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Advancing-Mobility-Through-Progressive-Technology.ppt

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DrAmanSaxena

The document introduces recent advances in rehabilitation technology and provides an overview of 11 devices. It discusses how these technologies can provide real-time feedback, objective measures of progress, and engaging rehabilitation. The technologies discussed include the Balancemaster and Biodex Balance System for balance training, Neuromove and Lokomat for gait rehabilitation, and Armeo for arm rehabilitation. Evidence is presented showing that these technologies have been effective for conditions like stroke and concussions when used as part of a comprehensive rehabilitation program.

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Chrissy Lighthill, MOT, OTR and Rachel Atkins, PT, DPT
 Introduce theory behind recent advances in rehab technology  Provide an overview of 11 devices  Description  Cost, if available  Availability of demo/in-service from the vendors  Other clinics who have the products  Evidence  Videos and Photos  Create an awareness of the presence of these items, not promoting or reflecting a “wish list”  Present to teams/therapists  Follow up with vendors
 Provide real-time biofeedback (feel, see, hear)  Objective Measures  Monitor progress, tracking outcomes, evidence for third party payers, clear to patient  Relevant to society  Motivating, Engaging, Stimulating  Marketing Tool: Screening, Research  Real Life Simulation in Clinic  Errorless learning  3 crucial elements for the acquisition of motor programs through rehab : adequate feedback, variability of practice, and design of learning situation.  “Patients with motor dysfunction are totally dependent on the information concerning the outcomes of the attempts to perform motor tasks especially during the acute stage”. -Mulder  “…allow precise recording of movements and application of forces…valuable tool for motor rehabilitation….visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task... information sent to the patient about exercise performance…address psychosomatic variables influencing therapy” (3).  “Assistive technologies can open new worlds for individuals with physical, communication, and cognitive limitations.” “A new technology may also help someone with a chronic or progressive disabling condition maintain or improve his or her independence” (4).
 Myomo  Neuromove  Balancemaster  Biodex Balance System SD  Armeo  Lokomat  Restorative FES Cycles  GAITRite  Free Supported Ambulation System (SAS)  Tibion  CAREN
 Description: Force platform for testing and training of static and dynamic standing balance.  Capabilities: Fall-risk screening and training, Postural stability, Clinical Test of Sensory Integration of Balance (CTSIB), compare scores to age-dependent norms, charts progress over time, determine which of 3 balance systems pt is relying on.  Screening: Concussions  Evidence: Effective with CVA and Mild TBI (Concussion)  Cost: ~ $12,000  Very common in clinics  Video http://www.biodex.com/physical-medicine/products/balance/balance-system-sd (3:08 total (to 1:40)
 6 interactive training modes in Static and Dynamic: Postural Stability, Maze Control, Weight Shift, random Control, Limits of Stability, Weight bearing. Large Color Touch Screen, Interactive, game-like balance. 4 Standardized tests: Static Measuring Capability, Increased Dynamic resistance, Standardized Fall Screening Test Protocol, Athlete Knee Injury Screening Test protocol.
Cleared by FDA in 2001 •Stroke rehab by muscle re-education •Relaxation of muscle spasms (spasticity) •Prevention of retardation of disuse atrophy •Increase local blood circulation •Maintaining or increasing ROM
Video: http://www.neuromove.com/neuromove-therapy-video/ Detects attempts below where trace movements are visible. Distinguishes between regular muscle activity, muscle tone, and real attempts. When a real attempt is detected, the unit rewards the patient with muscle contraction, visual and sensory feedback serves as an important element in relearning the movement. Very motivating, see they could make a difference, where previously, they had no indication of their attempts.
• Concentration and focus is the key to achieving better control of motor functions • Doesn’t work on confused or cognitively low patients • Use 1 - 3 X/day for ~ 20 minutes; longer intervals not common • Effective for spastic & flaccid extremities • International Functional Electrical Stimulation Society
• Classically backed by biofeedback principals • Most of the studies included patients between 6 months and 14 years post-stroke, subjects were motivated and cognitively intact, and the findings were: • Improvements were in form of improved strength, range-of- motion, reduced spasticity and tone, flexibility, and motor capability in general. *** Regular therapy and electrical stimulation was less than half as effective!
 Electrical Stimulation Driving Functional Improvements and Cortical Changes in Subjects With Stroke. (2003) Teresa J. Kimberley, Scott M. Lewis, Edward J. Auerbach, Lisa L. Dorsey, Jeanne M. Lojovich and James R. Carey, University of Minnesota. “Experimental Brain Research”. These findings suggest that NMES may have an important role in stimulating cortical sensory areas allowing for improved motor function.  Electromyographically triggered electric muscle stimulation for chronic hemiplegia. (1987) R.W. Fields, Arch. Phys. Med.Rehabil 68(7):407-14. Progress often far exceeded that of previous conventional therapy. Regarding mechanisms, impaired proprioceptive feedback is considered central to stroke-disrupted sensorimotor control. EMG-triggered EMS is intended to improve brain relearning by reinstating proprioceptive feedback time-locked to each attempted movement. Clinical results were consistent with this theory.  Mental Practice of Motor Skills used in poststroke Rehabilitation has Own Effects on Central Nervous Activation. (1994). T. Weiss, Ellen Hansen, R. Rost, L. Beyer, F. Merten, Christa Nichelmann, and C. Zippel. Intern J. Neuroscience, 1994, Vol. 78, pp 1 57-166. It has been shown that the use of the EMG triggered electrical myostimulation (ETEM) brings good results in poststroke. The technique is most powerful if imagination of motor acts (the so called mental practice) is used as an initial part of ETEM.  Home-based electromyography-triggered stimulation in chronic stroke. (2005). Clin Rehabil 19(7) 737- 745. ETMS use is feasible in the home environment. Neither participation in a traditional home exercise program nor ETMS use conveyed changes on the Fugl-Meyer or Action Research Arm Test. However, ETMS use increased active affected limb extension. This new movement may provide a potential pathway for subjects to participate in other interventions, such as modified constraint induced therapy.
•Clinic Use: MSRP $ 5,950, however there is a 20% discount for a total of $4,670 if the amount is paid in full •Patients can lease the Neuromove starting at $99/ month and other plans are available • Part time patients can feel confident they are not losing out on valuable Physical and Occupational Therapy, when their cognitive program is winding down or limited due to insurance •Discharge preparation- given as a resource to continue therapy when appropriate. • Especially for those who are losing insurance or prematurely discharging
 Moving platform posturography,: also called computerized dynamic posturography (CDP): method of quantifying balance.  Description: The PRO Balance Master® provides objective assessment and retraining of the sensory and voluntary motor control of balance with visual biofeedback on either a stable or unstable support surface. VESTIBULAR REHAB. Utility in malingering. Fall Risk Assessment and Balance conditioning.  Useful for identifying pts who could benefit from vestibular rehab and which balance system is involved  Moveable Forceplate and surround. EMG option.  Availability for demo: TWU  Other clinics (Shepherd, BIR, fairly common)  Video: http://www.youtube.com/watch?v=L72Vx_F-b18 (1:51)
 Visual feedback or conventional balance training in addition to regular therapy affords no added benefit when offered in the early stages of rehabilitation following stroke. – Walker, et al. 2000.  No additional effects compared to traditional PT -Geiger, et al. 2001  Improves standing balance, impact on independence is unclear.  The results of seven clinical trials indicated that providing feedback from a force platform resulted in patients standing more evenly but did not improve balance during active functional activities, nor did it improve overall independence.- Goddard, et al. 2009.
 Trunk balance in the acute stage of stroke is a functional outcome predictor. Clinical examination of balance is done in daily practice when stroke patients are assessed in rehabilitation units, but it is not usually done in a standardized and objective way.  Correlate outcome measures/clinical scales with specific motor results such as walking speed, distance walking perimeter and balance, measured with computerized systems such as posturography. - J Rehabil Med 2002; 34: 267–272. TRUNK CONTROL TEST AS A FUNCTIONAL PREDICTOR IN STROKE PATIENTS. E. Duarte, et al.  No statistically significant effects in function. -Van Peppen 2006.  Only a few studies look at long-term effects.  Dynamic balance function of patients in the visual feedback training group had significant improvements when compared with the control group. Activities of daily living (ADL) function in self-care and sphincter control, also had significant improvements at 6 months follow up in the trained group. Less improvement for locomotion on FIM. The results showed that balance training was beneficial for patients after hemiplegic stroke. -Chen ,et al. 2002
Suitable for individuals who have suffered strokes, traumatic brain injuries, or neurological disorders resulting in hand and arm impairment.
Video: http://www.hocoma.com/en/products/armeo/armeo-spring/ • Adjustable arm support with a highly sensitive hand grip and videogame-like exercises to simulate arm movements used in specific real-life tasks • Exercises are carried out in the virtual environment on a computer screen, providing you with goal-oriented tasks and giving you immediate visual feedback. • Because the weight of the arm is counterbalanced in the arm support, you can use residual neuromuscular control to perform the exercises and gradually build strength in your arm. • Built-in sensors and software record arm movements at each joint, so you and your therapist can track your improvement, determine the appropriate difficulty level for you and customize your training program as you progress.
Other clinics: UT Southwestern, TWU Dallas, TIRR Houston, RIC, Ireland, & Germany
• 87% of participants who received Armeo training demonstrated motor improvements in their arm compared to 69% of subjects who completed conventional arm exercise • More than 80% of all participants preferred Armeo to conventional exercises and would recommend the Armeo exercises over conventional exercises. • On the Fugl-Meyer clinical test; both groups had the same training time and therapist supervision. * (RIC study) The latest clinical findings show that therapeutic methods that are based on active, high-intensity, task-specific movement training are superior to traditional methods
 Housman, S. J., Scott K., M. et al. (2009). A Randomized Controlled Trial of Gravity Supported, Computer-enhanced Arm Exercises for Individuals with Severe Hemiparesis. Neurorehabil Neural Repair.  Prange, G. B., Jannink M. J. A. et al. (2009). Influence of Gravity Compensation on Muscle Activation Patterns During Different Temporal Phases of Arm Movements of Stoke Patients. Neurorehabil Neural Repair.  Stienen, A. H. (2009). Novel Devices for Upper-Extremity Rehabilitation. PhD Thesis, University of Twente, Enschede, The Netherlands.
 Cost: $60, 500  Lease to own option: $1,122 for 60 months  “.. very reasonably priced unit (called the ArmeoSpring) for patients who are able to self initiate movement. (I am scheduled to install 3 ArmeoSpring units and train the staff for each of the rehab hospitals in Houston/Austin, Texas next week!) Additionally, we have gotten 3 requests for quotes and information on this upper extremity technology from the Dallas area in the last 2 months! Right now the only units in Texas are at UT Southwestern and Texas Woman’s University in Dallas and at TIRR in Houston.” April Philpot, DPT Southeast Account Manager  Presenters will visit Dallas locations, if possible.
Nanos and Pro  Robotic Gait Orthoses  Longer and more intensive training sessions compared to manual treadmill Training (principles of motor learning), real time feedback for a higher motivation and compliance, physiological gait pattern provided by individually adjustable orthoses, guidance force and body weight support, assessment and reporting functionality for an easy measurement of the patient’s progress, task-specific, repeated practice of movement (errorless)  Gait asymmetry may be associated with many potential negative issues (eg, challenges to balance control, increased energy expenditure, increased risk of musculoskeletal injury to the nonparetic LE, and decreased overall activity levels) (12).
 Evidence: “assumed”Reduced spasticity, Improved walking ability, Increased alertness, Strengthened leg muscles, Improved stamina, Increased motivation  Cost: $150-300 K- available for lease for purchase  Availability for demo: Inservice or demo at UTSW  Other clinics- Craig, RIC, TIRR, Spaulding, Shepherd Center, Carolinas Rehab.  VA Houston, Dallas, San Antonio. UTSW Dallas. TIRR Houston. TIRR is only one used for tx. http://lifecenter.ric.org/index.php?tray=content&tid=top1&cid=5722  Videohttp://www.hocoma.com/en/products/lokomat/lokomatpro/(1 min)  Severely impaired ambulating stroke patients benefit from the task-oriented and intensive training .  Ambulating stroke patients show improvements with the Lokomat system as well but require a challenging and variable training program either via therapist assisted or Lokomat assisted locomotor training.•  Locomotor improvements might depend on an early training onset as well as a high number of repetitions which can be applied with the Lokomat system.
Research Summary:  Lokomat training combined with physical therapy has some promising effects on functional and motor outcomes in sub-acute, non- ambulatory stroke patients in comparison with physical therapy alone.  Despite the small number of patients, the present data suggest that the Lokomat robotic assistive device provides innovative possibilities for gait training in stroke rehabilitation while eliminating prolonged repetitive movements in a nonergonomic position on the part of the physical therapist.  Although there were no differences between ambulatory groups in gain of functional scores, the Lokomat group showed an advantage over conventional physiotherapy by improving gait symmetry and body tissue composition.  In ambulatory stroke survivors, with mild to moderate deficits, therapist assisted treadmill training may be superior to Lokomat assisted training.  For ambulatory, sub-acute stroke patients with moderate to severe gait impairments, the diversity of conventional gait training interventions appear to be more effective than robotic-assisted gait training.  MALADAPTIVE ambulatory
 Significantly better effects of robotic assisted treadmill training in comparison to therapist assisted treadmill training, though both groups improved in various locomotor tests. In these studies acute/subacute stroke patients with the inability to ambulate without assistance were trained within the first three months.  Manually assisted treadmill training has proven to be rather difficult in these patients due to their reduced body weight support, lack of distal control, and high demand on PTs. -Schwartz et al. (2009)  Systematic review. 414 CVA subjects. Electromechanical-assisted gait training combined with physiotherapy, improves recovery of independent walking and walking distance in patients who could initially not walk independently -(Mehrholz et al., 2007).  Studies comparing efficacy of either robotic assisted locomotor training (LT) or therapist assisted  Review of 30 articles  (14 RCTs, 16 non-RCTs)  Limited evidence – beneficial for improving walking function in populations of patients with CVA, MS, TBI, or PD  Teffertiller, et al -2011
FDA approved •Brain injury rehabilitation by muscle re-education •Maintain or increase range of motion
Video: http://www.youtube.com/watch?v=VvpFpZC4UZk&feature=player_embedded  The arm brace has EMG sensors that sit on the skin's surface and detect even a very faint muscle signal.  Person with weak or partially paralyzed arm tries to move their arm and a muscle signal fires, the robotics in the mPower 1000 engage to assist in completing the desired movement.  In helping achieve desired movement, the device can be worn as a functional aid, used during exercise to maintain gains or applied as a rehabilitation device that re-teaches arm movement to the brain.
Based on a completed clinical research study at University of Cincinnati, Myomo has developed the PERL Technique, a set of research-based treatment plans that integrate the mPower 1000 into therapy programs that aim to increase functional activity. (Push-Eat-Reach-Lift) The device has been clinically tested with scientific partners that are experts in stroke upper extremity rehabilitation. Their partnership along with the help of over 50 stroke subjects has allowed us to come up with clinical protocols and guidelines that work for both acute and chronic patients. These guidelines are given to our certified therapists during our CE accredited training for PTs and OTs. Electromyography-Controlled Exoskeletal Upper-Limb-Powered Orthosis for Exercise Training after Stroke. (2007). Stein J., et al. Am. J. Phys. Med. Rehabil. Vol. 86. The Myomo device may serve as a therapy gateway for severe chronic patients who are so impaired that they currently are ineligible for other upper extremity stroke treatments (Title Unknown). (2000). Lipert J. et al. Stroke. 31:1210-6 Shows that task-based repetitive training may facilitate neural plasticity with concomitant improved motor abilities and enhanced functional performance InREACH Study In December 2010, a randomized control study of 30 subjects was completed. The goal of the study has been to compare therapy with Myomo to standard treatment. Currently, thirty chronic stroke survivors are receiving six weeks of therapy three times per week for one hour. The treatment sessions focus on three outcome measures that have been proven to be valid and reliable in the literature. The outcome measures include the Fugl Meyer ( Impairment Measure ), COPM ( Functional Measure) and the SF36 ( Quality of Life Measure ). Additionally, kinematic data is being collected. The initial outcome measures have been very promising, with patient improvement seen in all areas. Publication of the first data set is pending.
MSRP for clinic use is $16, 500- includes left and right device, android tablet and training and certification for 6 therapists. Rental options also available. Myomo for Clinical Organizations- has been used by therapists in community hospitals, rehabilitation hospitals and clinics, skilled nursing facilities and home healthcare agencies as part of neurological rehabilitation programs since 2007. They can schedule an in-service presentation which takes about 30 minutes and can be presented via the Web. For individual use, insurance may cover all or part of the cost of the Myomo Mobility System for home use which would have similar benefits as the NeuroMove (hope after discharge; resource for recovery)
Simple observational gait analysis is subjective  Description: Big screen for patients, Portable, Carpeted, pressure sensors, computer, 1/8" thick, 2-feet wide by 16-feet long(can be up to 26-feet long) and contains 18,482 sensors sandwiched between a thin vinyl top-cover and a rubber bottom. Have norms.  It rolls up to fit into a wheeled carrying case. The carpet is portable, can be laid over any flat surface, and requires minimal setup and test time. No markers or devices have to be placed on the patient. Patients can be tested with or without shoes, including those patients using assistive devices.  Purpose: Objective measurement system, quantifiable evidence of change. Electronic footprints: Measures cadence, step length, Step-to-step symmetry and variability, velocity, and other gait parameters. Tracks, reports, graphs, prints- instantaneous data.  Validate impairments and progress to insurance/patient/family.  Determines dynamic balance and fall risk. Community Screening. Dual Task.  Prescribe assistive devices , FES devices, AFO, Neglect glasses.  Treatment-Weight Shifting.
Advancing-Mobility-Through-Progressive-Technology.ppt
 Evidence: high concurrent validity with various motion analysis systems(2). High test-retest reliability (2).  Cost $34-58K  Available for on-site demo.  Other clinics  COPE- Center for Orthotics and Prosthetics in Chicago; San Antonio  Videohttp://www.youtube.com/watch?v=DKdvEJDFRtE&feature=related (3:51)  http://www.screencast.com/t/148Gf42mT password = gaitrite (1:50)
 Precise, objective gait analysis is necessary to quantify changes in gait and identify fall risk  Dual task (7)  NP testing revealed mild deficits in attention and executive functioning so it was concluded that the cognitive impairment was responsible for gait disorder and recurrent falls while dual-tasking. She had normal gait with fast and slow speed as well as leisurely. As previously mentioned, walking is a complex motor task, yet generally performed automatically by healthy adults. The attentional demands are therefore minimal. In older adults, age-related neuromotor changes such as reduced motor strength or decreased sensory input (vision, hearing, proprioception) increase the attentional demands needed for walking. This increased demand is met at the cost of a reduction in the central processing capacity for attentional reserve  High agreement between temporospatial gait parameters derived from an electronic walkway and a video-based motion capture system in healthy and chronic stroke subjects (8).  Able to quantify variants in stroke gait compared to normal and with assistive device (9).  Slower gait speed and worse performance on: swing time variability, double support phase, stride length variability: associated with higher risk of falls. Quantitative gait markers are independent predictors of falls in older adults. (597 adults followed up for incident fall rate) (10).  Effect of AFO: Improved gait in CVA with AFO donned. Future study on types of AFO and timing in recovery (11).  Temporal asymmetry can be found in many independently ambulating stroke patients. There is a need for a standard assessment of poststroke gait symmetry in light of the complex relationship with motor impairment and velocity (13).  Quantitative gait measures predict future risk of cognitive decline and dementia in initially non-demented older adults (14).
Cleared by FDA in 2007 • Relax muscle spasms • Prevent or retard disuse atrophy • Increase local blood circulation • Maintain or increase range of motion
Video: http://www.youtube.com/watch?v=gcadj18Dsjc&feature=player_embedded#! • Activity based therapy, promoting wellness, and aiding in preventing further disease • Patients with dense hemiparesis or cognitive deficits of may still benefit from the effects FES has on both the cord and PNS components. • Controlled stimulation patterns sent to arms, shoulder and trunk through electrodes, producing a smooth cycling motion • 30 minute sessions at least 3 X/ week • Stimulate up to 10 muscle groups in one or both legs or arms and the trunk
 Weekly email detailing the progress of patients & make adjustments to therapy settings on the web  Therapy settings are stored online for instant access  Historical data for each patient & graphical progress and comparison charts available  Every 5 seconds logs- Oxygen saturation･Pulse rate･Power -power generated by the patient's muscles･Stimulation level･Resistance･Control speed･Crank velocity･Drive torque･Motor velocity  Every session graphs-･Distance Traveled ･Expended Energy ･Expended Energy per Hour ･Peak Pulse ･Average Pulse Rate ･Average Asymmetry ･ Average Stimulation ･Muscle tone measurements
Used in over 200 clinics in the USA including: Courage Center, MN; Craig Hospital, CO; CORE, Fl; Total Rehab Care, MD; Shepard Center, GA; Sheltering Arms,VA; Woodrow Wilson Rehab Center, VA RT300 may facilitate improvements that help patients reach functional gains in a shorter time period. While it should not be used in place of a functional activity, it can certainly be used as an adjunctive therapy. In a rehab setting, it is more typically used for shorter durations to impact a more task specific goal, such as breaking up spasticity or neuro re-education. "There is almost no patient with upper motor neuron weakness that can't benefit from some type of FES cycling. It has benefits for cardiovascular conditioning, strength, reciprocal gait patterns and tone modulation." Darryl Kaelin, M.D., Medical Director for the Acquired Brain Injury Program at Shepherd Center in Atlanta, GA.
• Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. (2011). Ambrosini E, et al. Stroke. 42(4):1068-73. The study demonstrated that 20 sessions of FES cycling training significantly improved lower extremity motor functions and accelerated the recovery of overground locomotion in postacute hemiparetic patients. Improvements were maintained at follow-up. • Bilateral upper limb training with functional electric stimulation in patients with chronic stroke. (2009). Chan, M. K., Tong, R. K., Chung, K. Y. Neurorehabil Neural Repair. 23(4):357-65. This study was a double-blinded randomized controlled trial. At baseline comparison, there was no significant difference in both groups. After 15 training sessions, the FES group had significant improvement on the Fugel-Meyer and Functional Test for the Hemiplegic Upper Extremity, and active range of motion of wrist extension when compared with the control group.
• $22,000 for device and cart • Trial period is available • 4 hour web based course required before your new RT in-service
 Description: Body weight supported harness for gait. Uses an overhead track and harness.  Purpose:  Therapist and pt safety and independence.  Decreases fear of falling  Requires less staff for balance activities  High fall risk pts 1:1  More assisting less supporting  FITT  Cost  Other clinics: Shepherd Center  Video: http://www.youtube.com/watch?v=lIfgyCy1TNg (3:11)
Advancing-Mobility-Through-Progressive-Technology.ppt
•Description: Robotic aid that aids the knee in flexion and extension. Activated by foot sensor, follows parameters set by PT. Worn during therapy sessions for strengthening and movement retraining. •Benefits: More sit-to-stand exercises, More overground steps per session, More repetition of stair-climbing, Increased potential for “neuroplasticity”. Compared to NMES, not affected by tone, spurs motor recovery via sensors that allow the device to respond to patients’ intentions. •Evidence: Improves gait speed, endurance, balance. Even in 10 years post CVA •Video: Before and After http://www.tibion.com/patients (1 min)
 Cost: $700-1,000/month to rent. $40,000.  Evidence  Untethered mobility. 3 ambulatory s/p CVA  All subjects improved balance, gait and functional performances with mean individual improvements of 12.6% for BBS, 12.0% for 6MWT and 16.7% for EFAP post-treatment. No adverse events occurred.  May have benefited from the task-specific functional training program augmented by RKO use.  -Wong, 2011
UCSF Study What do improved gait speed & endurance mean? •EM, 5 years post-stroke, went from a limited community ambulator to community ambulator •AC, 1.5 years post-stroke, went from a household ambulator to limited community ambulator •VH, 10 years post-stroke, who started therapy as a community ambulator, progressed to the status of an age-matched healthy adult
Advancing-Mobility-Through-Progressive-Technology.ppt
 Computer Assisted Rehabilitation Environment  The CAREN, a 21-foot dome, helps researchers analyze how patients react to different walking speeds, inclines and environments. (5)  “Walking down a busy street? See other pedestrians around you. See the buildings. Hear and see traffic. A walk in the woods? See the trees, hear the wind and the birds, feel the trail twist and turn under your feet. Computers linked to sensors on the body move a treadmill to match the ground you’d be walking over and adjust video images all around to what you’d see and hear as you walk.” (5)  Can be used with wheelchair.  7 in the world. Mild TBI and Amputee.  Center for the Intrepid  http://www.youtube.com/watch?v=ZCiGOWUPYZY&feature=related  http://www.youtube.com/watch?v=LfkkPsPaEF8&feature=related
Advancing-Mobility-Through-Progressive-Technology.ppt
Advancing-Mobility-Through-Progressive-Technology.ppt
 Bioness L300 Plus  Other Gait mats  Gait Rite 2  Walkway™ System  Defy Gravity Treadmill  (ADAPT: advanced differential air pressure technologies)
Advancing-Mobility-Through-Progressive-Technology.ppt
 Balance Master  http://resourcesonbalance.com/neurocom/products/SMARTBalanceMaster.aspx  Walker, et al. 2000. PTJ. Use of Visual Feedback in Retraining Balance Following Acute Stroke.  Goddard, et al. 2009. Force platform feedback for standing balance training after stroke. Cochrane Stroke Group Online Journal.  Geiger, at al. PTJ. 2001. Balance and Mobility Following Stroke: Effects of Physical Therapy Interventions With and Without Biofeedback/Forceplate Training  Van Peppen, et al. Journal of Rehabilitation Medicine 2006; 38(1): 3‐9 Effects of visual feedback therapy on postural control in bilateral standing after stroke: A systematic review  Chen, et al. Effects of Balance Training on Hemiplegic Stroke Patients. Med J 2002;25:583-90  Biodex Balance  http://www.biodex.com/physical-medicine/products/balance/balance-system-sd  Lokomat  http://www.hocoma.com/fileadmin/User/PDF/Patienten/Therapy_Info_TBI_0705_de_en.pdf  Efficacy of rehabilitation robotics for walking training in neurological disorders: A review. Candace Tefertiller, et al. JRRD. 2011  GAITRite  (1)http://www.gaitrite.com/Downloads/GAITRite_Newsletter.pdf  (2) Agreement between the GAITRite Walkway System and a Stopwatch-Footfall Count Method for Measurement of Temporal and Spatial Gait Parameters (Youdas, et al 2006) Arch Phys Med Rehabil  http://www.gaitrite.com/  Free Step  http://www.biodex.com/physical-medicine/products/supported-ambulation/freestep-sas  (3) Med Biol Eng Comput. 2011 Oct;49(10):1103-18. Epub 2011 Jul 20. Advances in upper limb stroke rehabilitation: a technology push. Loureiro RC, Harwin WS, Nagai K, Johnson M.  (4) Spaulding. www.spaulding rehab.org.  (5) CAREN. http://news.discovery.com/tech/computer-assisted-rehab-soliders.html. http://www.msnbc.msn.com/id/16266245/ns/technology_and_science-innovation/t/virtual-reality-boosts-rehab-efforts/  (6) Tibion.  A wearable robotic knee orthosis for gait training: a case-series of hemiparetic stroke survivors. Christopher Wong, Prosthetics and Orthotics International. 2011 .
 (7) Gerontology DOI: 10.1159/000322194. Laboratory Review: The Role of Gait Analysis in Seniors’ Mobility and Fall Prevention Stephanie A. Bridenbaugh Reto W. Kressig Department of Acute Geriatrics, University Hospital of Basel, Basel , Switzerland  (8) Am J Phys Med Rehab. 6 June 2009. Dobrivoje S. Stokic, MD, DSc, Terry S. Horn, PhD, John M. Ramshur, BS, John W. Chow, PhD. Agreement Between Temporospatial Gait Parameters of an Electronic Walkway and a Motion Capture System in Healthy and Chronic Stroke Populations  (9) Gait and Posutre Journal. 22 January 2010. Inter-limb centre of pressure symmetry during gait among stroke survivors Amanda E. Chisholm , Stephen D. Perry, William E. McIlroy . Toronto Rehabilitation Institute. Graduate Department of Rehabilitation Science, University of  (10) Journal of Gerontology. August 7 2009. Quantitative Gait Markers and Incident Fall Risk in Older Adults. Joe Verghese , 1 Roee Holtzer , 1 , 2 Richard B. Lipton , 1 , 3 and Cuiling Wang 3.  (11) The Effect of an Ankle-Foot Orthosis on Gait Parameters of Acute andChronic Hemiplegic Subjects February 2009. Jason Wening, MS, CP, Michael Huskey, Daniel Hasso, CPO, Alexander Aruin, PhD, Noel Rao, MD. The Academy Today: Advancing Orthotic and Prosthetic Care Through Knowledge  (12) Changes in Gait Symmetry and Velocity After Stroke: A Cross-Sectional Study From Weeks to Years After Stroke. Kara K. Patterson, PhD1,2, William H. Gage, PhD2,3, Dina Brooks, PhD1,2, Sandra E. Black, MD, FRCP1,2, and William E. McIlroy, PhD1,2,4. Neurorehabilitation and Neural Repair 24(9) 783– 790. 2010.  (13) Gait Asymmetry in Community-Ambulating Stroke Survivors. Patterson, Kara, et al. Arch Phys Med Rehab. Feb 2008.  (14) Quantitative gait dysfunction and risk of cognitive Decline and Dementia. Verghese, Joe, et al. J. Neurol. Neurosurg. Psychiatry 2007;78;929-935  (15) overview of Stroke Literature on Lokomat. https://docs.google.com/viewer?a=v&pid=gmail&attid=0.2&thid=133f0cfea4c8db29&mt=application/pdf&url=https://mail.google.com/ mail/?ui%3D2%26ik%3D9352447f67%26view%3Datt%26th%3D133f0cfea4c8db29%26attid%3D0.2%26disp%3Dsafe%26zw&sig= AHIEtbSxVApD8jfRDGLSUxi3JW1prTcw5w
 Please see “Research Resources” slide for each of the following device’s research article’s citations.  Neuromove: http://www.neuromove.com/neuromove/how-does- it-work/ http://www.neuromove.com/neuromove- therapy/clinical-studies/  Myomo: http://www.myomo.com/myomo-medical- professionals-neurological-rehabilitation-research  RT300: http://restorative-therapies.com/rt300-legarm  Armeo: http://www.hocoma.com/en/products/armeo/

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Advancing-Mobility-Through-Progressive-Technology.ppt

  • 1. Chrissy Lighthill, MOT, OTR and Rachel Atkins, PT, DPT
  • 2.  Introduce theory behind recent advances in rehab technology  Provide an overview of 11 devices  Description  Cost, if available  Availability of demo/in-service from the vendors  Other clinics who have the products  Evidence  Videos and Photos  Create an awareness of the presence of these items, not promoting or reflecting a “wish list”  Present to teams/therapists  Follow up with vendors
  • 3.  Provide real-time biofeedback (feel, see, hear)  Objective Measures  Monitor progress, tracking outcomes, evidence for third party payers, clear to patient  Relevant to society  Motivating, Engaging, Stimulating  Marketing Tool: Screening, Research  Real Life Simulation in Clinic  Errorless learning  3 crucial elements for the acquisition of motor programs through rehab : adequate feedback, variability of practice, and design of learning situation.  “Patients with motor dysfunction are totally dependent on the information concerning the outcomes of the attempts to perform motor tasks especially during the acute stage”. -Mulder  “…allow precise recording of movements and application of forces…valuable tool for motor rehabilitation….visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task... information sent to the patient about exercise performance…address psychosomatic variables influencing therapy” (3).  “Assistive technologies can open new worlds for individuals with physical, communication, and cognitive limitations.” “A new technology may also help someone with a chronic or progressive disabling condition maintain or improve his or her independence” (4).
  • 4.  Myomo  Neuromove  Balancemaster  Biodex Balance System SD  Armeo  Lokomat  Restorative FES Cycles  GAITRite  Free Supported Ambulation System (SAS)  Tibion  CAREN
  • 5.  Description: Force platform for testing and training of static and dynamic standing balance.  Capabilities: Fall-risk screening and training, Postural stability, Clinical Test of Sensory Integration of Balance (CTSIB), compare scores to age-dependent norms, charts progress over time, determine which of 3 balance systems pt is relying on.  Screening: Concussions  Evidence: Effective with CVA and Mild TBI (Concussion)  Cost: ~ $12,000  Very common in clinics  Video http://www.biodex.com/physical-medicine/products/balance/balance-system-sd (3:08 total (to 1:40)
  • 6.  6 interactive training modes in Static and Dynamic: Postural Stability, Maze Control, Weight Shift, random Control, Limits of Stability, Weight bearing. Large Color Touch Screen, Interactive, game-like balance. 4 Standardized tests: Static Measuring Capability, Increased Dynamic resistance, Standardized Fall Screening Test Protocol, Athlete Knee Injury Screening Test protocol.
  • 7. Cleared by FDA in 2001 •Stroke rehab by muscle re-education •Relaxation of muscle spasms (spasticity) •Prevention of retardation of disuse atrophy •Increase local blood circulation •Maintaining or increasing ROM
  • 8. Video: http://www.neuromove.com/neuromove-therapy-video/ Detects attempts below where trace movements are visible. Distinguishes between regular muscle activity, muscle tone, and real attempts. When a real attempt is detected, the unit rewards the patient with muscle contraction, visual and sensory feedback serves as an important element in relearning the movement. Very motivating, see they could make a difference, where previously, they had no indication of their attempts.
  • 9. • Concentration and focus is the key to achieving better control of motor functions • Doesn’t work on confused or cognitively low patients • Use 1 - 3 X/day for ~ 20 minutes; longer intervals not common • Effective for spastic & flaccid extremities • International Functional Electrical Stimulation Society
  • 10. • Classically backed by biofeedback principals • Most of the studies included patients between 6 months and 14 years post-stroke, subjects were motivated and cognitively intact, and the findings were: • Improvements were in form of improved strength, range-of- motion, reduced spasticity and tone, flexibility, and motor capability in general. *** Regular therapy and electrical stimulation was less than half as effective!
  • 11.  Electrical Stimulation Driving Functional Improvements and Cortical Changes in Subjects With Stroke. (2003) Teresa J. Kimberley, Scott M. Lewis, Edward J. Auerbach, Lisa L. Dorsey, Jeanne M. Lojovich and James R. Carey, University of Minnesota. “Experimental Brain Research”. These findings suggest that NMES may have an important role in stimulating cortical sensory areas allowing for improved motor function.  Electromyographically triggered electric muscle stimulation for chronic hemiplegia. (1987) R.W. Fields, Arch. Phys. Med.Rehabil 68(7):407-14. Progress often far exceeded that of previous conventional therapy. Regarding mechanisms, impaired proprioceptive feedback is considered central to stroke-disrupted sensorimotor control. EMG-triggered EMS is intended to improve brain relearning by reinstating proprioceptive feedback time-locked to each attempted movement. Clinical results were consistent with this theory.  Mental Practice of Motor Skills used in poststroke Rehabilitation has Own Effects on Central Nervous Activation. (1994). T. Weiss, Ellen Hansen, R. Rost, L. Beyer, F. Merten, Christa Nichelmann, and C. Zippel. Intern J. Neuroscience, 1994, Vol. 78, pp 1 57-166. It has been shown that the use of the EMG triggered electrical myostimulation (ETEM) brings good results in poststroke. The technique is most powerful if imagination of motor acts (the so called mental practice) is used as an initial part of ETEM.  Home-based electromyography-triggered stimulation in chronic stroke. (2005). Clin Rehabil 19(7) 737- 745. ETMS use is feasible in the home environment. Neither participation in a traditional home exercise program nor ETMS use conveyed changes on the Fugl-Meyer or Action Research Arm Test. However, ETMS use increased active affected limb extension. This new movement may provide a potential pathway for subjects to participate in other interventions, such as modified constraint induced therapy.
  • 12. •Clinic Use: MSRP $ 5,950, however there is a 20% discount for a total of $4,670 if the amount is paid in full •Patients can lease the Neuromove starting at $99/ month and other plans are available • Part time patients can feel confident they are not losing out on valuable Physical and Occupational Therapy, when their cognitive program is winding down or limited due to insurance •Discharge preparation- given as a resource to continue therapy when appropriate. • Especially for those who are losing insurance or prematurely discharging
  • 13.  Moving platform posturography,: also called computerized dynamic posturography (CDP): method of quantifying balance.  Description: The PRO Balance Master® provides objective assessment and retraining of the sensory and voluntary motor control of balance with visual biofeedback on either a stable or unstable support surface. VESTIBULAR REHAB. Utility in malingering. Fall Risk Assessment and Balance conditioning.  Useful for identifying pts who could benefit from vestibular rehab and which balance system is involved  Moveable Forceplate and surround. EMG option.  Availability for demo: TWU  Other clinics (Shepherd, BIR, fairly common)  Video: http://www.youtube.com/watch?v=L72Vx_F-b18 (1:51)
  • 14.  Visual feedback or conventional balance training in addition to regular therapy affords no added benefit when offered in the early stages of rehabilitation following stroke. – Walker, et al. 2000.  No additional effects compared to traditional PT -Geiger, et al. 2001  Improves standing balance, impact on independence is unclear.  The results of seven clinical trials indicated that providing feedback from a force platform resulted in patients standing more evenly but did not improve balance during active functional activities, nor did it improve overall independence.- Goddard, et al. 2009.
  • 15.  Trunk balance in the acute stage of stroke is a functional outcome predictor. Clinical examination of balance is done in daily practice when stroke patients are assessed in rehabilitation units, but it is not usually done in a standardized and objective way.  Correlate outcome measures/clinical scales with specific motor results such as walking speed, distance walking perimeter and balance, measured with computerized systems such as posturography. - J Rehabil Med 2002; 34: 267–272. TRUNK CONTROL TEST AS A FUNCTIONAL PREDICTOR IN STROKE PATIENTS. E. Duarte, et al.  No statistically significant effects in function. -Van Peppen 2006.  Only a few studies look at long-term effects.  Dynamic balance function of patients in the visual feedback training group had significant improvements when compared with the control group. Activities of daily living (ADL) function in self-care and sphincter control, also had significant improvements at 6 months follow up in the trained group. Less improvement for locomotion on FIM. The results showed that balance training was beneficial for patients after hemiplegic stroke. -Chen ,et al. 2002
  • 16. Suitable for individuals who have suffered strokes, traumatic brain injuries, or neurological disorders resulting in hand and arm impairment.
  • 17. Video: http://www.hocoma.com/en/products/armeo/armeo-spring/ • Adjustable arm support with a highly sensitive hand grip and videogame-like exercises to simulate arm movements used in specific real-life tasks • Exercises are carried out in the virtual environment on a computer screen, providing you with goal-oriented tasks and giving you immediate visual feedback. • Because the weight of the arm is counterbalanced in the arm support, you can use residual neuromuscular control to perform the exercises and gradually build strength in your arm. • Built-in sensors and software record arm movements at each joint, so you and your therapist can track your improvement, determine the appropriate difficulty level for you and customize your training program as you progress.
  • 18. Other clinics: UT Southwestern, TWU Dallas, TIRR Houston, RIC, Ireland, & Germany
  • 19. • 87% of participants who received Armeo training demonstrated motor improvements in their arm compared to 69% of subjects who completed conventional arm exercise • More than 80% of all participants preferred Armeo to conventional exercises and would recommend the Armeo exercises over conventional exercises. • On the Fugl-Meyer clinical test; both groups had the same training time and therapist supervision. * (RIC study) The latest clinical findings show that therapeutic methods that are based on active, high-intensity, task-specific movement training are superior to traditional methods
  • 20.  Housman, S. J., Scott K., M. et al. (2009). A Randomized Controlled Trial of Gravity Supported, Computer-enhanced Arm Exercises for Individuals with Severe Hemiparesis. Neurorehabil Neural Repair.  Prange, G. B., Jannink M. J. A. et al. (2009). Influence of Gravity Compensation on Muscle Activation Patterns During Different Temporal Phases of Arm Movements of Stoke Patients. Neurorehabil Neural Repair.  Stienen, A. H. (2009). Novel Devices for Upper-Extremity Rehabilitation. PhD Thesis, University of Twente, Enschede, The Netherlands.
  • 21.  Cost: $60, 500  Lease to own option: $1,122 for 60 months  “.. very reasonably priced unit (called the ArmeoSpring) for patients who are able to self initiate movement. (I am scheduled to install 3 ArmeoSpring units and train the staff for each of the rehab hospitals in Houston/Austin, Texas next week!) Additionally, we have gotten 3 requests for quotes and information on this upper extremity technology from the Dallas area in the last 2 months! Right now the only units in Texas are at UT Southwestern and Texas Woman’s University in Dallas and at TIRR in Houston.” April Philpot, DPT Southeast Account Manager  Presenters will visit Dallas locations, if possible.
  • 22. Nanos and Pro  Robotic Gait Orthoses  Longer and more intensive training sessions compared to manual treadmill Training (principles of motor learning), real time feedback for a higher motivation and compliance, physiological gait pattern provided by individually adjustable orthoses, guidance force and body weight support, assessment and reporting functionality for an easy measurement of the patient’s progress, task-specific, repeated practice of movement (errorless)  Gait asymmetry may be associated with many potential negative issues (eg, challenges to balance control, increased energy expenditure, increased risk of musculoskeletal injury to the nonparetic LE, and decreased overall activity levels) (12).
  • 23.  Evidence: “assumed”Reduced spasticity, Improved walking ability, Increased alertness, Strengthened leg muscles, Improved stamina, Increased motivation  Cost: $150-300 K- available for lease for purchase  Availability for demo: Inservice or demo at UTSW  Other clinics- Craig, RIC, TIRR, Spaulding, Shepherd Center, Carolinas Rehab.  VA Houston, Dallas, San Antonio. UTSW Dallas. TIRR Houston. TIRR is only one used for tx. http://lifecenter.ric.org/index.php?tray=content&tid=top1&cid=5722  Videohttp://www.hocoma.com/en/products/lokomat/lokomatpro/(1 min)  Severely impaired ambulating stroke patients benefit from the task-oriented and intensive training .  Ambulating stroke patients show improvements with the Lokomat system as well but require a challenging and variable training program either via therapist assisted or Lokomat assisted locomotor training.•  Locomotor improvements might depend on an early training onset as well as a high number of repetitions which can be applied with the Lokomat system.
  • 24. Research Summary:  Lokomat training combined with physical therapy has some promising effects on functional and motor outcomes in sub-acute, non- ambulatory stroke patients in comparison with physical therapy alone.  Despite the small number of patients, the present data suggest that the Lokomat robotic assistive device provides innovative possibilities for gait training in stroke rehabilitation while eliminating prolonged repetitive movements in a nonergonomic position on the part of the physical therapist.  Although there were no differences between ambulatory groups in gain of functional scores, the Lokomat group showed an advantage over conventional physiotherapy by improving gait symmetry and body tissue composition.  In ambulatory stroke survivors, with mild to moderate deficits, therapist assisted treadmill training may be superior to Lokomat assisted training.  For ambulatory, sub-acute stroke patients with moderate to severe gait impairments, the diversity of conventional gait training interventions appear to be more effective than robotic-assisted gait training.  MALADAPTIVE ambulatory
  • 25.  Significantly better effects of robotic assisted treadmill training in comparison to therapist assisted treadmill training, though both groups improved in various locomotor tests. In these studies acute/subacute stroke patients with the inability to ambulate without assistance were trained within the first three months.  Manually assisted treadmill training has proven to be rather difficult in these patients due to their reduced body weight support, lack of distal control, and high demand on PTs. -Schwartz et al. (2009)  Systematic review. 414 CVA subjects. Electromechanical-assisted gait training combined with physiotherapy, improves recovery of independent walking and walking distance in patients who could initially not walk independently -(Mehrholz et al., 2007).  Studies comparing efficacy of either robotic assisted locomotor training (LT) or therapist assisted  Review of 30 articles  (14 RCTs, 16 non-RCTs)  Limited evidence – beneficial for improving walking function in populations of patients with CVA, MS, TBI, or PD  Teffertiller, et al -2011
  • 26. FDA approved •Brain injury rehabilitation by muscle re-education •Maintain or increase range of motion
  • 27. Video: http://www.youtube.com/watch?v=VvpFpZC4UZk&feature=player_embedded  The arm brace has EMG sensors that sit on the skin's surface and detect even a very faint muscle signal.  Person with weak or partially paralyzed arm tries to move their arm and a muscle signal fires, the robotics in the mPower 1000 engage to assist in completing the desired movement.  In helping achieve desired movement, the device can be worn as a functional aid, used during exercise to maintain gains or applied as a rehabilitation device that re-teaches arm movement to the brain.
  • 28. Based on a completed clinical research study at University of Cincinnati, Myomo has developed the PERL Technique, a set of research-based treatment plans that integrate the mPower 1000 into therapy programs that aim to increase functional activity. (Push-Eat-Reach-Lift) The device has been clinically tested with scientific partners that are experts in stroke upper extremity rehabilitation. Their partnership along with the help of over 50 stroke subjects has allowed us to come up with clinical protocols and guidelines that work for both acute and chronic patients. These guidelines are given to our certified therapists during our CE accredited training for PTs and OTs. Electromyography-Controlled Exoskeletal Upper-Limb-Powered Orthosis for Exercise Training after Stroke. (2007). Stein J., et al. Am. J. Phys. Med. Rehabil. Vol. 86. The Myomo device may serve as a therapy gateway for severe chronic patients who are so impaired that they currently are ineligible for other upper extremity stroke treatments (Title Unknown). (2000). Lipert J. et al. Stroke. 31:1210-6 Shows that task-based repetitive training may facilitate neural plasticity with concomitant improved motor abilities and enhanced functional performance InREACH Study In December 2010, a randomized control study of 30 subjects was completed. The goal of the study has been to compare therapy with Myomo to standard treatment. Currently, thirty chronic stroke survivors are receiving six weeks of therapy three times per week for one hour. The treatment sessions focus on three outcome measures that have been proven to be valid and reliable in the literature. The outcome measures include the Fugl Meyer ( Impairment Measure ), COPM ( Functional Measure) and the SF36 ( Quality of Life Measure ). Additionally, kinematic data is being collected. The initial outcome measures have been very promising, with patient improvement seen in all areas. Publication of the first data set is pending.
  • 29. MSRP for clinic use is $16, 500- includes left and right device, android tablet and training and certification for 6 therapists. Rental options also available. Myomo for Clinical Organizations- has been used by therapists in community hospitals, rehabilitation hospitals and clinics, skilled nursing facilities and home healthcare agencies as part of neurological rehabilitation programs since 2007. They can schedule an in-service presentation which takes about 30 minutes and can be presented via the Web. For individual use, insurance may cover all or part of the cost of the Myomo Mobility System for home use which would have similar benefits as the NeuroMove (hope after discharge; resource for recovery)
  • 30. Simple observational gait analysis is subjective  Description: Big screen for patients, Portable, Carpeted, pressure sensors, computer, 1/8" thick, 2-feet wide by 16-feet long(can be up to 26-feet long) and contains 18,482 sensors sandwiched between a thin vinyl top-cover and a rubber bottom. Have norms.  It rolls up to fit into a wheeled carrying case. The carpet is portable, can be laid over any flat surface, and requires minimal setup and test time. No markers or devices have to be placed on the patient. Patients can be tested with or without shoes, including those patients using assistive devices.  Purpose: Objective measurement system, quantifiable evidence of change. Electronic footprints: Measures cadence, step length, Step-to-step symmetry and variability, velocity, and other gait parameters. Tracks, reports, graphs, prints- instantaneous data.  Validate impairments and progress to insurance/patient/family.  Determines dynamic balance and fall risk. Community Screening. Dual Task.  Prescribe assistive devices , FES devices, AFO, Neglect glasses.  Treatment-Weight Shifting.
  • 32.  Evidence: high concurrent validity with various motion analysis systems(2). High test-retest reliability (2).  Cost $34-58K  Available for on-site demo.  Other clinics  COPE- Center for Orthotics and Prosthetics in Chicago; San Antonio  Videohttp://www.youtube.com/watch?v=DKdvEJDFRtE&feature=related (3:51)  http://www.screencast.com/t/148Gf42mT password = gaitrite (1:50)
  • 33.  Precise, objective gait analysis is necessary to quantify changes in gait and identify fall risk  Dual task (7)  NP testing revealed mild deficits in attention and executive functioning so it was concluded that the cognitive impairment was responsible for gait disorder and recurrent falls while dual-tasking. She had normal gait with fast and slow speed as well as leisurely. As previously mentioned, walking is a complex motor task, yet generally performed automatically by healthy adults. The attentional demands are therefore minimal. In older adults, age-related neuromotor changes such as reduced motor strength or decreased sensory input (vision, hearing, proprioception) increase the attentional demands needed for walking. This increased demand is met at the cost of a reduction in the central processing capacity for attentional reserve  High agreement between temporospatial gait parameters derived from an electronic walkway and a video-based motion capture system in healthy and chronic stroke subjects (8).  Able to quantify variants in stroke gait compared to normal and with assistive device (9).  Slower gait speed and worse performance on: swing time variability, double support phase, stride length variability: associated with higher risk of falls. Quantitative gait markers are independent predictors of falls in older adults. (597 adults followed up for incident fall rate) (10).  Effect of AFO: Improved gait in CVA with AFO donned. Future study on types of AFO and timing in recovery (11).  Temporal asymmetry can be found in many independently ambulating stroke patients. There is a need for a standard assessment of poststroke gait symmetry in light of the complex relationship with motor impairment and velocity (13).  Quantitative gait measures predict future risk of cognitive decline and dementia in initially non-demented older adults (14).
  • 34. Cleared by FDA in 2007 • Relax muscle spasms • Prevent or retard disuse atrophy • Increase local blood circulation • Maintain or increase range of motion
  • 35. Video: http://www.youtube.com/watch?v=gcadj18Dsjc&feature=player_embedded#! • Activity based therapy, promoting wellness, and aiding in preventing further disease • Patients with dense hemiparesis or cognitive deficits of may still benefit from the effects FES has on both the cord and PNS components. • Controlled stimulation patterns sent to arms, shoulder and trunk through electrodes, producing a smooth cycling motion • 30 minute sessions at least 3 X/ week • Stimulate up to 10 muscle groups in one or both legs or arms and the trunk
  • 36.  Weekly email detailing the progress of patients & make adjustments to therapy settings on the web  Therapy settings are stored online for instant access  Historical data for each patient & graphical progress and comparison charts available  Every 5 seconds logs- Oxygen saturation･Pulse rate･Power -power generated by the patient's muscles･Stimulation level･Resistance･Control speed･Crank velocity･Drive torque･Motor velocity  Every session graphs-･Distance Traveled ･Expended Energy ･Expended Energy per Hour ･Peak Pulse ･Average Pulse Rate ･Average Asymmetry ･ Average Stimulation ･Muscle tone measurements
  • 37. Used in over 200 clinics in the USA including: Courage Center, MN; Craig Hospital, CO; CORE, Fl; Total Rehab Care, MD; Shepard Center, GA; Sheltering Arms,VA; Woodrow Wilson Rehab Center, VA RT300 may facilitate improvements that help patients reach functional gains in a shorter time period. While it should not be used in place of a functional activity, it can certainly be used as an adjunctive therapy. In a rehab setting, it is more typically used for shorter durations to impact a more task specific goal, such as breaking up spasticity or neuro re-education. "There is almost no patient with upper motor neuron weakness that can't benefit from some type of FES cycling. It has benefits for cardiovascular conditioning, strength, reciprocal gait patterns and tone modulation." Darryl Kaelin, M.D., Medical Director for the Acquired Brain Injury Program at Shepherd Center in Atlanta, GA.
  • 38. • Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. (2011). Ambrosini E, et al. Stroke. 42(4):1068-73. The study demonstrated that 20 sessions of FES cycling training significantly improved lower extremity motor functions and accelerated the recovery of overground locomotion in postacute hemiparetic patients. Improvements were maintained at follow-up. • Bilateral upper limb training with functional electric stimulation in patients with chronic stroke. (2009). Chan, M. K., Tong, R. K., Chung, K. Y. Neurorehabil Neural Repair. 23(4):357-65. This study was a double-blinded randomized controlled trial. At baseline comparison, there was no significant difference in both groups. After 15 training sessions, the FES group had significant improvement on the Fugel-Meyer and Functional Test for the Hemiplegic Upper Extremity, and active range of motion of wrist extension when compared with the control group.
  • 39. • $22,000 for device and cart • Trial period is available • 4 hour web based course required before your new RT in-service
  • 40.  Description: Body weight supported harness for gait. Uses an overhead track and harness.  Purpose:  Therapist and pt safety and independence.  Decreases fear of falling  Requires less staff for balance activities  High fall risk pts 1:1  More assisting less supporting  FITT  Cost  Other clinics: Shepherd Center  Video: http://www.youtube.com/watch?v=lIfgyCy1TNg (3:11)
  • 42. •Description: Robotic aid that aids the knee in flexion and extension. Activated by foot sensor, follows parameters set by PT. Worn during therapy sessions for strengthening and movement retraining. •Benefits: More sit-to-stand exercises, More overground steps per session, More repetition of stair-climbing, Increased potential for “neuroplasticity”. Compared to NMES, not affected by tone, spurs motor recovery via sensors that allow the device to respond to patients’ intentions. •Evidence: Improves gait speed, endurance, balance. Even in 10 years post CVA •Video: Before and After http://www.tibion.com/patients (1 min)
  • 43.  Cost: $700-1,000/month to rent. $40,000.  Evidence  Untethered mobility. 3 ambulatory s/p CVA  All subjects improved balance, gait and functional performances with mean individual improvements of 12.6% for BBS, 12.0% for 6MWT and 16.7% for EFAP post-treatment. No adverse events occurred.  May have benefited from the task-specific functional training program augmented by RKO use.  -Wong, 2011
  • 44. UCSF Study What do improved gait speed & endurance mean? •EM, 5 years post-stroke, went from a limited community ambulator to community ambulator •AC, 1.5 years post-stroke, went from a household ambulator to limited community ambulator •VH, 10 years post-stroke, who started therapy as a community ambulator, progressed to the status of an age-matched healthy adult
  • 46.  Computer Assisted Rehabilitation Environment  The CAREN, a 21-foot dome, helps researchers analyze how patients react to different walking speeds, inclines and environments. (5)  “Walking down a busy street? See other pedestrians around you. See the buildings. Hear and see traffic. A walk in the woods? See the trees, hear the wind and the birds, feel the trail twist and turn under your feet. Computers linked to sensors on the body move a treadmill to match the ground you’d be walking over and adjust video images all around to what you’d see and hear as you walk.” (5)  Can be used with wheelchair.  7 in the world. Mild TBI and Amputee.  Center for the Intrepid  http://www.youtube.com/watch?v=ZCiGOWUPYZY&feature=related  http://www.youtube.com/watch?v=LfkkPsPaEF8&feature=related
  • 49.  Bioness L300 Plus  Other Gait mats  Gait Rite 2  Walkway™ System  Defy Gravity Treadmill  (ADAPT: advanced differential air pressure technologies)
  • 51.  Balance Master  http://resourcesonbalance.com/neurocom/products/SMARTBalanceMaster.aspx  Walker, et al. 2000. PTJ. Use of Visual Feedback in Retraining Balance Following Acute Stroke.  Goddard, et al. 2009. Force platform feedback for standing balance training after stroke. Cochrane Stroke Group Online Journal.  Geiger, at al. PTJ. 2001. Balance and Mobility Following Stroke: Effects of Physical Therapy Interventions With and Without Biofeedback/Forceplate Training  Van Peppen, et al. Journal of Rehabilitation Medicine 2006; 38(1): 3‐9 Effects of visual feedback therapy on postural control in bilateral standing after stroke: A systematic review  Chen, et al. Effects of Balance Training on Hemiplegic Stroke Patients. Med J 2002;25:583-90  Biodex Balance  http://www.biodex.com/physical-medicine/products/balance/balance-system-sd  Lokomat  http://www.hocoma.com/fileadmin/User/PDF/Patienten/Therapy_Info_TBI_0705_de_en.pdf  Efficacy of rehabilitation robotics for walking training in neurological disorders: A review. Candace Tefertiller, et al. JRRD. 2011  GAITRite  (1)http://www.gaitrite.com/Downloads/GAITRite_Newsletter.pdf  (2) Agreement between the GAITRite Walkway System and a Stopwatch-Footfall Count Method for Measurement of Temporal and Spatial Gait Parameters (Youdas, et al 2006) Arch Phys Med Rehabil  http://www.gaitrite.com/  Free Step  http://www.biodex.com/physical-medicine/products/supported-ambulation/freestep-sas  (3) Med Biol Eng Comput. 2011 Oct;49(10):1103-18. Epub 2011 Jul 20. Advances in upper limb stroke rehabilitation: a technology push. Loureiro RC, Harwin WS, Nagai K, Johnson M.  (4) Spaulding. www.spaulding rehab.org.  (5) CAREN. http://news.discovery.com/tech/computer-assisted-rehab-soliders.html. http://www.msnbc.msn.com/id/16266245/ns/technology_and_science-innovation/t/virtual-reality-boosts-rehab-efforts/  (6) Tibion.  A wearable robotic knee orthosis for gait training: a case-series of hemiparetic stroke survivors. Christopher Wong, Prosthetics and Orthotics International. 2011 .
  • 52.  (7) Gerontology DOI: 10.1159/000322194. Laboratory Review: The Role of Gait Analysis in Seniors’ Mobility and Fall Prevention Stephanie A. Bridenbaugh Reto W. Kressig Department of Acute Geriatrics, University Hospital of Basel, Basel , Switzerland  (8) Am J Phys Med Rehab. 6 June 2009. Dobrivoje S. Stokic, MD, DSc, Terry S. Horn, PhD, John M. Ramshur, BS, John W. Chow, PhD. Agreement Between Temporospatial Gait Parameters of an Electronic Walkway and a Motion Capture System in Healthy and Chronic Stroke Populations  (9) Gait and Posutre Journal. 22 January 2010. Inter-limb centre of pressure symmetry during gait among stroke survivors Amanda E. Chisholm , Stephen D. Perry, William E. McIlroy . Toronto Rehabilitation Institute. Graduate Department of Rehabilitation Science, University of  (10) Journal of Gerontology. August 7 2009. Quantitative Gait Markers and Incident Fall Risk in Older Adults. Joe Verghese , 1 Roee Holtzer , 1 , 2 Richard B. Lipton , 1 , 3 and Cuiling Wang 3.  (11) The Effect of an Ankle-Foot Orthosis on Gait Parameters of Acute andChronic Hemiplegic Subjects February 2009. Jason Wening, MS, CP, Michael Huskey, Daniel Hasso, CPO, Alexander Aruin, PhD, Noel Rao, MD. The Academy Today: Advancing Orthotic and Prosthetic Care Through Knowledge  (12) Changes in Gait Symmetry and Velocity After Stroke: A Cross-Sectional Study From Weeks to Years After Stroke. Kara K. Patterson, PhD1,2, William H. Gage, PhD2,3, Dina Brooks, PhD1,2, Sandra E. Black, MD, FRCP1,2, and William E. McIlroy, PhD1,2,4. Neurorehabilitation and Neural Repair 24(9) 783– 790. 2010.  (13) Gait Asymmetry in Community-Ambulating Stroke Survivors. Patterson, Kara, et al. Arch Phys Med Rehab. Feb 2008.  (14) Quantitative gait dysfunction and risk of cognitive Decline and Dementia. Verghese, Joe, et al. J. Neurol. Neurosurg. Psychiatry 2007;78;929-935  (15) overview of Stroke Literature on Lokomat. https://docs.google.com/viewer?a=v&pid=gmail&attid=0.2&thid=133f0cfea4c8db29&mt=application/pdf&url=https://mail.google.com/ mail/?ui%3D2%26ik%3D9352447f67%26view%3Datt%26th%3D133f0cfea4c8db29%26attid%3D0.2%26disp%3Dsafe%26zw&sig= AHIEtbSxVApD8jfRDGLSUxi3JW1prTcw5w
  • 53.  Please see “Research Resources” slide for each of the following device’s research article’s citations.  Neuromove: http://www.neuromove.com/neuromove/how-does- it-work/ http://www.neuromove.com/neuromove- therapy/clinical-studies/  Myomo: http://www.myomo.com/myomo-medical- professionals-neurological-rehabilitation-research  RT300: http://restorative-therapies.com/rt300-legarm  Armeo: http://www.hocoma.com/en/products/armeo/

Editor's Notes

  • #6: Biosway static is $5,500 or 5900 with travel case Biodex Gait Trainer TM is about $10,000 http://www.youtube.com/watch?v=Rh88p8mZ8uM (starts 1:48-3:30)
  • #9: :12-1:50 (Shows ease of use) 5:44-till (Shows functionality) Q: When does NeuroMove therapy not work? A: When a patient is not cognitively intact, confused, not able to concentrate on simple tasks or is simply not motivated – Since it is “brain exercise” it does not work without motivation and concentration.
  • #14: FUNCTIONAL relation- riding in car, people moving around… Quantitatively: It is most applicable in situations where balance needs to be followed quantitatively, to determine whether a disorder is getting better or worse, or the response to treatment. There are several commercial vendors of posturography equipment. http://www.dizziness-and-balance.com/testing/posturography.html