Salas-Monedero M, et al.

, J Phys Med Rehabil Disabil 2024, 10: 091

DOI: 10.24966/PMRD-8670/100091

HSOA Journal of
Physical Medicine, Rehabilitation and Disabilities
Research Article

Robic Socially Assistive Robot Methods: This prospective observational study included 10 children
with chronic SCI that underwent an upper extremities endurance

Enables Upper Extremity En- programme (10 training sessions of 30 min each). Robic usability
was measured through patient’s heart rate reserve percentage, hit

durance Training in Spinal Cord rate, trunk deviation and shoulder and elbow range of motion during
sessions. User experience was address with QUEST Spanish Ver-
sion 2.0 and the Manikin Self-Assessment Scale. Adherence was
Injured Children evaluated using the Hopkins scale and manual dexterity using Leap
Motion Controller.
Miriam Salas-Monedero1,2, Victor Cereijo-Herranz3, Raquel Results and Conclusion: Robic’s platform emerges as an innova-
Madroñero-Mariscal4,8, Yolanda Pérez-Borrego5, Ángel Gil-Agu- tive technological tool demonstrating adequate usability and also a
do4,6,7, José-Carlos Pulido-Pascual3, Fuensanta García-Martín3, good user experience in an upper limb training program for PedSCI
José- Fernando Jiménez-Díaz2, Elisa López-Dolado4,7,8,* and patients. Future developments, incorporating eye-tracking strategies
Ana DelosReyes-Guzmán1,6 would help determine the engagement with the proposed task.
1
Biomechanics and Technical Aids Unit, Hospital Nacional de Parapléjicos
Keywords: Socially assisted robotic platforms; Robotic-based reha-
(SESCAM), Finca La Peraleda, s/n, 45071 Toledo, Spain
bilitation therapies; Pediatric spinal cord injury; Upper limbs endur-
2
International Doctoral School, Castilla La-Mancha University, Toledo, Spain ance training; Usability; Feasibility; User experience
3
Inrobics Social Robotics, S.L.L., Av. Gregorio Peces Barba, 1, 28919 Le-
ganés, Madrid, Spain
Introduction
4
Rehabilitation Department. Hospital Nacional de Parapléjicos (SESCAM),
Finca La Peraleda,s/n, 45071, Toledo, Spain Even though it is not a common condition in childhood and ado-
5
Functional Exploration and Neuromodulation of Nervous System Investiga-
lescence, managing growth and development after a Spinal Cord Inju-
tion Group, Hospital Nacional de Parapléjicos (SESCAM), Toledo, Spain ry (SCI) is a major challenge for the patient, their family, the medical
team and healthcare system and, ultimately, their entire educational
6
Unidad de Neurorrehabilitación, Biomecánica y Función Sensitivo-Motora
(HNP-SESCAM), Unidad Asociada de I+D+I al CSIC, Spain
and social environment. The incidence rate of Paediatric Spinal Cord
Injury (PedSCI) was estimated between 3.3 - 6.2 cases per million per
7
Medicine and Medical Speciallities Department, School of Medicine, Univer-
year in Europe [1]. Some of their sequelae include loss or impaired
sity of Alcalá (UAH), Spain
of Upper Extremity (UE) and trunk balance [2] in addition to a tough
8
Pediatric Rehabilitation Unit, Rehabilitation Department, Hospital Nacional
and challenging cardiovascular training during exercise compared to
de Parapléjicos (SESCAM), Toledo, Spain
healthy children [3]. These impairments affect not only independence
in Activities of Daily Living (ADL), but also quality of motor perfor-
Abstract mance, making social interactions a constant challenge.
Background: Some sequelae of pediatric spinal cord injury (PedS-
CI) include loss of upper extremity and trunk balance, in addition to a Typically, children with PedSCI receive multiple rehabilitative in-
tough and challenging cardiovascular training. Robic (NAO robot, Al- terventions throughout childhood to maintain or improve their func-
debaran Robotics) is a Class I medical device whose main goal is to tional level and to facilitate somatic growth. The intensity of such
provide assistance to human users through social interactions. In the therapies is usually moderate, aiming to recruit sufficient muscle mass
present proof-of-concept study, supported by an assistant therapist, to improve oxygen consumption and reduce Physical Strain (PS).
our objective is to evaluate the Robic’s usability, user experience and
Typically, a higher Physical Condition (PC) produces a lower PS [4].
clinical feasibility in a PedSCI population.
The success in rehabilitation programs is based on two prerequisites:
1) adhering to the prescribed sessions [5,6]; 2) maintaining attention
*Corresponding author: Elisa López-Dolado, Rehabilitation Department, Hos-
pital Nacional de Parapléjicos (SESCAM), Finca La Peraleda s/n 45071, Toledo,
to the task to be trained during each session. Both are crucial in the
Spain, Tel: +34 925 396827; E-mail: [email protected] analysis of therapeutic outcomes [7]. Several clinical studies in pae-
diatric populations have shown that patient motivation is a key aspect
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, of rehabilitation success and is directly related to patient adherence
Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot En-
and their ability to understand and maintain the level of care during
ables Upper Extremity Endurance Training in Spinal Cord Injured Children. J
Phys Med Rehabil Disabil 10: 091. use [8,9]. Motivation and attention are important for adherence in SCI
patients, as the subjective component of emotions decreases follow-
Received: March 25, 2024; Accepted: April 03, 2024; Published: April 10, 2024 ing the loss of peripheral body feedback [10]. On the other hand, it
has been shown that variations in some peripheral physiological vari-
Copyright: © 2024 Salas-Monedero M, et al. This is an open-access article dis-
tributed under the terms of the Creative Commons Attribution License, which per-
ables, particularly Heart Rate (HR), are strongly correlated with affec-
mits unrestricted use, distribution, and reproduction in any medium, provided the tive self-reports, even though emotions are mainly related to central
original author and source are credited. mental processes, especially cognition and behavior [11].
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 2 of 9 •

To mitigate this, technological solutions like Socially Assistive Exclusion criteria were: unstable orthopaedic injuries; moderate pain
Robotics (SAR), that is to say, robots whose main goal is to provide or joint stiffness; severe spasticity; severe bronchopneumopathy and/
assistance to human users through social interactions, are being ex- or heart disease requiring monitoring during exercise; visual impair-
plored [12]. SAR is slowly being integrated into healthcare systems as ment and cognitive impairment.
new avenues to provide care for chronically ill and disabled patients.
Sample Analyzed
However, this process is proving to be complex, as it is based on Variables
human-robot interactions and this kind of communication faces mul- Tetraplegic (n=5) Paraplegic (n=5)

tiple challenges, such as safety, usability or user experience, before its Sex(Male)* 1.00 (20.00) 3.00 (60.00)
clinical relevance can be assessed [13]. Age(Years)+ 9.67±4.04 10.67±2.08

Weight (kg)+ 39.66±7.50 36.03±12.22

A major advantage of using SAR as a motor rehabilitation tool
in PedSCI is that they can measure the child-robot interaction in real Height (cm)+ 138.66±11.06 140.33±16.92

time. In addition, they can be synchronized with other wearable de- Etiology Injury (
1.00 (20.00) 1.00(20.00)
vices like heart rate monitors or accelerometers, which makes it pos- Traumatic)*

sible to control and individualize therapies, thus optimizing the result- Time since injury
3.66±2.51 10.00±3.00
(months)+
ing motor learning by improving peripheral body feedback [10,13].
One of these platforms, Robic’s Inrobics Rehab Clinic (NAO robot, Injury Level* C1: 1.00 (20.00) T3: 1.00 (20.00)

Aldebaran Robotics), has been shown to successfully guide motor C2: 1.00 (20.00) T12: 1.00 (20.00)
training programmes in cardiac rehabilitation [14] and in children C5: 1.00 (20.00) L1: 1.00 (20.00)
with cerebral palsy and obstetric brachial plexus palsy [15]. Using the C6: 1.00 (20.00) L2: 1.00 (20.00)
same Robic humanoid robot, our group was able to analyze smooth-
C7: 1.00 (20.00) L3: 1.00 (20.00)
ness and efficiency metrics in a group of chronic SCI children follow-
AIS Classification*
ing UE training, supporting the hypothesis that SAR can be used as a
technique to guide and evaluate motor training therapies [16]. A - -

B 3.00 (60.00) -
In the present proof-of-concept study supported by Robic platform
C 1.00 (20.00) 3.00 (60.00)
as assistant therapist, our objective is to evaluate usability, user ex-
D 1.00 (20.00) 2.00(40.00)
perience and clinical feasibility of Robic in a chronic PedSCI pop-
ulation. We followed SAR’s AUSUS evaluation framework, where UEMS+ 31.33 ± 15.27a 50.00 ± 0.00a

usability is defined as effectiveness, efficiency, learnability, flexibility, SCIM-III+

robustness and utility. User experience is understood as embodiment, Self-Care 6 ± 5.39 17.2 ± 2.05
emotion, human-oriented perception, sense of security and co-experi- Breathing 18.2 ± 9.65 28.8 ± 8.41
ence [13]. Mobility 13.4 ± 14.88 32.2 ± 5.22

Materials and Methods Total+ 37.6 ± 29.56a 78.2 ± 14.85a

Study design and participants Table 1: Demographic characteristics and International Standards for the
Neurological Classification of SCI (ISNCSCI) of the sample analyzed.
This prospective observational study included 10 children with Significant statistically differences are expressed in bold font. a (p<0.01);
* categorical variables are expressed as frequency and percentage; + con-
chronic SCI, Five of them had cervical PedSCI (tetraplegic), with tinuous variables are expressed as mean and standard deviation. American
some degree of impaired motor function of the arms and trunk, and Spinal Association Impairment Scale (AIS Classification). Upper Extremi-
the other five had thoracolumbar PedSCI, (paraplegic), with pre- ty Motor Score (UEMS) Spinal cord measures (SCIM-III).
served motor function of both arms, but varying degrees of impaired
balance trunk control all of them attended in the Pediatric Unit of the
The Upper Extremity Motor Score (UEMS) and Spinal Cord Inju-
Hospital Nacional de Parapléjicos of Toledo (Spain). It was approved
ry Independence Measure version III (SCIM III) were obtained prior
by the Local Ethics Committee (Comité Ético de Investigación Clíni-
to the start of UE robotic endurance training. UEMS is a rated score
ca con Medicamentos, Complejo Hospitalario de Toledo; Approval of the strength of 10 key muscle groups of both UE, 5 on each arm.
number: 760; 29 September 2021) and was conducted in accordance Every one of them could be scored from 0 (no function) to 5 (nor-
with Good Clinical Practice guidelines and the Declaration of Helsin- mal function), with a maximum of 25 points for each UE, 50 points
ki. Prior to enrolment, written informed consent was obtained from all considering both arms [17] (Table 1). SCIM-III is the specific scale
participants, signed by parents or legal guardians. for assessing the level of functional independence for SCI subjects,
taking into account aspects of self-care, breathing, sphincter control
Children with SCI who participated in this study met the follow- and mobility [18].
ing inclusion criteria (Table 1): 1) having a SCI of level C6 or below
for complete motor injuries, classified according to the International Socially assistive, Robic platform description
Standards for the Neurological Classification of Spinal Cord Injuries Robic (NAO robot, Aldebaran Robotics) is a SAR platform reg-
(ASIA Impairment Scale [AIS]) [17] as AIS grades A or B, or any istered by the AEMPS from 22nd March 2021 as a Class I medical
incomplete SCI of AIS level C or D that allows UE range of motion device (registration number RPS/777/2021).
to be performed; 2) age between 7 and 14 years and scored 1 or 2
according to the Tanner Scale (prepuberal); 3) able to maintain a sit- The Inrobics system is a platform for rehabilitation and patient
ting position. Allowed to use their own wheelchair; 4) and signed the monitoring based on the interaction between various hardware and
appropriate written informed consent (by parent or legal guardian). software components (Figure 1).

J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 3 of 9 •

intensity, 30% to 39% of reserve heart rate (%HRR), and moderate

intensity (40% to 59% HRR) [20].

All recruited children underwent a UE endurance training pro-

gramme consisting of 10 experimental sessions of 30 min each, divid-
ed into three parts: warm-up (10 min), main part (20 min) and cool-
down (10 min). Before starting, an experimental session consisting
of 3 exergames separated by 2 resting periods was performed. These
sessions were scheduled for 2 or 3 days per week, with the aim of
completing the endurance training in a maximum of 5 weeks. Patients
performed the experimental sessions in their own wheelchairs, in a
comfortable room with the same light and temperature conditions.
Robic was positioned in front of the participant at the appropriate
Figure 1: Human-Robot Interaction (HRI). Graphical diagram sum- distance for real-time data recording. The therapist, who was close
marising the content of the training with Robic platform and the evaluation enough to ensure the patient’s safety, had full view of the motion
methodology. monitoring sensor at all times and could intervene during the session
if necessary. To select the specific exercises included in the training
At the core of this system is the Orbbec Persee, featuring a Red- protocol, it was taken into account that the muscles involved in each
Green-Blue-Deep (RGB-D) sensor and a 3D sensor, which includes exercise should be the same as that of the ADLs (deltoids, shoulder
a compact computer running on the software architecture developed rotators, elbow flexors and extensors, and wrist flexors and exten-
by Inrobics. This sensor enables accurate detection of the patient’s sors), in order to meet the objective of reducing the energy cost of
movements, which is essential for the evaluation of the accuracy and movement and improving the quality of life of children with SCI.
effectiveness of rehabilitation exercises. The movements are recorded
and measured with high accuracy in terms of active range of mo- Evaluation variables for hand motor control dexterity
tion (maximum ROM achieved), trunk and neck deviation, amount The hand motor dexterity was recorded through the smoothness
of movement (hit rate) and attention span (visual connection to the metric, which was calculated at the beginning and at the end of the
platform, adherence). A core element in this ecosystem is the NAO training program using a non-immersive virtual application based on
V6 robot, designed to guide the rehabilitation sessions. NAO not only the Leap Motion Controller (LMC) available in the RehabHand soft-
demonstrates and explains exercises to patients, but also acts as an ware developed in our center [21,22]. This application proposed the
interactive facilitator, enhancing the therapy experience. The patient’s execution of a functional task based on following a previously defined
well-being is monitored by the Polar Verity Sense wristband, a heart trajectory with an enveloping shape, passing only once through each
rate sensor that records the heart rate during the sessions. This infor- node. With the aim of comparing the trajectories the order to reach
mation is needed to monitor the patient’s physical response to the the nodes is previously established. So the smoothness metric is ob-
exercises. The app installed on a tablet provides a user interface to set tained as the peaks number or movement units detected from the hand
up exercises and monitor sessions. This app collects data on both the velocity profile during the execution of the task, and the efficiency
patient’s heart rate and performance captured by the 3D camera, pro- metric was evaluated by calculating the length of the hand trajectory
viding a comprehensive view of the patient’s progress. The computer performed.
embedded in the system’s 3D sensor manages the entire architecture,
controlling the NAO robot in a fully autonomous way and receiving Evaluation variables related to Robic interaction: usability
data from the 3D sensor. Its function is to ensure that patients perform and users experience
the exercises correctly, providing real-time feedback to correct any
errors. This ensures that each session is as effective as possible. Ad- To address usability, Robic provided feedback on the patient’s
ditionally, the system’s architecture is responsible for, once receiving performance during the sessions in terms of heart rate reserve per-
the configuration of the session, carrying out reasoning to execute the centage (HRR%), hit rate, trunk deviation and shoulder and elbow
session. This reasoning is based on the transformation of low-level range of motion (ROM). Mean values for each of these variables were
states into high-level PDDL (Planning Domain Definition Language) calculated over the entire session. In addition, a graphical represen-
predicates that the Monitoring and Decision Support modules can tation of the trend of the data was included, along with the corre-
process [19]. This allows for reasoning based on the state and actions sponding linear regression curve and its characteristic equation. This
of the different devices (robot, 3D sensor, and tablet), facilitating ad- facilitated the interpretation of changes in performance over time.
aptation to the needs of the rehabilitation session. Finally, after the Heart Rate Reserve Percentage (HRR%) was estimated from con-
conclusion of each session, the data collected is stored in a cloud da- tinuous monitoring of the patient’s heart rate throughout the session
tabase. This information is used to query and calculate key metrics, using the Polar Verity Sense, which was placed in the middle of the
allowing a detailed assessment of patient progress over time. This humerus of the dominant arm and previously connected to the Robic
data-driven approach is essential to personalize and continuously im- platform via Blue Tooth. Session PS [4] defines the intensity session
prove the rehabilitation process. and was estimated as percentage reserve HR based on the individual’s
Experimental UE endurance training protocol HR:

The design of this programme, developed at the Hospital Nacional HRR% = [(HRPeak - HRObserved)/(HRPeak -HRRest))*100,
de Parapléjicos of Toledo, is in line with the aerobic endurance rec- Where HRPeak is the maximum HR (HRMax) value found during
ommendations of the International Spinal Cord Society (ISCoS): light the execution of the session and HRRest is the lowest heart rate found
J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 4 of 9 •

during the entire session period. HRObserved is taken from the HR Pearson correlation was applied to assess the association between the
Range value observed. UEMS scale and effectiveness and smoothness of movement vari-
ables, including peaks number and trajectory length.
HR Range= (HRMin- HRMax)
Results
Hit rate, trunk deviation and kinematic goniometric data was reg-
istered with Robic using R software (version 4.3.1 for Ubuntu (R For the present study, 10 children with chronic SCI were recruited,
all of them from the Paediatric Rehabilitation Unit of the Hospital
Core Team, 2020)). The kinematic variables were measured separate- Nacional de Parapléjicos of Toledo (Spain).
ly in elbows and shoulders. For the elbow joint, the first measure was
the range of extension from 90° to full extension in the anatomical Demographic variables along with the International Standards for
the Neurological Classification of SCI (ISNCSCI) are summarized in
position. It should be noted that children with tetraplegic PedSCI
Table 1.
generally do not reach full extension at 0°. Thereupon, elbow flexion
was assessed, from 90° to 180°. Regarding to shoulder joint, shoulder No statistically significant differences were found between tetra-
flexion was recorded from 10° of flexion with the arm extended in an- plegic versus paraplegic children in the demographic variables, but
as expected, UEMS and SCIM scores were significantly lower in the
atomical position to 90°. Displacements of the shoulder between 90° former group. In fact, the UEMS score discriminated between the two
and 180° were considered to be part of the shoulder elevation range. experimental groups. Only the tetraplegic had UEMS scores below
50 (mean UEMS 31.33 ± 15.27 in tetrapelgic versus 50.00 ± 0.00 in
To measure the user experience, we used two different question- paraplegic), since by definition, all levels of paraplegic score a max-
naires: the Spanish version of the Quebec User Satisfaction Evaluation imum on this variable, which discriminates between tetraplegics and
with Assistive Technology (QUEST Spanish Version 2.0) (D-QUEST) paraplegics, but not between different levels of paraplegia. Similar-
and the Manikin Self-Assessment Scale (SAM), of which a record was ly, the total score of the SCIM III and its subscores are significantly
lower in tetrpalegic (total 37.6 ± 29.56; selfcare 6 ± 5.39; breathing
taken at each of the sessions after completion. D-QUEST consists of a 18.2 ± 9.65; mobility 13.4 ± 14.88) than in paraplegic PedSCI (total
written questionnaire and has proven to be a reliable and valid instru- 78.2 ± 14.85; selfcare 17.2 ± 2.05; breathing 28.8 ± 8.41; mobility
ment to assess their satisfaction with UE endurance training through 32.2 ± 5.22). However, and also as expected, in terms of the level of
SAR with respect to 8 differential aspects using a rating scale from 1 independence in performing ADLs, none of the subjects in the latter
to 3, with 1 being the aspect with the highest relevance or importance, group achieved maximum scores, confirming the existence of infrale-
sional motor sequelae in those less damaged subjects and the potential
and 3 being the aspect with the lowest relevance or importance [23]. usefulness of training programmes such as that proposed for all levels
The SAM scale is a nonverbal pictorial assessment questionary that and severities of SCI.
directly measures the pleasure, arousal, and dominance associated
with a person’s affective reaction to a wide variety of stimuli [24]. Comparison related to dexterity and performance with Ro-
bic Platform
Evaluation of adherence to the training programme
Regarding the analysis of hand motor control dexterity, tetra-
After the last training session, the Hopkins scale (HOPKINS) was plegic children showed significantly less efficient movements than
used to measure the patient’s adherence to the endurance training pro- paraplegic children, as evidenced by the longer trajectories measured
tocol [25]. This scale measures the involvement in the UE endurance by the non-immersive virtual LMC application (286.01 ± 59.87 ver-
training program. The score reflects a summary impression of the par- sus 123.61 ± 17.14; p=0.004) (Figure 2). However, no statistically
ticipants’ engagement during their respective therapy sessions. The significant differences were found between the number of spikes in
scoring consisted of summing all scores, reversing item 2. the trajectories performed by the tetraplegic compared to paraplegic
children. Nevertheless, the peaks number mean was higher in tetra-
Statistical analysis plegic (81.67 ± 48.21 vs. 79.00 ± 31.34), which may indicate that they
could have less smooth UE movements (Table 2, Figure 3), which
All statistical analyses were conducted using SPSS 17.0 for Win-
will require larger sample sizes to investigate.
dows (SPSS Inc., Chicago, IL, USA). The clinical and demographic
characteristics of the participants underwent descriptive statistical
analysis, and the results were presented as mean and standard devia-
tion.

For performance and training variables, including HRR%, hit rate,

trunk deviation, goniometry (elbow flexion and extension; shoulder
flexion and elevation), and dexterity (length and number of peaks),
a normality analysis was performed using the Shapiro-Wilk test. Re-
lated-samples analyses were conducted to assess the means of vari-
ables in the baseline and Ending endurance EU training sessions for
each group using the paired-samples t-test as a parametric test and
the Wilcoxon signed-rank test as a non-parametric test. Additional-
ly, independent-samples analyses were conducted in the first and last Figure 2: Length Trajectory. The columns represent the mean and the
sessions to check for significant differences between the analyzed error bars represent the standard quadratic mean. * p<0.05. Tetraplegic
PedSCI are represented in grey, and paraplegic PedSCI are represented
groups, utilizing the independent-samples t-test as a parametric test in black.
and the Mann-Whitney U test as a non-parametric test.

J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 5 of 9 •

Variables Tetraplegic (n=5) Paraplegic ( n=5)

At baseline At ending Diff. At baseline At ending Diff.

Reserve HR (Percentage) 47.72 ± 11.25 42.56 ± 12.97 4.20 ± 7.25 52.92 ± 4.15 * 47.64 ± 4.38 * 6.60 ± 2.22

Trunk deviation (Degrees) 3.00 ± 2.15 2.61 ± 1.57 * 0.50 ± 1.30* 4.19 ± 1.68 * 9.18 ± 3.42 * -6.09 ±2.71*

Tries successful (Attempts) 35.20 ± 20.11 *

40.80 ± 18.18 0.33 ± 10.78 58.00 ± 7.58 *
54.60 ± 11.14 7.75 ± 6.55

Trajectory length (mm) 286.01 ± 59.87** 128.73 ± 30.07 157.27 ± 50.45 123.61 ± 17.14** 114.13 ± 34.59 59.72 ± 101.59

Peaks number (units) 81.67 ± 48.21 62.67 ± 6.65 19.00 ± 43.58 79.00 ± 31.34 44.25 ± 18.57 34.75 ± 39.12

Elbow flexion (Degrees) 106.92 ± 10.83 112.48 ± 11.09 9.13 ± 5.22 108.26 ± 3.01 108.02 ± 7.65 1.11 ± 8.14

Elbow extension (Degrees) 17.96 ± 5.62 14.70 ± 2.02 4.40 ± 7.70 16.79 ± 5.39 15.62 ± 5.48 7.09 ± 2.26

Shoulder Elevation (Degrees) 117.65 ± 36.26 120.48 ± 26.61 0.66 ± 11.34 125.05 ± 15.02 113.20 ± 19.51 -13.54 ± 11.70

Shoulder Flexion (Degrees) 40.45 ± 9.89 39.67 ± 9.48** 1.89 ± 14.48 28.61 ± 7.17 25.81 ± 3.98** 0.59 ± 6.09

Table 2: Performance and motor control variables at the beginning and end of endurance. UE training in tetraplegic and paraplegic children. The results are
expressed as mean and standard deviation. Diff., difference between the Baseline and the Ending session of the mean and the standard deviation.*p<0.05,
**p<0.01.

Figure 4: Percentage of heart rate reserve. Points represent the average of

Figure 3: Peaks Number. The columns represent the mean and the error each of the endurance training program sessions and the linear regression
bars represent the standard quadratic mean. * p<0.05. Tetraplegic PedSCI line (R2).
are represented in grey, and paraplegic PedSCI are represented in black.

The dexterity and performance variables related to the use and

interaction with Robic Platform (HRR%, trunk deviation and hit rate)
obtained for both experimental groups were compared at the begin-
ning and ending of UE endurance training (Table 2).
With respect to HRR%, there was a decrease in the mean HHR% at
the end of the intervention, suggesting that the cardiovascular chang-
es achieved were those intended by the programme implemented. But
this decrease reached statistical significance in paraplegic (baseline
52.92 ± 4.15, ending value 47.64 ± 4.38; p=0.029), but not in tetra-
plegic (baseline 47.72 ± 11.25, ending value 42.56 ± 12.97; p>0.05).
Further studies with larger sample sizes will need to analyze whether Figure 5: Hit Rate. Points represent the average of each of the endurance
tetraplegic subjects need more sessions to achieve the same effect as training program sessions and the linear regression line (R2).
paraplegics children, or whether a different therapeutic approach is
needed (Table 2, Figure 4).
for tetraplegic children (baseline 3.00 ± 2.15; 2.61 ± 1.57; p=0.028)
The hit rate in carrying out the training programme was signifi- (Table 2, Figure 6). This data highlights clear trunk deviation differ-
cantly lower in tetraplegic than in paraplegic (35.20 ± 20.11 versus ences directly due to the level of SCI, with greater capability for trunk
58.00 ± 7.58; p=0.045) (Table 2, Figure 5). No statistically signifi- training in paraplegic than in tetraplegic subjects.
cant differences were found in the hit rate attributable to the training
programme between the two groups studied, but tetraplegic tended The kinematic analysis of the goniometric variables depicts the
to improve (baseline 35.20 ± 20.11; ending value 35.20 ± 20.11) and different impacts of the SCI on upper limb movement, revealing clear
paraplegic tended to deteriorate (baseline 58.00 ± 7.58; ending value alterations in elbow flexion and shoulder movements in tetraplegic
54.60 ± 11.14).
children. After completing all training sessions, a significantly great-
Paraplegic children significantly increased trunk deviation move- er increase in shoulder flexion was found in tetraplegic compared to
ments as a result of the endurance training programme (baseline 4.19 paraplegic children (39.67 ± 9.48 versus 25.81 ± 3.98; p=0.028) (Ta-
± 1.68; ending value 9.18 ± 3.42; p=0.044), which was not the case ble 2, Figure 7b). Regarding shoulder elevation, although paraplegic
J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 6 of 9 •

Figure 8: Correlation between UEMS and trajectory length: (a) in the

first session of the training (Baseline timepoint); (b) in the last session
(ending timepoint).

Figure 6: Trunk Deviation .Points represent the average of each of the

endurance training program sessions and the linear regression line (R2).

patients started the programme with a greater range of motion (125.05

± 15.02 in tetraplegic subjects versus 117.65 ± 36.26 in paraplegic
subjects), no statistically significant differences in the improvement
due to the training programme were found in both experimental
groups. Nor were there any changes in the maximum ranges of move-
Figure 9: Correlation between UEMS and Peaks number: (a) in the
ment of elbow flexion and extension as a result of the training pro- first session (Baseline timepoint); (b) in the last session (ending timepoint).
gramme (Figure 7a).
(20%), and thirdly, “safety” (40%), “ease of use” (20%), and “setting”
(20%). Yet, the paraplegic PedSCI (Figure 10b) ranked “effective-
ness” (40%), “safety” (20%) and “comfort” (20%) first; “ease of use”
(40%), “effectiveness” (20%) and “comfort” (20%) second; and “ease
of use” (40%), “safety” (20%) and “dimensions” (20%) third. The
qualities “weight” and “durability” were not chosen by any patient,
neither paraplegic nor tetraplegic. In addition, tetraplegic children ig-
nored the quality “dimensions”, while paraplegic children neglected
the quality “ setting”.
Figure 7: Goniometry. Tetraplegic PedSCI are represented in grey, and
paraplegic PedSCI are represented in black. (a) Elbow goniometry: Flex-
ion and extension; (b) Shoulder goniometry: Elevation and Flexion.

Upper limb motor performance measures correlations

The correlation between the UEMS score and upper extremity
dexterity, measured by trajectory length (Figure 8) and number of ve-
locity peaks (Figure 9). The analysis performed in tetraplegic children Figure 10: The Spanish version of the Quebec User Satisfaction Eval-
suggested a high correlation between UEMS and hand trajectory, both uation with Assistive Technology (D-QUEST Spanish Version 2.0). The
qualities chosen with more importance or relevance are shown with darker
at baseline (r = -0.980, p=0.126) and also at ending timepoint (r= colour bars. Qualities chosen with less importance or relevance are shown
-0.915, p=0.394). On top of that, we found a positive correlation be- with lighter colour bars. (a) Outcomes Tetraplegic SCIPed. (b) Outcomes
tween the number of peaks and the UEMS score (Figure 9), although Paraplegic SCIPed.
it only reached statistical significance upon completion of the training
programme with Robic (r = 0.500, p=0.667 at baseline and r = 1, Sam Scale
p<0.01 at ending). As the UEMS score was always 50 points for all
paraplegic subjects, no correlation can be made between this variable For each of the three direct rating questions “pleasure”, “arousal”,
and the upper limb dexterity measures for this group (Figure 8, Figure and “dominance”, responses from both groups across 10 sessions were
9). analyzed (Figure 11). The maximum possible score for each question
SAR user experience and training program adherence was 9 points. For “pleasure”, there was no change in scores between
baseline and final sessions, but scores were high for both groups (tet-
D-QUEST
raplegic 9.00±0.89; paraplegic 8.00±1.15). For “arousal”, the scores
As explained above referring to the QUEST questionnaire, the differed from the baseline session (tetraplegic 7.00±0.89; paraplegic
experimental subjects described their user experience by means of 6.00±1.91) to the final session, where both groups scored lower (tet-
quality attributes. raplegic 1.00±1.09; paraplegic 3.00±1.00). Scores for “dominance”
The qualities firstly chosen by tetraplegic PedSCI (Figure 10a) behave just the opposite, were lower for both groups in the baseline
were “comfort” (60%) and “effectiveness” (20%). Secondly, “effec- session (tetraplegic 5.00±1.41; paraplegic 6.00±1.91) and increased
tiveness” (40%), “safety” (20%), “ease of use” (20%), and “comfort” in the final session (tetraplegic 7.00±1.41; paraplegic 8.00±2.82).

J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 7 of 9 •

program applied to tetraplegics and paraplegics, while paraplegic

patients manage to train and thus modify the parameters of physi-
cal capacity such as isometric strength, peak power output (POpeak)
and peak oxygen uptake or PS as HRR%, tetraplegic patients do not
[26,27] , likely, this can be explained by the neurological severity of
the SCI in tetraplegic patients, which does not allow them to reach the
desired training intensity [28]. This could explain why our results in-
dicate that despite the decrease in HRR% at the end of training in both
groups, it is only statistically significant in the paraplegic group. They
seem to be the group capable of achieving the desired cardiovascular
training, with the use of this robotic tool. Regarding dexterity move-
Figure 11: Manikin Self-Assessment Scale (SAM). The drawings with
ments, the results show that Robic can detect that tetraplegic patients
a light grey round shape represent the responses of the children with tre-
traplegia and the drawings with a triangular shape represent the responses exhibit a higher deviation peaks number in the trajectories performed
of the children with paraplegia. (a) First session programme Training, (b) by the upper limbs, as demonstrated in other studies [16,22]. This
Last session programme training. suggests that with this training program assisted by the robot, tetraple-
gic patients achieve upper limb dexterity training. On the other hand,
Hopkins Scale it is the paraplegic patients who manage to increase trunk deviation,
while tetraplegics do not. This aligns with their level of injury, where
Involvement of each patient in their training was evaluated by the their potential target for dexterity training will be trunk balance work.
therapist using Hopkins scale, that assigned a value from 5 to 30. Tet- Tetraplegic patients may not be able to train this function due to the
raplegic children scored significantly lower than paraplegic PedSCI severity of the injury level. Another result that indicates the positive
(27.00±0.54 versus 29.50±0.95; p=0,013). However, the high level capability of the robot for dexterity training is that, as one would logi-
of engagement of both groups with the training provided by Robic cally expect, the accuracy rate for any task will be lower in tetraplegic
platform was a very positive aspect (Figure 12). patients than in paraplegics. This is what the robotic platform detects
when comparing both groups. Additionally, the fact that although
there are no statistically significant differences when comparing
this accuracy rate at the beginning versus the end of training in each
group, there is a trend towards improvement in tetraplegic patients at
the end of training. This could further highlight that while tetraplegic
patients are able to train motor dexterity, paraplegic patients may not
do so because the task is not stimulating for them or because it is
not impaired in them, and therefore, they do not train it. Moreover, it
is expected that in tetraplegic patients, the muscle groups that show
the most improvement are those closest to the level of injury. Thus,
in tetraplegic patients who already face difficulty in proximal move-
ments of the upper limbs due to their level of injury, it is the proximal
muscle groups that show more improvement compared to the distal
Figure 12: Hopkins scores obtained by both experimental groups. Tetra-
plegic PedSCI group is represented in grey and paraplegic PedSCI group musculature [28]. After training with the robot, statistically signifi-
in black. cant improvement is observed in tetraplegics in shoulder flexion but
not in elevation (as the latter is not expected to depend on the training
Discussion program but on the neurological recovery capacity allowed by the
severity of the injury). Paraplegic patients do not show improvement
This study aims to evaluate the capacity of Robic’s Inrobics Rehab as this group starts from a baseline of normality.
Clinic (NAO robot, Aldebaran Robotics) to act as a therapeutic assis-
tant for a sample of SCI children, assisting them to perform an upper In terms of user experience, our results show that SCI children
limb endurance training programme. For this purpose, we carried out were successful in interacting with the Robic platform, as evidenced
a proof-of-concept study and analyzed the usability of Robic, the user by their choice of the most important qualities through the QUEST
experience of the children in their interaction with it, to elucidate the questionnaire: “comfort”, “effectiveness”, “safety” and “ease of use”.
feasibility of using it as a therapeutic aid in rehabilitation programs Interestingly, the effectiveness perceived by the users corresponds to
designed for PedSCI population. the positive evolution of the usability variables recorded by Robic.
The qualities “weight” and “durability” were not chosen by any pa-
Usability is a parameter that describes the effectiveness, efficien- tient, neither paraplegic nor tetraplegic, possibly because the children
cy, ease of learning, flexibility, robustness, and utility applicable to did not perceive Robic as a device to be worn, but as a tool to interact
devices provided by new robotic technologies that can be used in up- with the environment in order to be trained. The strong perception
per limb training, such as the ARMEO Spring [22], or new robotic of child-Robic interaction as “safe” is a strength, but at least in part
power wheelchair [26]. For the purpose of proving the Robic plat- it could be related not to the Robic platform itself, but to the envi-
form usability, our results allow us to describe the behavior of two ronment in which the therapist, the Robic platform and SCI children
training variables: on one hand, physical capacity and physical strain, were located to conduct the present study. Robic platform was recog-
and on the other, dexterity movements. As expected, and as already nized as an effective tool for upper limb training for both paraplegic
described in other previous studies, with the same aerobic training children, with upper limbs without neuromuscular restrictions, and

J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
Extremity Endurance Training in Spinal Cord Injured Children. J Phys Med Rehabil Disabil 10: 091.

• Page 8 of 9 •

tetraplegic children, whose arms have varying degrees of paralysis, E.L.-D.; supervision, A.dlR.-G, J.-C.P.-P and E.L.-D.; project admin-
making training more difficult but more necessary. istration, A.dlR.-G, J.-C.P.-P. and E.L.-D. All authors have read and
agreed to the published version of the manuscript. All authors have
It is well established in human-robot interactions that SAR are read and agreed to the published version of the manuscript.
perceived as social actors because they are able to evoke some pat-
terns typical of human-human interaction [29]. Because of that, an Funding
emotional user experience evaluation through the SAM scale was in-
cluded. SAM scale responses showed that the interaction with Robic This research received no external funding.
was described always and by all SCI children as pleasant, increasing- Institutional Review Board Statement
ly calm and also with a growing sense of control (dominance) by the
child over the training programme. These results are very encourag- The study was conducted in accordance with the Declaration of
ing for future developments and could be related to the human-like Helsinki and approved by the Institutional Review Board (or Ethics
morphology of the Robic platform, the Robic’s direct gaze on the ex- Committee) of Complejo Hospitalario de Toledo (protocol code 760
perimental subjects and, in the case of our paediatric sample, perhaps and date of approval 29th September 2021).
its paediatric dimensions. These results are in line with recent studies
that have shown that the perception of the direct gaze of a humanoid
Informed Consent Statement
robot can have similar effects to the perception of the direct gaze of Informed consent was obtained from all subjects involved in the
another human [30]. study (by parents or legal guardians).
Apart from the limitations in the analysis of the variables due to Data Availability Statement
the small size of our sample, which is adequate for a usability proof-
of-concept study but not for drawing precise conclusions on the effec- The raw data supporting the conclusions of this article will be
tiveness of the intervention applied, the main limitation of this study made available by the authors on request.
is the impossibility of evaluating the engagement with the Robic plat-
Acknowledgment
form, as it lacks sensors for visual tracking of the user. Eye-track-
ing-based measurements have been described as reliable tools for Grant PID2020-117361RB-C22 funded by MCIN/
accurately predicting autism diagnoses in the paediatric population AEI/10.13039/501100011033.
[31,32], so future developments of the Robic platform will need to
incorporate eye-tracking sensors and support real-time learning of the Conflicts of Interest
user’s engagement with the proposed task. The authors declare no conflict of interest.
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J Phys Med Rehabil Disabil ISSN: 2381-8670, Open Access Journal Volume 10 • Issue 1 • 100091
DOI: 10.24966/PMRD-8670/100091
Citation: Salas-Monedero M, Cereijo-Herranz V, Madroñero-Mariscal R, Pérez-Borrego Y, Gil-Agudo A, et al. (2024) Robic Socially Assistive Robot Enables Upper
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