Robotherapy
Monday May 14, 2012
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(Photo by Bud Glick, NYU Langone Medical Center)
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Robotic-assist rehabilitation devices are growing in popularity and offer the potential to care for neurological patients more safely with fewer people involved.
"By putting patients in robotic environments, we have full control; we can reduce the compensating strategies and work toward facilitating normal movement, and that’s so important along with reducing the risk of injuries," said John Feeley, PT, MS, a physical therapist at MossRehab in Philadelphia.
Therapists use robotic-assist devices with adults and children who have experienced a stroke, a spinal cord injury or a brain injury and those with cerebral palsy or another neurological condition.
"Using robotics as a tool for rehab, we are just breaking in to see the potential of how they can assist us to make our patients better," said Lauri Bishop, DPT, a research physical therapist at Columbia University Medical Center in New York City.
John Corcoran, PT, DPT, MS, Cert. MDT, director of inpatient therapy at Rusk Rehabilitation at NYU Langone Medical Center in New York City, added the use of robotic assist "is going to increase in the future because it’s a great opportunity to have another set of hands."
Despite therapists embracing the devices and more coming onto the market, research is limited.
"At this time, there are no devices shown to be better than the therapy [patients] would receive conventionally," said Edelle C. Field-Fote, PT, PhD, a professor at the University of Miami Miller School of Medicine and director of the Neuromotor Rehabilitation Research Laboratory at The Miami Project to Cure Paralysis. However, she said the devices can save therapists’ time and allow for measurement of impairment. If robotic-assist is not worse than traditional therapy, it may be cost effective, she said.
"The devices have to be able to make the person work in a way that is functionally meaningful, and not all of them do," Field-Fote said, adding some devices may not engage a patient’s nervous system.
An argument for robotic assist
Robotic devices offer more people the opportunity to start working their muscles earlier. Shepherd Center in Atlanta uses the Lokomat, a robotic-assisted walking device from Hocoma of Switzerland, as soon as patients are medically stable, even on a ventilator, and may continue using it as they progress to outpatient therapy.
"When people are so weak they cannot sit or roll or stand, the robotic mechanism of the Lokomat is the only way to get the person up and moving and handling the body against gravity because a manual treadmill is too tough on the staff," said Clare Hartigan, MPT, BSBio, a PT at the Shepherd Center.
Shepherd Center gets people up on a manual body-weight support treadmill system, but that takes four staff members, compared with one person with a Lokomat. The manual system may provide 15-20 minutes of stepping time in an hour session, compared with 40 minutes on a robotic-assist device.
"You can achieve a lot of the same things — the repetition, the stepping, the muscle memory, the strengthening, getting weight to their legs and effort by the patient — with less staff and reduced risk of injuries," Hartigan said.
Corcoran considers safety — for patients and therapists — one of the most important advantages of robotic devices. "You know [the patient is] accounted for, and the therapist can concentrate on other things like the quality of gait and cadence," he said.
Also, eliminating therapist fatigue associated with manual systems allows the patient to take more steps or to get more repetitions with an upper-extremity device, Feeley added.
Upper-extremity devices
Amadeo, a hand rehabilitation system from Tyromotion GmbH of Austria, for instance, enables patients to complete more repetitions than with manual therapy in the same amount of time, Bishop said.
The ReoGo from Motorika Medical of Trussville, Ala., facilitates repetitive arm movements as patients reach for a target or play a game on a computer screen. If they cannot reach the target, the machine will guide them. "You are getting correct feedback to the brain," Bishop said.
The mPower 1000 from Myomo in Cambridge, Mass., relies on patients having an active contraction and interacting with the technology.
"Once someone experiences movement, they learn movement," said Anne Jacobs, PT, PhD, SensoMotor Neurological Rehabilitation in Sonora, Calif., who uses Myomo mPower with chronic stroke survivors who have fixed deficits.
The mPower 1000 has come down in cost, so more clinics are adding the equipment, and a portable unit allows patients to continue their program at home and push past a plateau. "It’s something they can use for ongoing therapy," said Jacobs, who reported improved function, such as turning on lights or preparing meals, in patients who have experienced paralysis for more than five years.
Lower-extremity devices
Robotic devices, such as the Lokomat and the G-EO System from Reha Technology of Switzerland, benefit patients by increasing activity tolerance, reducing the risk of wounds and other complications associated with immobility, Feeley said.
"We have seen phenomenal results," Hartigan said. "We have had patients double their tidal volume from the first to the second session on the Lokomat. There is a lot of cardiovascular and respiratory benefit."
With Lokomat, therapists can adjust the amount of robotic assist. As the patient progresses, therapists can challenge them and target different muscle groups, Hartigan said.
Feeley said he finds the G-EO, a robotic-gait device with footplates, similar to an elliptical machine, and a harness system, helpful when working on ascending and descending stairs. "Stair training can be a very unsafe situation, requiring several people on the stairs," he said. Simulating stepping not only helps the patient gain function, but it also is safer for the therapist, he said.
ReWalk from Argo Medical Technologies of Israel enables people with lower-limb disabilities to ambulate and climb stairs while wearing the system’s brace support, computer and sensors and using forearm crutches. When Feeley initially gets patients up, a rehab aide operates a wristwatch that controls walking, standing and sitting and assists while the patient gains balance. Later, the patient learns to give the commands. Again, there is less risk of falling than if the therapist got the patient up with braces. Patients may begin using ReWalk even years after the injury.
"The Lokomat is an intervention for recovery, and ReWalk is an adaptive device for walking," Feeley explained.
The Tibion Bionic Leg from Tibion Corp. in Sunnyvale, Calif., designed for patients recovering from a stroke, controls the knee and prevents buckling so patients can walk in a more natural pattern, stand from a chair or transfer. Some studies indicate patients maintain some of the improvements after removing the Tibion device, Corcoran said.
"It allows you to walk and put weight on the affected leg," Bishop said. "It is essentially a second set of hands. I can focus on the gait pattern."
Some centers have said lower-body robotic-assist devices take too much time to set up. Shepherd and Rusk solved that by training certain therapists as Lokomat experts or primary users who are able to set up patients in about 10-15 minutes.
"Until you get a lot of experience or [if you] don’t use it all of the time, it can be time consuming," Hartigan said.
Robotic-assist as a tool
Robotic-assist devices represent one component of a comprehensive physical therapy plan. Patients may use the robotic device once or several times a week, interspersed with other modalities. "These devices are designed to get more isolated motion and more functional motion," Corcoran said. "These are a great tool for the patients and for the therapist."
Robotic devices expand the scope of what a therapist can do with the patient. "Therapists don’t have to worry about job security," Corcoran said. "If anything, it will increase the demand for therapists because these patients who have had conditions for many years will be coming back to use these devices to improve their function." •
Debra Wood is a freelance writer.
"By putting patients in robotic environments, we have full control; we can reduce the compensating strategies and work toward facilitating normal movement, and that’s so important along with reducing the risk of injuries," said John Feeley, PT, MS, a physical therapist at MossRehab in Philadelphia.
Therapists use robotic-assist devices with adults and children who have experienced a stroke, a spinal cord injury or a brain injury and those with cerebral palsy or another neurological condition.
"Using robotics as a tool for rehab, we are just breaking in to see the potential of how they can assist us to make our patients better," said Lauri Bishop, DPT, a research physical therapist at Columbia University Medical Center in New York City.
John Corcoran, PT, DPT, MS, Cert. MDT, director of inpatient therapy at Rusk Rehabilitation at NYU Langone Medical Center in New York City, added the use of robotic assist "is going to increase in the future because it’s a great opportunity to have another set of hands."
Despite therapists embracing the devices and more coming onto the market, research is limited.
"At this time, there are no devices shown to be better than the therapy [patients] would receive conventionally," said Edelle C. Field-Fote, PT, PhD, a professor at the University of Miami Miller School of Medicine and director of the Neuromotor Rehabilitation Research Laboratory at The Miami Project to Cure Paralysis. However, she said the devices can save therapists’ time and allow for measurement of impairment. If robotic-assist is not worse than traditional therapy, it may be cost effective, she said.
"The devices have to be able to make the person work in a way that is functionally meaningful, and not all of them do," Field-Fote said, adding some devices may not engage a patient’s nervous system.
An argument for robotic assist
Robotic devices offer more people the opportunity to start working their muscles earlier. Shepherd Center in Atlanta uses the Lokomat, a robotic-assisted walking device from Hocoma of Switzerland, as soon as patients are medically stable, even on a ventilator, and may continue using it as they progress to outpatient therapy.
"When people are so weak they cannot sit or roll or stand, the robotic mechanism of the Lokomat is the only way to get the person up and moving and handling the body against gravity because a manual treadmill is too tough on the staff," said Clare Hartigan, MPT, BSBio, a PT at the Shepherd Center.
Shepherd Center gets people up on a manual body-weight support treadmill system, but that takes four staff members, compared with one person with a Lokomat. The manual system may provide 15-20 minutes of stepping time in an hour session, compared with 40 minutes on a robotic-assist device.
"You can achieve a lot of the same things — the repetition, the stepping, the muscle memory, the strengthening, getting weight to their legs and effort by the patient — with less staff and reduced risk of injuries," Hartigan said.
Corcoran considers safety — for patients and therapists — one of the most important advantages of robotic devices. "You know [the patient is] accounted for, and the therapist can concentrate on other things like the quality of gait and cadence," he said.
Also, eliminating therapist fatigue associated with manual systems allows the patient to take more steps or to get more repetitions with an upper-extremity device, Feeley added.
Upper-extremity devices
Amadeo, a hand rehabilitation system from Tyromotion GmbH of Austria, for instance, enables patients to complete more repetitions than with manual therapy in the same amount of time, Bishop said.
The ReoGo from Motorika Medical of Trussville, Ala., facilitates repetitive arm movements as patients reach for a target or play a game on a computer screen. If they cannot reach the target, the machine will guide them. "You are getting correct feedback to the brain," Bishop said.
The mPower 1000 from Myomo in Cambridge, Mass., relies on patients having an active contraction and interacting with the technology.
"Once someone experiences movement, they learn movement," said Anne Jacobs, PT, PhD, SensoMotor Neurological Rehabilitation in Sonora, Calif., who uses Myomo mPower with chronic stroke survivors who have fixed deficits.
The mPower 1000 has come down in cost, so more clinics are adding the equipment, and a portable unit allows patients to continue their program at home and push past a plateau. "It’s something they can use for ongoing therapy," said Jacobs, who reported improved function, such as turning on lights or preparing meals, in patients who have experienced paralysis for more than five years.
Lower-extremity devices
Robotic devices, such as the Lokomat and the G-EO System from Reha Technology of Switzerland, benefit patients by increasing activity tolerance, reducing the risk of wounds and other complications associated with immobility, Feeley said.
"We have seen phenomenal results," Hartigan said. "We have had patients double their tidal volume from the first to the second session on the Lokomat. There is a lot of cardiovascular and respiratory benefit."
With Lokomat, therapists can adjust the amount of robotic assist. As the patient progresses, therapists can challenge them and target different muscle groups, Hartigan said.
Feeley said he finds the G-EO, a robotic-gait device with footplates, similar to an elliptical machine, and a harness system, helpful when working on ascending and descending stairs. "Stair training can be a very unsafe situation, requiring several people on the stairs," he said. Simulating stepping not only helps the patient gain function, but it also is safer for the therapist, he said.
ReWalk from Argo Medical Technologies of Israel enables people with lower-limb disabilities to ambulate and climb stairs while wearing the system’s brace support, computer and sensors and using forearm crutches. When Feeley initially gets patients up, a rehab aide operates a wristwatch that controls walking, standing and sitting and assists while the patient gains balance. Later, the patient learns to give the commands. Again, there is less risk of falling than if the therapist got the patient up with braces. Patients may begin using ReWalk even years after the injury.
"The Lokomat is an intervention for recovery, and ReWalk is an adaptive device for walking," Feeley explained.
The Tibion Bionic Leg from Tibion Corp. in Sunnyvale, Calif., designed for patients recovering from a stroke, controls the knee and prevents buckling so patients can walk in a more natural pattern, stand from a chair or transfer. Some studies indicate patients maintain some of the improvements after removing the Tibion device, Corcoran said.
"It allows you to walk and put weight on the affected leg," Bishop said. "It is essentially a second set of hands. I can focus on the gait pattern."
Some centers have said lower-body robotic-assist devices take too much time to set up. Shepherd and Rusk solved that by training certain therapists as Lokomat experts or primary users who are able to set up patients in about 10-15 minutes.
"Until you get a lot of experience or [if you] don’t use it all of the time, it can be time consuming," Hartigan said.
Robotic-assist as a tool
Robotic-assist devices represent one component of a comprehensive physical therapy plan. Patients may use the robotic device once or several times a week, interspersed with other modalities. "These devices are designed to get more isolated motion and more functional motion," Corcoran said. "These are a great tool for the patients and for the therapist."
Robotic devices expand the scope of what a therapist can do with the patient. "Therapists don’t have to worry about job security," Corcoran said. "If anything, it will increase the demand for therapists because these patients who have had conditions for many years will be coming back to use these devices to improve their function." •
Debra Wood is a freelance writer.
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Monday May 14, 2012