Timed), Goal-Directed
Therapy (GDT) and its evaluation through Goal Attainment
Scaling (GAS).
Methods
Figure 1 shows the methodological proposal of how the human-
oid robot was used in a therapeutic intervention for a child with
cerebral palsy.
Participant
The participant in this single-case study was an 8 year-old boy
who has dyskinetic cerebral palsy, and level III in the Gross Motor
Function Classification System (GMFCS), the Manual Abilities
Classification System (MACS), and the Communication Function
Classification System (CFCS) [27]. According to the medical history,
the child does not have any health complications. He interacts
with the environment and understands the immediate context.
The consent for participation in this research was given and
approved by the Human Ethical Committee of the University of
Valle. The informed consent was obtained from the parent of
child in accordance with approved ethics guidelines.
Defining and scaling therapeutic objective
According to the child’s medical history, in the last six months he
increased from walking 16 steps to 18 without falling. The child
has regularly attended physical therapy twice a week during the
last three years.
For this work we want to find a therapeutic strategy to
increase the number of steps without falling. If the child increased
2 steps without falling in six months, it was proposed to validate
the effectiveness of a therapeutic intervention using a social
assistive robot to increase 2 steps without falling in eight weeks.
With this information and the concept of the therapist that
treats the child, the therapeutic objective is defined for the inter-
vention through the robot. The objective for this study was
SMART type: Specific, Measurable, Achievable, Realistic and Timed
[28]. Goal Attainment Scaling (GAS) was used to quantify and
scale the objective [29]. GAS uses a five-item scale: 0 is the
expected level, 1 current level of performance, 2 regression
from current level, þ1 greater than expected outcome and þ2
much greater than expected outcome. Table 1 presents the scal-
ing of the objective using GAS. Scale GAS 1 is the current status
of the child and the baseline to assess the objective [30].
Objective: Following verbal instructions given by the therapist
and the humanoid robot, the child is able to go from sitting to
standing and walk 20 steps without falling, using an ankle-foot
splint and a proprioception vest. This is the expected level, scale
0. For þ1 and þ2, 23 and 26 steps without falling are defined
respectively. For these two scales we established a greater goal (3
more steps without falling).
Humanoid robot
In this study the NAO robot was used, which is an autonomous
and programable humanoid robot developed by Aldebaran
Robotics. This robot has 25 degrees of freedom; it is 58 cm tall
and weighs 4.5 kg [31].
The robot is used to give orders and feedback actions through
interaction and physical contact with the child. It is a social medi-
ator to invite and promote walking exercises, but it is not used
for the child to imitate walking patterns. The problems of using
this robot in walking imitation tasks are described in the study by
Malik et al. [25]. Taking advantage of the physical appearance of
the robot, which looks like a child, the robot acts as a mate in
therapy. The robot gives verbal instructions to the child to start,
continue and maintain the walk.
This robot is used to evaluate the effect and the impact of the
fulfilment of the objective in the therapy. And in this way, we
contribute with new uses of humanoid robots in rehabilitation
processes for children with cerebral palsy.
The robot was programed to interact autonomously with the
child in therapy through audible phrases in the Spanish language
and movements of its arms and head. It was programed with the
Choregraphe Suite software and the Python SDK - NAO software.
Therapeutic intervention
Based on the principle of promoting functional performance, the
intervention was done as Goal-Directed Therapy (GDT) in order to
achieve the success of the task [32]. GDT is focussed on activity-
based therapy [33]. This principle is based on the realization of
activities aimed at achieving functional objectives, rather than
achieving “normal”patterns of movement. These achievements
can be converted into efficient behaviours for performance in
daily life activities.
Before initiating the intervention, a recognition section was
made and the child met the robot and interacted with it for the
first time. During this session, the robot only greeted the child
saying “Hello Juan”(the name “Juan”is a nickname) and per-
formed random movements of the head and upper limbs. This
recognition was carried out with the objective of not having a
negative impact on the first therapy section, since the child could
be distracted and decide not to attend the proposed rehabilita-
tion process.
The therapeutic intervention consisted of 16 sessions of phys-
ical therapy, two weekly sessions of 45 min each. The first session
was a conventional therapy focussed on the child’s motor control
skills, and the second session was a therapy focussed on the
objective of motor learning to walk using the humanoid robot as
a social assistant. This alternation between conventional therapy
Table 1. Objective –GAS scale.
Scale GAS Objective 1
þ2…and walk 26 steps without falling, …
þ1…and walk 23 steps without falling, …
0 Following verbal instructions by the therapist and the human-
oid robot, the child is able to go from sitting to standing and
walk 20 steps without falling, using an ankle-foot splint and a
proprioception vest.
1
(level current)
…and walk 18 steps without falling, …
2…and walk 16 steps without falling, …
THERAPY CEREBRAL PALSY SOCIAL ASSISTIVE ROBOT 3
and therapy using the robot was repeated until the 16 sessions
were completed.
Thetherapywasdefinedbasedontheobjectiveproposed
in the previous phase and the technical functionalities of the
humanoid robot. Also, the participants and their roles,
the activity’s description and its duration, the environment’s
conditions where the therapy was performed and the robot’s
configuration are described. The therapists role was to direct
thetherapyandthechilds role was to participate in the ther-
apy, interacting with the robot and the environment (see
Figure 2). The therapy routine is described in the follow-
ing steps:
1. The therapist started the therapy by telling the child to take
a toy to where the robot was.
2. The child started the activity while sitting. He made the tran-
sition from sitting to standing and began to walk carrying
the toy.
3. The child walked and carried the toy to where the robot was.
If the child fell in this first attempt, the therapist would ask
the child to return and start the activity again. For the
second attempt, if the child fell, the therapist would encour-
age him to get up to finish the activity.
4. When the child arrived where the robot was, he would
deliver the toy and touch the robot’s head.
5. The robot gives feedbacks to the child by saying positive
sentences for having completed the task. Some feedback
phrases were:
a. Juan, very well done.
b. You have done it very well.
c. Very good Juan, you have brought the toy.
6. The exercise was repeated the other way around: robot -
therapist. Now the robot gave the order to the child to go
back to where the therapist was. The child touched the
robot’s head again and the robot verbally indicated him
extending an arm in the middle line that he had to go to
where the therapist was to bring another toy. Some indica-
tion phrases were:
a. Please, bring back a toy.
b. Juan, go and bring another toy.
c. Go for another toy, please.
This activity was repeated and performed for about 30 or
40 min in a gym where the child could walk more than 20 steps.
Evaluation
Finally, the intervention was evaluated using GAS, which quanti-
fies and evaluates the results in objectives [29]. GAS is a scale
that allows setting individual objectives and is sensitive to min-
imum changes, which are clinically significant and difficult to
appreciate using standardized scales, as Gross Motor Function
Measure (GMFM), Timed Up and Go or 10 Metre Walk Test. For
example, if GMFM had been used, it would not have had the sen-
sitivity required to measure the proposed goal, in Item E: walking,
running and jumping. The walking items only quantify 10 steps
and the child at the beginning of this study performed 18 steps.
The evaluation of the objective was performed by a therapist
who did not participate in the therapies (so as not to bias the
assessment) through videos recorded in sessions 5 (first), 11
(second) and 16 (last).
Results and discussion
In the present study, it was found that the child managed to
increase the number of steps carried out continuously during the
training mediated by the humanoid robot. In session 5 of the
therapeutic intervention it was observed that the child managed
to reach the number of steps proposed by the proposed objective
(þ2 on the GAS scale). In session 11, (þ1 on the GAS scale) was
quantified and, in session 16, 31 steps were observed. Table 2
shows the results of the objective evaluation.
The persistence in the walk can be the factor that determined
the achievement of the proposed objective. According to Miller
et al. [34], the persistence in the directed task is a key indicator of
the motivation and predictor of the individualized results.
Likewise, Burdea et al. [35] mentions that unlike typical non-
motivational movement therapy, game-based robotic is an attract-
ive way to induce neuroplasticity.
Figure 2. Therapeutic intervention with the humanoid robot.
Table 2. Objective Evaluation.
Child
Evaluation First Second Last
Objective 1 þ2þ1þ2
26 steps 24 steps 31 steps
4 J. BUITRAGO ET AL.
Eleven weeks after this study, another evaluation was per-
formed by another professional who did not participate with this
investigation, and it was found that the child continued to
increase the number of steps without falling. In fact, the child
walked 100 steps without falling.
Although it was not determined as an objective, it is important
to mention qualitative aspects such as the persistence and the
motivation of the child to participate in therapy’s activity as well
as the commitment of the family with the research. Furthermore,
the family’s role and home-based training had great relevance;
since the exercises were reinforced with clear and precise instruc-
tions of the walk.
There are several limitations in this study. First, it is not clear if
the increase in the number of steps without falling was due to
the motivation and persistence generated by the presence of the
humanoid robot, or to the methodology proposed and devel-
oped, or to a critical moment of the child’s motor learning, as a
consequence of the therapeutic process that had been carried
out before this intervention. Second, it was not specified how
many attempts should have been made in each intervention ses-
sion and how many of them were expected to have been carried
out positively. This avoided measuring details that could incur
biases in the evaluation, because if the child "took a rest", he was
more likely to perform the next attempt with greater stability and
control. However this could also show that the child adjusted his
energy to complete the activity. Third, it was observed that þ2
on the GAS scale had been reached in session 5. Therefore, the
definition of a new objective was made, but the task or the envir-
onment was not modified.
Conclusions
Through this work we presented the experience of using a
humanoid robot as a social assistive robot in the rehabilitation
process of a child with cerebral palsy, in the field of physical ther-
apy. The importance of the methodology developed, the defin-
ition of the objectives and the goal-directed therapy are
highlighted, since they provide a formal way to achieve interven-
tions in rehabilitation processes for children with cerebral palsy
and allow the therapeutic team, the family and the child to par-
ticipate in the definition and assessment of the proposed objec-
tives. Also, the motivation generated by the interaction with the
robot could facilitate the persistence in the task and the fulfilment
of the objectives.
It is necessary to conduct new research with more participants
to determine if the use of a social assistive robot in therapeutic
interventions could be decisive to achieve greater participation
and fulfilment of objectives in rehabilitation processes for children
with cerebral palsy.
Acknowledgements
The authors would like to acknowledge the child’s family for their
commitment to the therapies and NeuroRehabilitation Center
SURGIR that allows interventions.
Disclosure statement
The authors report no conflicts of interest. The authors are only
responsible for the content and writing of this work.
Funding
This work was funded by the research project “Methodological
proposal to use robotics in therapies to develop physical and cog-
nitive skills in children with motor disability”contract CI2851 of
the Universidad del Valle, Cali-Colombia
ORCID
Jaime Alberto Buitrago http://orcid.org/0000-0002-8328-8470
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