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We move you
Rehabilitation Applications of
Robotic TechnologyDr. Stefan Bircher
Hocoma AG, Zürich, Switzerland
CICLO DE CONFERENCIAS - 14 abril 2008
Cátedra Fundación Instituto Valenciano de Neurorrehabilitación
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Outline
Evolution of robotic devicesEvolution of robotic devices
Robotic devices for rehabilitation of lower ExtremitiesRobotic devices for rehabilitation of lower Extremities
Robotic devices for rehabilitation of upper ExtremitiesRobotic devices for rehabilitation of upper Extremities
Basics of NeurorehabilitationBasics of Neurorehabilitation
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Neuroplasticity
The brain's natural ability to form
new connections in order to
compensate for injury or changes in
one's environment (Medical Dictionary)
“One of the most extraordinary
discoveries of the twentieth century”(Norman Doidge)
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Neuroplasticity
Lesion: Waller degeneration
„Sprouting“ (molecular, biochemical, electrophysiological process)
Collaterals of healthy neurons coversynapses: „Unmasking“
take over functions
structural reorganisation: changes in corticalrepresentation (not complete restoration)
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Neurorehabilitation
“Modern clinical
neurorehabilitation is
grounded in the premise
that activity is beneficial
to persons with central
nervous system injury”
(Dromerick AW et al. Activity-based
therapies. NeuroRx 2006;3:428-438)
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Goal Setting in Neuro-Rehab: S.M.A.R.T
Specific
Measurable
Achievable
Relevant
Timely
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Functional Recovery
• Fucntional recovery is influenced by a variety of biological and
environmental factors (Bach-y-Rita et al., 1990)
• Recovery profiles are characterized by a high interindividual variability
• Several clinical and demographic variables may be valid predictors of
general functional recovery, including neurologic factors such as
consciousness at onset, disorientation in time and place, sitting balance, and
severity of motor deficits (Kwakkel et al., 1996)
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Motor Learning – Key facts
• Functional training helps recover
function
• Training beyond the present
capability
• Active participation
• Afferent feedback is stimulating
reorganization of the CNS
• More training leads to greater
success
• Motivation
(Kwakkel et al., 1999; Nelles, 2004;
Butefisch et al., 1995; Bayona et al., 2005)
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Video courtesy of University Hospital Balgrist, Zurich
Manual assisted treadmill training
Mimics functional movement
but has limitations:
• Not a very intensive training
• Training time is limited to PT
• Gait pattern is not reproducible
• Gait pattern is not optimal
• Physical strain
• Ergonomically bad position
• Can use up to 3 physiotherapists
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Outline
Evolution of robotic devicesEvolution of robotic devices
Robotic devices for rehabilitation of lower ExtremitiesRobotic devices for rehabilitation of lower Extremities
Robotic devices for rehabilitation of upper ExtremitiesRobotic devices for rehabilitation of upper Extremities
Basics of NeurorehabilitationBasics of Neurorehabilitation
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Robots for healthy Individuals
“Yagn’s running aid”(Yagn, 1890)
“General Electric’s
Hardiman”(Fick & Mackinson, 1971)
“Bleex”(Kazerooni & Steger, 2006)
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Early Active Orthosis
Cobb’s “wind-up”
orthosis
(Cobb, 1935)
Pupin Institute
“complete”
exoskeleton
(Vukobratovic, 1990)
Wisconsin exoskeleton
orthosis
(Seireg & Grundmann, 1981)
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Actuated Leg and Gait Orthosis
“Cyberthosis”(Schmitt et al., EPFL)
“HAL” (Hybrid Assistive Limb) (Yohikuyi Sankai et al., Tsukuba
University, JP)
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International Congress for Rehabilitation
Robotics 2007
•“Lopes”
•University of Twente,
Holland
•“Alex”
University of Delaware,
USA
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“Haptic Walker”,
Frauenhofer Institut Berlin,
Germany
International Congress for Rehabilitation
Robotics 2007
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Human Centered Robotics
A Human-centered Robot should be
� Safe � Communicative
� Compliant, gentle, adaptive � Humanoid in his behaviour & appearance
� Easy to use, entertaining
A Human-centered Rehabilitation Robot should
� Be able to detect intention and support patient motion
� Not bind patient to a predetermined motion
� Motivate the patient
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Outline
Evolution of robotic devicesEvolution of robotic devices
Robotic devices for rehabilitation of lower ExtremitiesRobotic devices for rehabilitation of lower Extremities
Robotic devices for rehabilitation of upper ExtremitiesRobotic devices for rehabilitation of upper Extremities
Basics of NeurorehabilitationBasics of Neurorehabilitation
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Robotic devices for lower extremity
Lokomat ® System Gait Trainer REOAmbulator
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Lokomat® System
Treadmill
• Speed range: 0 – 5 km/h
• Parallel bar with adjustable height
and width
Lokobasis
• Body weight support system (BWSS)
Lokomat
• Adjustable driven gait orthosis
• Treadmill training speed: 1 – 3.2 km/h
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Lokomat® - Spinal cord injury patient
Video courtesy of the University of Texas SW, Dallas, U.S.
Before
Lokomat
training
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Lokomat® - Spinal cord injury patient
Video courtesy of the University of Texas SW, Dallas, U.S.
During
Lokomat
training
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Lokomat® - Spinal cord injury patient
Video courtesy of the University of Texas SW, Dallas, U.S.
After
Lokomat
training
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Lokomat Feedback Control
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Control-Strategy
• Position Control
ϕ1 (hip angle)
ϕ2(kneeangle)
stancephase swingphase
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Control-Strategy
• Impedance Control
ϕ1 (hip angle)
ϕ2(kneeangle)
(Riener et al. 2005)
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Assessments are important
Neurological Injuryspinal cord injury, brain injury, stroke
Neurological Injuryspinal cord injury, brain injury, stroke
Reduced voluntarymuscle force
Reduced voluntarymuscle force
General weakness
General weakness
Weaknessduring walking
Weaknessduring walking
Spasticity,Contractures
Spasticity,Contractures
L-FORCEL-FORCE L-WALKL-WALK L-STIFFL-STIFF L-ROML-ROM
Increased involuntary muscle force
Increased involuntary muscle force
Overview
General Effect
Specific Effect
Assessment Tools
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• Biofeedback
• Control of progress
• Outcome measures
• Research
Interaction between Lokomat and patient can be measured
Assessment tools (L-WALK)
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Lokomat Assessment tools
L-FORCE
• The isometric force (torque) generated by the subject while in a static position
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Lokomat Assessment tools
L-STIFF
• The mechanical stiffness of the
patient's joints while the legs are
passively moved in a specific
pattern (Outcome-Value:
Nm/degree)
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Pediatric Lokomat®
Photo courtesy of Children's University Hospital Zurich, Switzerland
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What do we need in the future?
Modified from Johnson MJ. Recent trends in robot-assisted therapy
environments to improve real-life functional performance after stroke.
J NeuroEngineering and Rehabilitation, 2006.
Augmented
Feedback
Carryover to
Real World
CNS
Plasticity
• Motivation ↑
• Augmented Feedback ↑
• Task-oriented nature ↑
• Task Complexity ↑
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Justification of using Virtual reality
• Training is important for rehabilitation.
• Motivation is essential for active training.
• Interactive feedback can support motivation.
• Robotic and computer technology can supply interactive feedback.
• Key concepts of rehabilitation:
- frequent repetitive practise
- functional feedback to patients
- Increase motivation
• Several studies show improved therapy results with the use of virtual reality
technologies, or at least the potential of benefits.
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Lokomat Augmented Feedback Module
• Components
- additional software for displaying and controlling virtual environments
- large screen monitor (or optional projection) with stereo sound
- additional computer
• Features
- The patients receive feedback on their walking behaviour in the Lokomat by movements in a virtual environment. The movements of the patients’ representation – the so called “avatar” – can be controlled by the patients through their leg movements.
- The patient have to perform certain tasks (e.g. collect objects).
- The therapist can adjust the system before and during the training to the patients’ preferences and needs.
• The module is still under development. Software updates are included.
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Future: Augmented feedback
Video courtesy of University Hospital Balgrist, Zurich
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Lokomat Augmented Feedback Module
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Augmented Feedback
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Evidence based data
• Lokomat therapy improves gait symmetry, increases aerobic metabolism and muscle tissue in stroke patients (Husemann et al., 2007)
• Lokomat intervention demonstrated to improve walking speed, endurance, muscle strength and muscle tone compared to conventional physical therapy in stroke patients (Mayr et al., 2007)
• Intensive locomotor training with the Lokomat results in improved overground walking in chronic incomplete SCI patients (Wirz et al., 2005)
• Intensive task-specific training, such as Lokomat therapy, can promote supraspinalplasticity in the motor centers known to be involved in locomotion of SCI patients (Winchester et al., 2007)
• Lokomat training is feasible for children with central gait impairments from 4 years of age and leads to significant improvement in velocity, endurance and motor function (Meyer-Heim et al., 2007)
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Outline
Evolution of robotic devicesEvolution of robotic devices
Robots for rehabilitation of lower ExtremitiesRobots for rehabilitation of lower Extremities
Robots for rehabilitation of upper ExtremitiesRobots for rehabilitation of upper Extremities
Basics of NeurorehabilitationBasics of Neurorehabilitation
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Robots for upper Extremity
Endeffector-Based Exoskeleton
���� Easy to adjust to patient
���� Arm posture is not fully
determined, no full extension
���� Risk of joint injury
����
���� Joint axes fully determined
���� Robot axes have to allign
with anatomical axes
���� Challenging at shoulder
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EU Project: GENTLE/s
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The PECRO Exoskeleton
(Dario et al., St‘Anna, Pisa, Italy)
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Kist Wearable Robotic Arm
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ARMin
(Riener et al., ETH Zürich, Switzerland)
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Devices for upper extremity
Armeo® Reo™ System InMotion Shoulder-Elbow
Robot
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Armeo®
Functional upper extremity therapy
The Armeo combines:
• An adjustable arm support that
counterbalances the weight of the
patient’s arm
• Augmented feedback for improved
motivation and assessment of the
patient’s progress
• A large 3-D workspace that allows
functional therapy exercises
in a virtual reality environment
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Armeo® - Stroke patient
• Functional
exercises with
arm support
• Augmented
feedback
• Enhanced
motivation
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Subjective evaluation of Armeo
• Less boring
• More likely to complete at home
• Tracking progress
Efficacy of Armeo® training: Results
Data from the study conducted at RIC under
Prof. D. Reinkensmeyer and S. Housman
Comparison of Armeo Therapy
with conventional Therapy
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• Significant improvements in quality and amount of arm use at follow up
only in the Armeo group
• Significant functional improvements (Fugl Meyer Score) in both groups
• Significant improvement in active range of motion only in the Armeo group
• Armeo is the favored therapy approach: Higher motivation and satisfaction
with therapy in the Armeo group
Efficacy of Armeo® training: Summary
Data from the study conducted at RIC under
Prof. D. Reinkensmeyer and S. Housman
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Conclusion
• There is increasing experimental evidence that individuals receiving
more therapy with a robotic device can recover more movement ability
• Robotic devices are opening up new opportunities and therapies which
might enhance conventional therapy approaches
• The correct use of these new devices will be crucial to ensure most
effective treatments
• Robotic devices should be understand as assistants which will not
replace therapists
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Thank you for
your attention