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