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Upper and Lower Extremity Robotics

Apr 14, 2018

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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

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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

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    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]