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Vol. LIX, No. 16
August 10, 2007
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STEP Forum Makes Robotic Medicine Come to Life

On the front page...

It seemed more fantasy novel than symposium: a paralyzed woman moves a circle on a monitor using only her thoughts, a robot assists in surgery, a student practices an operation on a simulated person and medics-in-training treat soldiers in a virtual version of the streets of Baghdad.

"But this is not science fiction. This is happening," said Dr. John Donoghue, director of the Brain Science Program at Brown University, referring to just some of the technology described in a recent Staff Training in Extramural Programs forum here. Yet, his statement could be applied to all of the areas of research covered by the event titled, "Robotic Medicine: Dr. R2D2 Will See You Now."

Continued...


  Dr. John Donoghue of Brown University discusses neural interface systems.  
  Dr. John Donoghue of Brown University discusses neural interface systems.  
We're at the beginning of a new age, Donoghue said. His area of interest, neural interface systems, is "something you're going to see grow immensely in the next decades.devices that interface with the nervous system and allow new ways of diagnosing and treating nervous system disorders," he said. What will be "truly spectacular," is the ability to restore lost movement to persons with paralysis, blindness, deafness and even epilepsy.

Donoghue's focus centers on "connecting the brain to the outside world." To do this, researchers began by trying to understand what goes on in the brain when a person moves. Normally, a signal goes from the brain to the nervous system to the muscles to create an action. In people with paralysis, there's a physical disconnection between the brain and the path through the spinal cord to the muscles. "The idea [of this research] is to create a bridge between the brain and the outside world," he said. Researchers plan to use brain signals "to do something meaningful," by connecting to devices such as computers, assistive technologies, artificial limbs or even to the muscles themselves.

  In a photo from Dr. Russell Taylor’s presentation, a surgeon at Johns Hopkins controls a “snake robot” using master controllers from a DaVinci surgical robot. He is observing the robot through stereo endoscopic video on a head-mounted display.
  In a photo from Dr. Russell Taylor's presentation, a surgeon at Johns Hopkins controls a "snake robot" using master controllers from a DaVinci surgical robot. He is observing the robot through stereo endoscopic video on a head-mounted display.

One of the most promising technologies is a sensor that's implanted into the brain and detects the electrical activity of neurons that control arm movement. When scientists started this research, they first had to determine whether these signals still existed in people who were paralyzed-from spinal cord injury, stroke or amyotrophic lateral sclerosis (ALS). After watching a patient who had been unable to communicate for 9 years move a dot on a screen with her thoughts, they knew those signals were still intact. "It had a profound impact on what we know about how the brain actually works," Donoghue said.

So far, patients have used this technology in demonstrations to open email, play video games and type letters. In a film Donoghue showed, a paralyzed ALS patient even moved a dot on a screen as his 6-year-old son instructed him. "This just brings out what this technology has the potential to do," he said. "It has a profound effect on these individuals who once had intact lives, enabling them to regain function."

Dr. Geoffrey Ling, a colonel in the U.S. Army Medical Corps and a program manager for the Defense Advanced Research Projects Agency, agrees with Donoghue about this technology's potential-especially its extension into limb prosthetics. Because of the wars in Iraq and Afghanistan, DARPA has focused on the need for prosthetics. "To date there have been 10,397 casualties and 80 percent of them involve the arm or the leg," Ling said. The arm is an especially important focus of research, he explained, as it contains "the most complex biological tool in nature-the human hand."

Because current prosthetics are limited by their dependence on residual muscle and lack of sensory feedback, he said, a "paradigm shift" is being made toward prosthetics with neural control. As in Donoghue's work, these prosthetics utilize brain signals for movement, providing sensory feedback and "enhancing the sense that the prosthesis is truly a replacement limb," Ling said.

He described two efforts under way to create neural-controlled prosthetic arms, one with a 2-year plan and one due in 4 years. This means that by 2009, a prosthetic arm will be developed that people can move simply by thinking, just as they would a natural limb.

As far as robotics used in medical procedures, Dr. Russell Taylor, a professor and director of the NSF Engineering Research Center for Computer- Integrated Surgical Systems and Technology at Johns Hopkins, provided an overview of computer-integrated interventional medicine. He predicts that partnerships between "clinicians and computer-based technology will fundamentally change the way surgery.is performed in the 21st century in much the same way that computer-based technology changed manufacturing in the 20th century."

New capabilities will provide better outcomes and more cost-effective processes, he said. Researchers are developing a family of surgical systems that "combine innovative algorithms, robotic devices, imaging systems, sensors and human-machine interfaces to work cooperatively with surgeons in the planning and execution of surgical procedures."

He also stressed that a lot of the work he described was done with NIH funding, and that "NIH will be more and more important as this work progresses."

Dr. Michael Marohn, director of the Minimally Invasive Surgery Training Center at Johns Hopkins, furthered this discussion by explaining work being done in natural orifice surgery and pointing out the "digital potential" of converging medical technologies.

  In an experimental microsurgery workstation at Johns Hopkins, a “steady hand” robot uses specialized compliant control; both surgeon and robot hold the instrument. A sensor detects force exerted by the surgeon and the robot’s controller moves the robot accordingly. Because the robot actually moves the instrument, the motion is tremor-free and can be very precise.
  In an experimental microsurgery workstation at Johns Hopkins, a "steady hand" robot uses specialized compliant control; both surgeon and robot hold the instrument. A sensor detects force exerted by the surgeon and the robot's controller moves the robot accordingly. Because the robot actually moves the instrument, the motion is tremor-free and can be very precise.

But perhaps the most "sci-fi" of all the areas discussed was medical simulation. Dr. Alan Liu described his work as director of virtual medical environments for the National Capital Area Medical Simulation Center, Uniformed Services University of the Health Sciences. He said that because of current challenges in medical education, and because of the Institute of Medicine report citing the rising rate of deaths due to medical errors, simulation is increasingly seen as a way to improve training and decrease mistakes. At his center, several methods of simulation training are used, including standardized patient examinations (in which actors mimic symptoms of diseases for diagnosis), computer- based "virtual" patients or mannequins and training in a virtual reality lab, where different procedures can be completely simulated.

One especially exciting project under development is a wide-area virtual environment for team training, Liu said. In several large rooms, back-projected walls, loud noises and virtual images will simulate an Iraqi war zone where teams will have to deal with mass casualties. It's still in early stages, but it's another step forward in proving the usefulness of simulation, he explained.

Dr. Elizabeth Hunt, director of the Johns Hopkins Simulation Center, echoed this point, describing the types of simulation used by her students. These include micro simulation, where students use computer programs to practice skills, partial-task simulators, virtual reality, standardized patients (with whom students also practice communication skills), mannequin simulators and hybrid simulators, in which two or more of these types are employed. Hunt brought with her a simulated mannequin "baby" that squirmed just a like a real, tiny patient; this was just one of several demonstrations of robotic wizardry held after the talks.

Despite the futuristic research on display, however, all of the researchers emphasized that the underlying idea is a very practical one. "The real bottom line is patient care," said Taylor, "and to provide new capabilities that transcend human limitations." NIH Record Icon

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