robótica y rehabilitación. dra. diane damiano

ROBOTICSANDREHABILITATION

DianeDamiano,PhDPTNa8onalIns8tutesofHealth

RehabDevicesforLocomotorTraining§  Harnessedtreadmillsorrobo8cgaittrainerscommoninrehabilita8oncenters

§  Goalistoprovidesteptrainingandprac8cethroughspecificsensoryinputsbytherapistorrobot;i.e.hipextension,plantarflexion

§  Expandedwhocouldprac8cegaitandhowmuch

•  Firstreporton10childrenwithCP;trained3mos.with0-40%BW;withsignificantgains

•  TraininginCPpriortothiswasmainlyNDT;nostrengtheningormotorlearningapproaches,sotreatmentmadesignificantgainsinGMFM

Body-WeightSupportedTreadmillTraining(Schindletal.,2000)

AsAmountofEvidenceIncreased

•  RCTsandsystema8creviewsindicatedtheseapproacheswereeffec8vewhencomparedtoNOTREATMENT,butnotbesuperiortoequallyintensealterna-ves

•  Whywerethesenotmoreeffec-veandhowcanweimproveonthese?

ShouldBodyWeight-SupportedTreadmillTraining&Robo8c-Assis8veSteppersforLocomotorTraining

TrotBacktotheStar8ngGait?

§  LEAPS:LocomotorExperienceAppliedPost-Stroke($21M)§  400+RCTcomparinggaitoutcomesat1yeayforBWSTT2&6mos.poststroketohomeexercise§  NODIFFERENCE!

.Dobkin&Duncan,NeurorehabNeuroRepair,2012

Sowearewenow?

W.ZRymer,2010“Theproblemisnotwiththerobots(devices),itswithus!”

Whyareresultsnotbeeer?

•  Devicestoohelpful?Assistancereducespa8enteffort

•  Trunksupportedtoomuch•  Supportreducesloading(strength)•  Rhythmtooregular(constantspeed)•  Availability&feasibilityissues:center

based,labor&cost-intensive;limitslengthanddura8onoftraining

ChildwithCPonRobo8cGaitDevice

NeurosciencePrinciplesforMOTORTRAINING

•  Trainingop8mallyshouldinclude:•  Self-ini8atedmovement&physicaleffort• Underlyingloosebutvariablerhythm(CPG)•  Sufficientprac8ceandintensity• Mentalengagement(cogni8veeffort)•  Involveerrorrecogni8onandcorrec8on• Bemeaningful&mo8va8ngtopa8ent

Otherexplana8onsforwhyresultsnotbeeer?(Rymer,2010)

§ Missed“therapeu8cwindow”§ Trainingnotintenseorlongenough?§ Need“combina8on”therapiestounleashbenefits?(e.g.usingbrains8mula8onduringtraining)

Whatisthe“therapeu8cwindow”incerebralpalsy?

•  GOODNEWS:Brain&musclesremainplas8cthroughoutlife;morepoten8alwhenyounger

•  NOTSOGOODNEWS:Mayloseopportuni8esbynotinterveningduringdevelopmentofcor8cospinaltract(windownarrowsquicklyin1styearoflifeforbrainRECOVERY)

NeurobiologyofCIMT

•  KITTENUnilateralCPmodel(Mar8n&Friel)•  3levelsofplas8city:SCinterneuronshaveearliestcri8calperiod(3-6mos);M1map,CSTtoSC.

“Dose”oftherapy

•  Intensitykeyfactorintreatmenteffec8veness,bothintensityofpa8enteffortand8meinprac8ce

•  60+hourseffec8veinupperlimbtraining•  Mostlowerlimbtrainingprogramsusemuch

lowerdosesanditmaynotbesufficient

Future:SmarterScien8sts§  Needstrongertheore8calbackgroundforrehabdevicesbasedonmotorlearningprinciplesandhowthesemay(not)differinbraininjuries

§  Mustcon8nuetoinves8gatemechanismsunderlyinggaitdisorderstodesignnoveltreatmentsanddevices

Future:SmarterClinicians•  Mustbemorecri8calconsumerssincetheyarethe

bridgefromsciencetofamily• Helpdecidewhentouseadeviceandwhichisbest(watchoutforbogusdevices)

• matchdeviceandpa8entcapabili8es• Recognizethatchangecomesfrompa8enteffort,notthedevice!

Future:SmarterDevices

•  Onesthatcanop8mallychallenge&progressusers,e.g.computerizedandVR-basedtrainingdevices

•  Devicesthatrespondtousers&adaptaccordingly:• Mobilitydevicesthatsensemovement“inten8on”oreaserequirements

Exampleofmakingtrainingmore“dynamic”§  Insteadofconstantspeed,weprogramrandomspeedchangesoraskpa8enttovoluntarilychangespeed.

§  VisualtargettoIncreaseengagement&brainac8vity§  Specialharnessprovidessafetybutlieletrunksupportorcontrol;increasesloadingandeffort.

Example2:“Smart”harness

Gracias / Thank you