jenny wang, pt, dpt, ms swedish medical center englewood, co

Jenny Wang, PT, DPT, MSSwedish Medical Center

Englewood, CO

Discuss how robotics can enhance training, learning, and rehabilitation goals.

Selecting appropriate patients and outcome measures.

Class of robots that can integrated into rehabilitation programs at home, in health care settings, at work, or in the community to enhance function.

Integrated as a tool to enhance the effectiveness of one on one therapy to promote recovery, independence, and maximal function.

Learning based robotic systems include virtual reality, games for memory, and technology to improve physical performance

Enables patient to perform quality controlled, repetitive, progressive, task- oriented practice to improve learningBioness systemsTibion Bionic leg

Can be classified as non-wearable or wear-able

Robotic exoskeleton placed on patient’s leg during training.

Provides mechanized assistance for patient initiated active movement Flexible plantar pressure-sensing shoe insert Loose fitting plastic ankle straps attaching

the shoe insert without providing ankle support

Leg and thigh uprights Single axis knee joint with angle sensors Textile straps secured with zippers Velcro and adjusting knobs Onboard actuator motors with control panel

housing Rechargeable lithium battery

Plantar pressure sensors detect gait phases through weight bearing

Angle sensors detect knee motion angles

Actuator torque sensors determine knee torque

Maximizes neural plasticity and recovery of motor control, sensation, and physical skills through controlled, progressive repetition

Improves endurance, quality of movement, more complete task performance, independence, and quality of life

Task specific training focused on functional tasks like transfers, gait training, and stairs

During stance phase, stair climbing, and sit>stand movements, knee actuator assists knee concentric extension.

During toe off and non-weight bearing conditions, actuator decouples and allows for free knee swing.

Patient initiated knee extension with weight bearing triggers mechanically assisted knee extension based on programming.

Resistance and timing parameters can be set by P.T. based on patient performance.

Weight: 110-300 lbs. Start force: weight on foot plate required

to initiate powered assist Assist factor: amount of knee extension

assistance provided (concentric) Resist factor: amount of knee extension

assistance provided during flexion (eccentric)

Assist extension limit: degree of extension through which assistance is provided. Helps limit knee hyperextension when present

Patient population:Comprehensive Rehab unit (amputees,

orthopedics/multi-trauma)CVA*Brain tumorsSCITBIMSPD

Patient motivation Physical/cognitive ability to use and

follow multi-step directions Height

Stroke patients with the most consistent outcomes

59 yo female Medical history: L pontine and cerebellar

ischemic infarcts, basilar artery thrombosis s/p TNK and stent angioplasty

Past medical history: R femur fracture s/p IM nailing from auto accident 30 yrs ago, dyslipidemia, pre-HTN, migraines

Premorbid functional status: Independent with functional mobility and ADLs, working full time as dental assistant

Discharged from rehab unit after 4 weeks with supervision/assistance from family

Impairments: Mobility and StrengthBed mobility: Minimal assistanceTransfers: Minimal-Moderate assistanceGait: Ambulate 2 steps forward w/out UE

support, Min-Max Assist for balance and R foot placement. Trendelenburg and Genu Recurvatum on RLE.

Right leg strength Hip flexion 2-/5 Knee flexion 2-/5 Knee extension 2-/5 Dorsiflexion 0/5

Functional status: bed mobility, transfers, gait, stairs

Five time sit to standBody structure and function Domain of ICF

model of disabilityMeasures:

Lower limb strength and function Balance and mobility Predictor of recurrent falls General test of physical performance

Correlates with DGI, TUG, Gait speed, BBS

Gait speed Activity DomainMeasures:

Motor control Muscle performance Endurance and activity level Musculoskeletal condition

Correlates with discharge location, additional need for rehabilitation, functional status

Indicator for household ambulator, limited community ambulator, or community ambulator

Projected functional goals at discharge established at initial evaluationBed mobilityTransfersGaitStairs

Initial treatment aimed at quality of movement ie. trunk control, hip stability, midline orientation, safety with mobility, and lower extremity activation.

Based on principles of motor control and learning, performed function based training using Tibion Bionic leg initially for standing weight shifting, sit><stand, then gait.

Tibion initiated on Day 9 for gait training, after interventions addressing safety, midline orientation, knee control, appropriate hip stability, and trunk control/alignment.

Continual intervention for functional mobility in conjunction with use of Tibion and Bioness L300.

Also participating in 1.5 hrs of OT and 1 hr of SLP services

Threshold Assistance Resistance

Day 1 5 85 High

Day 2 5 85 Medium

Day 3 10 80 Medium

Day 4 10 75 Medium

Day 5 10 75 Medium

Day 6 15 75 Medium

Initial Evaluation Discharge

Bed mobility Minimal Assistance Independent

Transfers Minimal-Moderate Assistance

Stand by assistance

Gait 2 Steps Moderate- Maximal Assistance

Cane, R AFO x 150 ft Contact guard assistance

Stairs NA Up/down 7 inch curb w/ cane and AFO, Minimal Assistance. 10 steps w/ rail, Contact guard assistance

Five time sit to stand 31 sec 17 sec

Gait speed 0.4 m/s 0.8 m/s

RLE status Hip Flexion Knee Extension Knee Flexion Dorsiflexion

2-/52-/52-/50/5

3/52+/53/51/5

Long Term Goals Status

Bed mobility: Independent Goal Met

Transfers: SBA Goal Met

Gait: Ambulate with cane, SBA on indoor surface

Goal not Met

Stairs: Up/down flight of stairs w/ cane or rail, CGA

Goal Met

Challenges: Not available for personal rental for home

useDifficult fit for smaller stature/petite

patients