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Upper and Lower ExtremityRobotics: Bringing
Technology to the Clinic
Andrew Packel PT, NCS
Lori Sledziewski MS, OTR/L
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Objectives
Upon completion of the presentation learners will be able to:
Express understanding of emerging concepts inneuroplasticity and neurorehabilitation
Identify basic principles supporting the use of robotictraining to treat upper and lower extremity dysfunction inthe SCI population
Express a basic understanding of the Reo Go andARMEO robotic exercise programs
Identify key considerations and training parameters whenperforming robotic gait-training interventions
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Emerging Robotic Technology
Three contributing sources
Advances in computers and technology
Improved understanding of neuroplasticity
and central pattern generators (CPGs)
Increased focus on treatment interventions
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Advances in Computers andTechnology
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Understanding Neuroplasticity
The capacity for continuous alteration of the
neural pathways and synapses of the living
brain and nervous system in response to
experience of injury(Merriam-Webster medical dictionary)
Recognize that neuroplasticity occurs every
day of our lives, as our nervous system
changes in response to experience We are focusing on neuroplasticity following
SCI
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Types of Neuroplasticity
Brain plasticity following injury
Increasingly studied following CVA, TBI
Advances in imaging techniquesAnimal models
Much more extensive than previously
thought
Recognize that brain plasticity occurs
following SCI
Likely in response to changes in afferent and
efferent information
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Types of Neuroplasticity
Spinal cord plasticity following injury
Cannot be entirely separated from brain
Continuous reciprocal tracts between brain andspinal cord
Emerging area of study
Animal models
Advances in microscopic study
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Levels of Analysis of RestorationFollowing SCI
Behavioral
Recovery of sensory, motor, autonomic
function
Physiological Normalization of reflexes
Strengthening of motor-evoked potentials
Structural
Axonal sprouting
Dendritic sprouting Neurogenesis
Cellular Synaptogenesis
Synaptic strengthening
Molecular
Regulation of neurotransmitters, neurotrophic factors
Alterations in gene expression
(adapted from Lynskey et al, 2008)
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What does neuroplasticity mean to me??
Recognize that changes following SCI can be viewed
upon many levels
We still largely do not know physiological mechanisms
responsible for change Neuroplasticity is main object driving change
Adaptive
Maladaptive
Neuroplasticity responsible for major paradigmshift in SCI rehabilitation over past 20 years
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"What does neuroplasticity mean to me??"
SCI CompensationRecoveryNeuroplasticity
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Therapeutic Principles
Practice is the biggest factor in neuroplasticity
and recovery of function. Period.
Amount of practice is #1. More is better.
Task-specific practice
Motivation/engagement
Skilled, appropriately graded activity
Feedback received For LE training, Central Pattern Generators
(CPGs) need to be considered as well
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Upper Extremity RoboticsLori Sledziewski MS, OTR/L
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Objectives
Upon completion of the presentation learners will be able to:
Identify basic principles supporting the use of robotic
training to treat upper extremity dysfunction in the
SCI population. Demonstrate a basic understanding of the Reo Go
and Armeo robotic therapy systems.
Identify inclusion criteria for participation in an upper
extremity robotic exercise program. Identify methods to assess outcomes for clients
engaging in an upper extremity robotic exercise
program.
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Applying Neuroplasticity Principlesto UE Dysfunction
Reo Massed practice
Knowledge of results(KR)given through visual and
auditory feedback in
program
Knowledge ofperformance(KP)
frequently needed
through therapist
Armeo Conditions for either
random or massed
practice Knowledge of results(KR)
given through auditory
and visual feedback in
program
Knowledge ofperformance(KP)
frequently needed
through therapist
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CPGs and UE Function
Recovery for UE function from robotic
training unlikely influenced by CPGs
Limited understanding of role CPGs play inUE function
UE CPGs responsible for rhythmic
movement such as arm swing
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Whats out there?
Myomo
In Motion
Bi-Manu-Track
MIME
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Todays Focus
Reo Go Armeo
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Candidate Considerations
AIS (American Spinal Injury Association Impairment Score)
Complete versus Incomplete
Recommend at least trace strength
Special precautions that may limit
performance (subluxation, pain, peripheral
nerve injury, etc.)
Positioning requirements (sitting/standingtolerance, transferring to machine, etc.)
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Reo Go
Telescopic arm withinterchangeable handcontrol
Provides repetitive,
engaging, and functionalarm exercises
Computer softwarecustomizes exercisepatterns and measure
performance over time Initially developed inIsrael; was introduced tothe U.S. market in 2006
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Reo Go
Interface screen
Laptop
Available exercises
Shoulder flexion, abduction, internal and external rotation Elbow flexion/extension
Lacks any pronation/supination, wrist or grasp exercises
Seating and positioning
Best if client is ambulatory or can easily transfer to seat Must have good dynamic trunk control
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Levels of Resistance
Guided
Initiated
Step-Initiated Follow-assist
FreeForward Reach 3D
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Case Report #1:Mr. R and Reo Go
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Meet Mr. R.
51 y.o. right handed male
MVA (passenger)
C4-C5 anterior cervical decompression/fusion
C3-C6 posterior laminectomy with fusion C4 AIS D
Presented with RUE and LLE weakness and
decreased AROM
Vertebral artery dissection Mild TBI noted (deficits in short term memory)
PMH: non-contributory
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Meet Mr. R
Lived with wife in 2 story home (duplex)
Bedroom and bathroom on second floor
Plans to return home to 1st floor apartment
Worked as roofer in spring/summer months Planned to assist wife with online travel agency business
after discharge
Was independent in all ADLs/IADLs prior to accident
(including driving)
Leisure: Watching sports, going to bars, socializing
Goals: To walk around normal and To not need
help doing things for myself.
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Assessment Tools
UE Assessment
Goniometry
Manual Muscle
Testing (MMT)
Sensory
Light Touch
Pin prick
Self Care
Assessment
FIM(functional independence measure)
Eating
Grooming
Bathing
Dressing (UE & LE) Toileting
Functional Transfers
(bed, toilet, tub)
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Admission Video: AROM
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Admission Video: Functional Task
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Procedures: Intervention
Mr. R received 2 hours of OT, 1 hour of PT
and .5 hour of recreational therapy daily
20 days inpatient rehab
OT sessions (Mon Fri)
1 hr morning self care session
Included breakfast, shower, dressing, grooming
1 hr Reo training session
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Reo training program
Exercise program Forward reach 3D
(3 sets of 5)
Hand mouth
(3 sets of 5) Forward thrust
(3 sets of 5)
Horizontal reach
(3 sets of 5)
Resistance levels Six sessions at guided
level
Twelve sessions at
initiated level Attempted step-initiated
level; however, pt wasunable to complete 1 setof repetitions 2 increasedpain and discomfort
Hand mouth
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Midpoint Video: AROM
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Midpoint Video: Functional Task
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Changes in Self Care FIM Scores fromAdmission, Mid Point, and Discharge
0
1
2
3
4
5
6
7
Eati ng Groom in g Bath in g UE dre ss LE dre ss Toi le ti ng Be d Toi le t Tu b
AdmitMid PointD/C
Area of Self Care
FIMScores
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Discharge Video: AROM
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Discharge Video: Functional Task
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Results
Increased AROM for elbow flexion,
extension; shoulder internal and external
rotation
Increased MMT scores for shoulder
internal/external rotation and elbow
flexion/extension
Increased independence in self-care No changes in sensory scores noted
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Results
What happened at the shoulder?
Apoptosis at site of injury
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Armeo Arm and eo (latin for go)
Hocoma
Armeo Power Armeo Spring
Armeo Boom Armeo Spring
Instrumented arm orthosis withintegrated weight compensationmechanism
3D position detection of armsegments and grip strength
sensing Visual and auditory feedback
provided during games
Records clients performanceover time
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Armeo
Interface screen
24 inch flat screen monitor with speakers
Available exercises
Shoulder: abduction, horizontal abduction/adduction, rotationand flexion (limited to 90 degrees)
Elbow flexion/extension
Pronation/supination
Wrist flexion/extension
Grasp and release
Seating and positioning
Can be seated in manual wheelchair or in standard chair
without arms
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Levels of Difficulty
Levels are based on
time to complete
game and target
size Very easy
Easy
Medium
Hard
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Case Report #2:Mrs. Z and Armeo
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Meet Mrs. Z
81 y.o. right handed female
Sustained fall over 2 steps
C2 Type II dens fracture with epidural hematoma
C1-C2 posterior cervical fusion
Bilateral C5 facet fractures
C2 AIS D
Presented with RUE weakness and decreased AROM
Allodynia present in right hand and forearm. Resolved after 8
days. Experienced LOC after fall; however, no acute cognitive deficits
were noted
PMH: PVD, HTN, osteoarthrisis, shoulder pain treated with
cortisone shots
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Meet Mrs. Z
Lives with husband in 1 story home (55+ community)
Retired business owner
Was independent in most ADLs/IADLs prior to
accident (+ driving) Leisure: Watching T.V., spending time with family
Goal: To be able to do things myself.
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Assessment Tools
UE Assessment Goniometry
MMT
Dynamometer scoresfor grip strength
Sensory Light Touch
Pin prick
Self Care Assessment
FIM
Eating
Grooming Bathing
Dressing (UE & LE)
Toileting
Functional Transfers
(bed, toilet, tub)
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Admission Video: AROM
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Admission Video: Functional Task
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Procedures: Intervention
Mrs. Z received 2 hours of OT and
1 hour of PT daily
19 days inpatient rehab
OT sessions (Mon Fri)
1 hr morning self care session
Included breakfast, shower, dressing, grooming
1 hr Armeo training session
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Armeo Training Program
Completed same 5
exercises:
Rain mug
Fruit shopping
Reveal picture
Fish catching
Goalkeeper
Level selection
based on initial
performance
Level increased ifMrs. Z completed
100% of exercise in
time allotted on 2
days
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Midpoint Video: AROM
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Midpoint Video: Functional Task
Ri ht Upp r E tr mit In r in
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Right Upper Extremity Increases inActive Range of Motion
Degrees of
Movement
Time of Measurement
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Changes in Right Upper Extremity StrengthUsing Manual Muscle Testing (MMT)
MMT
Score
Upper Extremity Motion
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Changes in Self Care FIM Scores fromAdmission, Midpoint, and Discharge
FIM
Scores
Area of Self Care
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Changes in Grip Strength
Admission Midpoint Discharge
Right hand 0.0 lbs 9.3 lbs 9.0 lbs
Left hand 20.0 lbs 18.3 lbs 18.0 lbs
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Discharge Video: AROM
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Discharge Video: Functional Task
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Results
Increased AROM at all joints
Increased strength for all movements
Increased independence in self-care Increased grip strength
No changes in sensory scores noted
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Results
What happened at the shoulder?
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Client Perspectives
It makes you want to do more than you
think you can.
I want to get the score! Im very competitive. I want to win.
The Reo feels good, its like
stretching.
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Therapist Perspectives
Documentation - easy!
Easy setup/cleanup
Cutting-edgeMotivation
Clear evidence of improvement
Invested in treatment plan Fun
Distracted from other issues
(pain,socioemotional, etc.)
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In Summary
Lack of research
Principles of neuroplasticity repetition!
Motivating and engagingCutting edge
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Lower Extremity RoboticsAndrew Packel PT, NCS
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Objectives
Upon completion of the presentation learners will be able to:
Identify characteristics of appropriate candidates for SCI
Locomotor training
Describe features of most commonly used robotic
locomotor interventions
Enhance their practice through theoretically grounded
treatment principles
Considerations for
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Considerations forLocomotor Training (LT) in SCI
Neuroplasticity is major goal of training
Practice, practice, practice!
Consideration of CPGs for LT
Who is an appropriate candidate for LT?
MMT / AIS not the whole story
What type of LT is best?
There is still much that we dont know!
What do I do with my patient?
Applying Neuroplasticity Principles
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Applying Neuroplasticity Principlesto LE Dysfunction
Need for large quantities of PRACTICE
Task specificity
If you want to improve walking, then practice walking
Recognize that practicing tasks/activities other than walkingmay have little carryover to walking task
Motivation
Inherent in task, for many
Grading/engagement
Very important aspect
Feedback
May be under-addressed component
What about CPGs??
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So, what is a CPG???
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CPGs
Definition: Dedicated networks of nerve cells that
generate movements and that contain the information
that is necessary to activate different motor neurons
in the appropriate sequence and intensity to generate
motor patterns (Grillner, 2003)
Three key principles:
Presence of a developmentally defined neuronal circuit
Capacity to generate intrinsic pattern of rhythmic activity
independently of sensory inputs
Presence of modulatory influences from central and
peripheral inputs
Associated with many rhythmic movements (i.e.-
breathing, swallowing, coughing, swimming, etc.)
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CPG Research
What we know
Ability to generate
intrinsic rhythmic activity
Activated by repetitive
movements
Likely distributed
network(s) as opposed to
focal location
Sensory information
critical in shaping motor
output
What we dont know
Innate, adapted by
experience or both?
Location and particular
architecture
How influenced by injury
Good understanding of
influence of central and
peripheral inputs
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What do CPGs mean to me??
Recognize that CPGs may be important mechanism
to exploit in LT
Training characteristics that are thought to promote
facilitation of CPGs Appropriate hip extension ~20 degrees
Significant weight bearing
> ~80% body weight
Significant speed ~1.8 MPH
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LT Candidate Considerations
Timing/setting of intervention
Earlier following SCI may be more beneficial
Higher potential for neuroplasticity
Avoidance of maladaptive changes
Significant barriers to early LT
Medical considerations
Focus on other rehab goals
Pace of rehab
Potential limited carryover to other areas
Significant barriers to late LT
Time
Money
Accessibility
Challenges in Prognosis for
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Challenges in Prognosis forAmbulatory Ability
Significant changes in impairment, function acutely
Changes in AIS levels, grades
Multiple, redundant motor tracts
Including CPGs Corticospinal tract is primary for discrete, intentional
movements
Including MMT
Vestibulospinal/rubrospinal/reticulospinal also important for
postural control and locomotion Propriospinal (intraspinal) pathways also involved
Research Findings in Ambulation
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Research Findings in AmbulationPrognosis
Limited ability for prognosis for ambulation
AIS level
SCILT: Patients still graded at AIS B 8 weeks after onset
have low probability for functional walking MMT
Inconsistent among studies
May relate to locomotor ability better in chronic stages
Bowel and bladder function, reflex activity studied
Research Findings in Ambulation
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Research Findings in AmbulationPrognosis
Spinal Cord Assessment Tool for Spastic Reflexes
(SCATS)
Benz et al, 2005
Adjunct to ashworth scores to measure spastic, non-
volitional behavior
Clonus
LE flexor spasms
LE extensor spasms
Helpful in prognosis for ambulation for individuals with motor
incomplete injuries
Winchester et al, 2009
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Types of LT
Overground training
Can vary considerably among patients, therapists
Use of bracing, assistive devices, assistance
May be difficult to elicit CPG
Limited speed, non-continuous movement
Limited hip extension
Limited LE weight bearing
Manual BWS treadmill training
May better be able to elicit CPGs
May vary based on therapist experience
Amount of practice may be limited
Mostly by therapists tolerance!
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Robotic LT
Developed to address limitations of other training
Consistency between therapists
Allows for large bulk of practice
Significant concerns/criticisms exist Reduced task-specificity vs. overground walking Focus on sagittal plane movements only
Decreased engagement of patients
Too passive
Limited task variability may impair learning
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Lokomat
Driven gait
orthosis
Most widely used
around the world Since 2001
Over 300
worldwide
Several models
Including
pediatric
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Lokomat
Augmented
feedback virtual
reality package
attempts to improve
feedback, increase
engagement
Guidance control feature allows variation from
prescribed pattern
Allows increased task variability
May improve feedback
May improve active engagement
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G-EO
Newer robotic
training option
Limited research
available
Uses end effector
model
Vs. exoskeletonmodel
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ReWalk
Exoskeleton that allows
for overground training
Has only been used as
orthotic device to thispoint
Individuals with motor
complete injuries
Overground training may
be more task-specific
May allow for increased
practice for training
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Intervention Options
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Locomotor Research Findings
SCILT
Multicenter RCT comparing body-weight supported treadmill
training (BWSTT) to overground mobility therapy
117 participants admitted to acute rehab
Trained for 1hr/day up to 12 weeks
No significant difference between groups in any
measures:
Locomotor FIM for AIS A & B groups
Walking speed for AIS C & D groups Also Berg balance score, strength scores, endurance, pain,
or Ashworth scores
Significant intensity of treatment for both groups may
have been responsible for lack of difference
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Locomotor Research Findings
Cochrane Review (Merholz et al, 2008)
LT for walking after SCI
Systematic review in 2008
Identified 33 potentially eligible trials 4 included for analysis
There is insufficient evidence to conclude that one
locomotor training strategy is more effective thananother for improving walking ability in people with
spinal cord injury.
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Locomotor Research Findings
Effectiveness of robot-assisted gait training in
persons with spinal cord injury: a systematic review
Swinnen et al, 2010
Started with 722 papers with first literature search
Final review based on criteria included 6 papers
There is currently no evidence that robot-assisted
gait training improves walking function more than
other locomotor training strategies. Well-designed
randomized controlled trials are needed. Multiple other studies on SCI and robotic inteventions with
varied, inconsistent results
(See Tefertiller et al, 2011 for recent review)
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What do I do with my patients??
Integrate research evidence with clinical
decision making
Based upon principles of neuroplasticity/CPGs
Consider attributes/deficits of particular patient Structure intervention to address deficits
Trunk control/balance
May not be addressed as much with robotic, treadmill
intervention
Ability to step
Overground may not be as feasible
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Concluding Thoughts
Principles of neuroplasticity and task-specific
practice help to guide interventions
Use of robotics as a therapy modality can
enhance treatment options
Consideration of relevant training parameters
matched to particular needs of client can help
to optimize outcomes
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References
Backus D, Tefertiller C. (2008). Incorporating manual and robotic locomotor
training into clinical practice: Suggestions for Clinical Decision Making.
Topics in Spinal Cord Injury Rehabilitation, 14(1), 23-33
Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. (2005). A
physiologically based clinical measure for spastic reflexes in spinal cord
injury.Arch Phys Med Rehabil, 86(1), 52-59. Berman, Young, Sarkarait, Shefner. (1996) Injury zone denervation in
traumatic quadriplegia in humans. Muscle & Nerve, 19, 701-706.
Dietz V. (2009). Body weight supported gait training: From laboratory to
clinical setting.Brain Res Bull, 78, IVI.
Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge D, Ditunno J,
Dudley G, Elashoff R, Fugate L, Harkema S, Saulino M, Scott M; Spinal
Cord Injury Locomotor Trial Group. (2006). Weight-supported treadmill vs
over-ground training for walking after acute incomplete SCI.Neurology,
66(4), 484-493.
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References
Dobkin B. (2009). Motor rehabilitation after stroke, traumatic brain, and spinal
cord injury: common denominators within recent clinical trials. Current
Opinion in Neurology, 22(6), 563-569. Field-Fote EC, Roach KE. (2011).
Influence of a locomotor training approach on walking speed and distance in
people with chronic spinal cord injury: a randomized clinical trial.Phys Ther,
91(1), 48-60. Grillner S. (2003). The motor infrastructure: from ion channels to neuronal
networks.Nat. Rev. Neurosci. 4, 573586.
Hesse S, Waldner A, Tomelleri C. (2010). Innovative gait robot for the
repetitive practice of floor walking and stair climbing up and down in stroke
patients.J Neuroeng Rehabil, 28(7), 30-39.
Hocoma Inc. (n.d.).Armeo Therapy Concept. Retrieved June 6th, 2011 from
http://www.hocoma.com/en/products/armeo/
Klimstra, Thomas, Stoloff, Ferris, & Zehr. (2009). Neuromechanical
considerations for incorporating rhythmic arm movement in the rehabilitation
of walking.American Institute of Physics- Chaos, 19, 026102-1 026102-14.
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Lam T, Eng J, Wolfe D, Hsieh J, Whattaker M. (2007). A systematic review of
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Lynskey JV, Beanger A, Jung R. (2008). Activity-dependent plasticity in spinal
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Marsh, Astill, Utley, Ichiyama. (2001). Movement rehabilitation after SCI:
Emerging concepts and future directions.Brain Res Bull, 84, 4-5, 327-336.
Mehrholz J, Kugler J, Pohl M. (2008). Locomotor training for walking after
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gait recovery.Brain Res Bull, 78, 2225.
Nooijen CF, Ter Hoeve N, Field-Fote EC. (2009). Gait quality is improved by
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References
Pohl M, Werner C, Holzgraefe M, Kroczek G, Mehrholz J, Wingendorf I,
Holig G, Koch R, Hesse S. (2007). Repetitive locomotor training and
physiotherapy improve walking and basic activities of daily living after stroke:
a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie,
DEGAS). Clin Rehabil, 21(1), 17-27.
Rossignol S, Frignon A. (2011). Recovery of Locomotion After Spinal CordInjury: Some Facts and Mechanisms.Annu. Rev. Neurosci, 34, 413440.
Swinnen E, Duerinck S, Baeyens JP, Meeusen R, Kerckhofs E. (2010).
Effectiveness of robot-assisted gait training in persons with spinal cord injury:
a systematic review.J Rehabil Med, 42(6), 520-526.
Tansey KE. (2010). Neural plasticity and locomotor recovery after spinal cordinjury.PM R, 2(12 Suppl 2), S220-226.
Winchester P, Smith P, Foreman N, Mosby JM, Pacheco F, Querry R, Tansey
K. (2009). A prediction model for determining over ground walking speed
after locomotor training in persons with motor incomplete spinal cord injury.J
Spinal Cord Med, 32(1), 63-71.
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Picture References
http://www.popsci.com/files/imagecache/article_image_large/articles/2010041
4154658-1.jpg
http://www.rehabstim.de/cms/assets/images/BMTperson.jpg
http://www.rehab.research.va.gov/jour/00/37/6/images/BURG-F01.JPG
https://reader009.{domain}/reader009/html5/0420/5ad9552e8c785/5ad955626d6c4
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Questions & Comments?
Thank you! For additional information
please feel free to contact us:
Andrew Packel, PT, [email protected]
Lori Sledziewski MS, OTR/[email protected]