International Neurorehabilitation Symposium 2009 Rehabilitation of the Upper Limbs: First Experiences with Armor and Amadeo

Size: px

Start display at page:

Download "International Neurorehabilitation Symposium 2009 Rehabilitation of the Upper Limbs: First Experiences with Armor and Amadeo"

Alaina Copeland
8 years ago
Views:

1 International Neurorehabilitation Symposium 2009 Rehabilitation of the Upper Limbs: First Experiences with Armor and Amadeo Leopold Saltuari Hospital Hochzirl, Austria Zurich, February 2009

2 Different approaches with Robotics in Neurorehabilitation of the Upper Limb

3 Swedish Helparm Kinsman Enterprises, Inc.

4 ARM guide - Armeo Renkensmeyer et al. 1999

5 Hesse arm trainer Hesse et al. 2003

6 MIT-Manus Hogan et al. 1995

7 ARMin Nef and Riener 2004

kinematic structure (8 active and 3 passive DOFs) - Various control schemes Master-Slave configuration (real time) Sample &

8 Armor Mayr et al Entire arm involved, from shoulder to fingers - Easy adaptable for individual users - 11 degrees of freedom (DOF) kinematic structure (8 active and 3 passive DOFs) - Various control schemes Master-Slave configuration (real time) Sample & Playback function Teach In of desired arm configuration - Permanent sampling of relevant motion parameters (joint angles, torque and static forces) - Redundant security systems - Import of motion data also from other sources e.g. C3D-files

9 Amadeo Tyromotion AG, A

10 Scientific Evidence for Robotic Devices in Neurorehabilitation Two main strategies improve stroke outcome: - Intensive therapy (number of therapy sessions, duration of therapy session) - Task-specific training (faster and better outcome, improvement of ADL s) Wagenaar & Meijer, J Rehabil Sci 1991: Effects of Stroke Rehabilitation (1) Platz, Nervenarzt 2003: Evidence-based Arm Rehabilitation - A Systematic Review of the Literature Kwakkel et al., Stroke 2004: Effects of Augmented Exercise Therapy Time After Stroke: A Meta-Analysis Van Peppen et al., Clin Rehabil 2004: The Impact of Physical Therapy on Functional Outcomes After Stroke: What's the Evidence?

Rehabilitation (1) Platz, Nervenarzt 2003: Evidence-based Arm Rehabilitation - A Systematic Review of the Literature Kwakkel et al.

11 Scientific Evidence for Robotic Devices in Neurorehabilitation Hakkennes & Keating, Aust J Physiother 2005: Constraint-Induced Movement Therapy Moeley et al., Cochraine Database Syst Rev 2005: Treadmill Training and BWS Hogan & Krebs, Restor Neurol Neurosci 2004: Interacitve Robots for Neuro-Rehabilitation Volpe et al., Curr Atheroscler Rep 2004: Robotics and Other Devices in Stroke Rehabilitation

, Cochraine Database Syst Rev 2005: Treadmill Training and BWS Hogan & Krebs, Restor Neurol

12 Upper motor neurone syndrome (UMNS) UMNS can occur following any lesion affecting some or all the descending motor pathways The clinical features of the UMNS can be divided into two broad groups: - Negative phenomena - Positive phenomena

motor pathways The clinical features of the UMNS can be

13 Contractures Mechanisms for contractures - Stretch hyperreflexia, spasticity, does not contribute to contractures (O Dwyer et al. 1996) - Prolonged muscle shortening (irrespective of whether there is active muscle contraction or not) - Accompanied by increased muscle stiffness (passive connective tissue of muscles, tendons and joints) - Contracture can also occur without hypertonia - Contracture may aggravate spasticity by shortening intrafusal fibres as well as extrafusal, thus activating them earlier in the stretch than usual Williams&Goldspink 1978

stiffness (passive connective tissue of muscles, tendons and joints) - Contracture can also occur without hypertonia - Contracture may

14 Lokomat

15 Prospective, Blinded, Randomized Crossover Study of Gait Rehabilitation in Stroke Patients using the Lokomat Gait Orthosis Andreas Mayr, MS, Markus Kofler, MD, Ellen Quirbach PT, Heinz Matzak MD, Katrin Fröhlich, MD and Leopold Saltuari MD Sum score of relative changes Percentage Weeks Neurorehabil Neural Repair, published on May 2, 2007

MD, Katrin Fröhlich, MD and Leopold Saltuari MD Sum score of relative changes Percentage 400 350

19 Summary Significant improvements in function, strength and reduction of spasticity Patients profit more from ABA than BAB Patients in low remission phases seem to profit more in improvement of spasticity and functional outcome and necessity for nursing care The wide range of remission phases and clinical pictures with relative low numbers of patients reduce the reliability of the data.

improvement of spasticity and functional outcome and necessity for nursing care The wide range

20 Follow-up Lokomat Study Demographic data Eligible patients: 179 Allocated patients: 74 (withdrawn patients group1: 1; group 2: 6) Completed trial: - group 1: 36 - group 2: 31 Training strategies: each 8 weeks - Lokomat group (group 1): conv. PT plus ad-on Lokomat training (45 min each) - Control group (group 2): conv. PT plus conv. PT with special focus on walking (45 min each)

Training strategies: each 8 weeks - Lokomat group (group 1): conv.

21 modified Emory Functional Ambulatory Categories (mefap): Sumscore large correlation between week 2 and week 8 in group 1 (r=0.72**) and in group 2 (r=0.68**) Sumscore Seconds ** ** ** ** ** bend ** bl w2 w4 w6 w8 Time of assessment group 1 group 2

22 Interpretation The Lokomat training seems to be an equal strategy in comparison to conventional phyiscal therapy power calculation: a 20%-improvement assumption for the new strategy seem to be too high too little attention to loading in the Lokomat group in later phases of the training little variety during training on the Lokomat The outcome with the Lokomat seems to be better if the patient is trained with the assigned physical therapist Training with the Lokomat should start earlier in the rehabilitation process The Lokomat group seems to develop a better and earlier walking ability than standing balance ( If you want to walk, you have to walk ) The left hemispheric lesioned patients (aphasic) seems to profit more from the Lokomat training then the patients with right hemispheric lesion How technically sophisticated must Robotics be in order to be effective in neurorehabilitation?

23 Armor System

24 Resistance measurement

25 Strength measurement

26 Mayr/Kofler/Saltuari ARMOR: An Electromechanical Robot for Upper Limb Training Following Stroke. A Prospective Randomized Controlled Pilot Study, Handchir Mikrochir Plast Chir 2008;40: patients following stroke (2,4 m post stroke) 6 weeks following an AB-BA crossover-design A: ARMOR training B: EMG-NMES Outcome-Measures - Chedoke-McMaster - mod. Ashworth Scale - ROM - Dynamometry - Functional Dexterity Test

27 Armor Study Design prospective, randomized, single-blinded study with 40 patients Baseline 2 Wochen Design Follow up 3 Monate Studienbeginn Trainingsbeginn Trainingsende Studienende Spontanremission Training Woche 1 Follow-up Training Woche 2 Training Woche 3 Training Woche 4

28 Armor Intervention Control Intervention PT PT PT ET Arm Arm 30 ET 15 ET Armor Armor total 90 90

29 Vergleich der Widerstände im Ellenbogen über die Geschwindigkeit Kontrolle &Intervention KG IG Widerstandsreduktion bei der Intervention Widerstandszunahme bei dem Patienten der KG

30 Vgl. Resistance elbow Intervention - Kontrolle Resistance elbow - Kontorllgruppe ,9 11,07 10,5 8 [N] 6 Bl 5M 4 2 1,09 0,77 1,8 0 elbow 10 deg/s elbow 40 deg/s elbow 175 deg/s Resistance elbow [ /s] - Interventionsgruppe 20 18, ,5 [N] 10 8 Bl 5M 6 4 3,6 4,8 3,83 2 1,92 0 elbow 10 deg/s elbow 40 deg/s elbow 175 deg/s

31 Amadeo System

34 Amadeo Study Design

35 Amadeo Intervention prospective, randomized, single-blinded study with 40 patients Amadeo I Amadeo II Control PT ET Amadeo 30 active 30 passive 30 PMR total

36 Strength Control (PMR) Amadeo Strength Flex Ex Newton Strength Flex Ex week5 endtraining followup week4 Newton baseline starttraining week3 week4 week5 endtraining followup baseline starttraining week3

37 Resistance Control (PMR) Amadeo Resistance Slow Moderate Fast Newton Resistance Slow Moderate Fast endtraining followup week4 week5 Newton baseline starttraining week3 week4 week5 endtraining followup baseline starttraining week3

38 Action Research Arm Test (ARAT) Control (PMR) Amadeo ARAT ARAT Score 30 Score baseline starttraining week3 week4 week5 endtraining followup 0 baseline starttraining week3 week4 week5 endtraining followup

39 Conclusion The preliminary data show a reduction of muscle tone and increased range of motion in the ARMOR training group Dexterity is improved, but not on a statistical level in the ARMOR pilot study The present data are insufficient in the AMADEO study Robotic treatment is well accepted by the patients and increases their motivation in rehabilitation BUT: Robotic devices should be understood as assistants, which cannot replace therapists

40 The final data will be presented in 2010 at the World Congress in Vienna, where one of the main topics will be Robotics!

41 Vergleich der Widerstände im Handgelenk über die Geschwindigkeit Kontrolle & Intervention KG IG Widerstandszunahme bei dem Patient der Interventionsgruppe Gleichbleibender Widerstand bei dem Patienten der Kontrollgruppe

The Use of the Lokomat System in Clinical Research

International Neurorehabilitation Symposium February 12, 2009 The Use of the Lokomat System in Clinical Research Keith Tansey, MD, PhD Director, Spinal Cord Injury Research Crawford Research Institute,