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