Upper and Lower Extremity Robotics: Bringing Technology to the Clinic

Andrew Packel PT, NCS Lori Sledziewski MS, OTR/L

Objectives
Upon completion of the presentation learners will be able to:
Express understanding of emerging concepts in

neuroplasticity and neurorehabilitation

Identify basic principles supporting the use of robotic

training to treat upper and lower extremity dysfunction in the SCI population
Express a basic understanding of the Reo Go and

ARMEO robotic exercise programs

Identify key considerations and training parameters when

performing robotic gait-training interventions

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

Advances in Computers and Technology

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

Types of Neuroplasticity
Brain plasticity following injury Increasingly studied following CVA, TBI
Advances

in imaging techniques Animal models

Much more extensive than previously thought Recognize that brain plasticity occurs following SCI
Likely

in response to changes in afferent and efferent information

Types of Neuroplasticity
Spinal cord plasticity following injury Cannot be entirely separated from brain
Continuous

reciprocal tracts between brain and

spinal cord

Emerging area of study

Animal

models Advances in microscopic study

Levels of Analysis of Restoration Following 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)

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 paradigm

shift in SCI rehabilitation over past 20 years

"What does neuroplasticity mean to me??"

Compensation Neuroplasticity SCI Recovery

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

Upper Extremity Robotics

Lori Sledziewski MS, OTR/L

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.

Applying Neuroplasticity Principles to UE Dysfunction

Reo
Massed practice

Armeo
Conditions for either random or massed practice Knowledge of results(KR) given through auditory and visual feedback in program Knowledge of performance(KP) frequently needed through therapist

Knowledge of results(KR) given through visual and auditory feedback in program

Knowledge of performance(KP) frequently needed through therapist

CPGs and UE Function

Recovery for UE function from robotic

training unlikely influenced by CPGs

Limited understanding of role CPGs play in UE function UE CPGs responsible for rhythmic movement such as arm swing

Whats out there?

In Motion Myomo Bi-Manu-Track

MIME

Todays Focus
Reo Go Armeo

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/standing tolerance, transferring to machine, etc.)

Reo Go
Telescopic arm with

interchangeable hand control Provides repetitive, engaging, and functional arm exercises Computer software customizes exercise patterns and measure performance over time Initially developed in Israel; was introduced to the U.S. market in 2006

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

Levels of Resistance
Guided

Initiated
Step-Initiated

Follow-assist
Free
Forward Reach 3D

Case Report #1: Mr. R and Reo Go

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

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.

Assessment Tools
UE Assessment Goniometry Manual Muscle Testing (MMT) Sensory

Self Care

Assessment
FIM
(functional independence measure)

Light Touch Pin prick

Eating Grooming Bathing Dressing (UE & LE) Toileting Functional Transfers (bed, toilet, tub)

Admission Video: AROM

Admission Video: Functional Task

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

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 was unable to complete 1 set of repetitions 2 increased pain and discomfort

Hand mouth

Midpoint Video: AROM

Midpoint Video: Functional Task

Changes in Self Care FIM Scores from Admission, Mid Point, and Discharge
7

Admit Mid Point D/C

FIM Scores
4

0 Eating Grooming Bathing UE dre ss LE dre ss Toile ting Be d Toile t Tub

Area of Self Care

Discharge Video: AROM

Discharge Video: Functional Task

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

Results
What happened at the shoulder? Apoptosis at site of injury

Armeo

Arm and eo (latin for go)

Hocoma Armeo Power

Armeo Spring Armeo Boom Armeo Spring

Instrumented arm orthosis with integrated weight compensation mechanism 3D position detection of arm segments and grip strength sensing Visual and auditory feedback provided during games Records clients performance over time

Armeo
Interface screen
24 inch flat screen monitor with speakers

Available exercises
Shoulder: abduction, horizontal abduction/adduction, rotation and 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

Levels of Difficulty
Levels are based on

time to complete game and target size

Very easy Easy Medium Hard

Case Report #2: Mrs. Z and Armeo

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

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.

Assessment Tools
UE Assessment Self Care Assessment Goniometry FIM MMT Eating Grooming Dynamometer scores for grip strength Bathing Dressing (UE & LE) Sensory

Light Touch Pin prick

Toileting Functional Transfers (bed, toilet, tub)

Admission Video: AROM

Admission Video: Functional Task

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

Armeo Training Program

Completed same 5 Level selection

exercises:
Rain mug Fruit shopping Reveal picture Fish catching Goalkeeper

based on initial performance Level increased if Mrs. Z completed 100% of exercise in time allotted on 2 days

Midpoint Video: AROM

Midpoint Video: Functional Task

Right Upper Extremity Increases in Active Range of Motion

Degrees of Movement

Time of Measurement

Changes in Right Upper Extremity Strength Using Manual Muscle Testing (MMT)

MMT Score

Upper Extremity Motion

Changes in Self Care FIM Scores from Admission, Midpoint, and Discharge

FIM Scores

Area of Self Care

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

Discharge Video: AROM

Discharge Video: Functional Task

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

Results
What happened at the shoulder?

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.

Therapist Perspectives
Documentation - easy!

Easy setup/cleanup
Cutting-edge

Motivation
Clear evidence of improvement Invested in treatment plan Fun Distracted from other issues (pain,socioemotional, etc.)

In Summary
Lack of research

Principles of neuroplasticity repetition!

Motivating and engaging

Cutting edge

Lower Extremity Robotics

Andrew Packel PT, NCS

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 Locomotor 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 to 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 walking may 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??

So, what is a CPG???

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.)

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

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 > ~80% body weight ~1.8 MPH

Significant weight bearing

Significant speed

LT Candidate Considerations
Timing/setting of intervention
Earlier following SCI may be more beneficial

Higher potential for neuroplasticity Avoidance of maladaptive changes Medical considerations Focus on other rehab goals
Pace of rehab Potential limited carryover to other areas

Significant barriers to early LT

Significant barriers to late LT

Time Money Accessibility

Challenges in Prognosis for Ambulatory 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 Prognosis

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 Prognosis

Spinal Cord Assessment Tool for Spastic Reflexes

(SCATS)
Benz et al, 2005 Adjunct to ashworth scores to measure spastic, nonvolitional behavior

Clonus LE flexor spasms LE extensor spasms

Helpful in prognosis for ambulation for individuals with motor incomplete injuries

Winchester et al, 2009

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 May better be able to elicit CPGs May vary based on therapist experience Amount of practice may be limited Mostly by therapists tolerance!

Manual BWS treadmill training

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 Too passive

Decreased engagement of patients

Limited task variability may impair learning

Lokomat
Driven gait

orthosis Most widely used around the world

Since 2001 Over 300 worldwide

Several models

Including pediatric

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

G-EO
Newer robotic

training option Limited research available Uses end effector model Vs. exoskeleton model

ReWalk
Exoskeleton that allows

for overground training Has only been used as orthotic device to this point
Individuals with motor complete injuries

Overground training may

be more task-specific May allow for increased practice for training

Intervention Options

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

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 than another for improving walking ability in people with spinal cord injury.

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)

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

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

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.

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.

References
Knikou M. (2010). Neural control of locomotion and training-induced plasticity

after spinal and cerebral lesions. Clinical Neurophysiology, 121, 16551668. Lam T, Eng J, Wolfe D, Hsieh J, Whattaker M. (2007). A systematic review of the Efficacy of Gait Rehabilitation Strategies for spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 13(1), 32-57. Lynskey JV, Beanger A, Jung R. (2008). Activity-dependent plasticity in spinal cord injury. JRRD, 45(2), 229240. 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 spinal cord injury. Cochrane Database of Systematic Reviews, Issue 2. Molinari M. (2009). Plasticity properties of CPG circuits in humans: Impact on gait recovery. Brain Res Bull, 78, 2225. Nooijen CF, Ter Hoeve N, Field-Fote EC. (2009). Gait quality is improved by locomotor training in individuals with SCI regardless of training approach. J Neuroeng Rehabil, 6:36.

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 Cord Injury: 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 cord injury. 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.

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 http://www.jneuroengrehab.com/content/figures/1743-0003-8-5-1.jpg

Questions & Comments?

Thank you! For additional information please feel free to contact us:
Andrew Packel, PT, NCS
apackel@einstein.edu

Lori Sledziewski MS, OTR/L

sledziel@einstein.edu