How do I integrate a step function

Robotics in Rehabilitation

The use of robotics in rehabilitation is currently being discussed very critically. Is it worth buying and maintaining these expensive devices? What are the benefits and what are the chances? Who benefits from which devices? Will the therapist be replaced by robotics or do robot-assisted devices relieve the therapist at work?


Electromechanical devices or robot-assisted devices have become an indispensable part of modern rehabilitation. They have long had their place in both gait and arm rehabilitation. Almost every rehabilitation clinic in Switzerland maintains robot-assisted devices as prestige objects, even if their use is not undisputed. What benefits and what opportunities do these devices offer? How can robot-assisted devices be integrated into everyday clinical practice? These questions are explained in this article using the example of gait rehabilitation.

Types of robot-assisted devices

There are basically two types of robot-assisted devices:

  1. Exoskeleton: External skeleton, which is attached directly from the outside to the respective extremity
  2. End effector: the last link of a kinematic chain (for example the foot or the hand) is moved by means of a footplate or handle


A distinction is also made between stationary and mobile devices (so-called wearable robots), although the latter has not yet been able to establish itself in everyday clinical practice in the field of neurorehabilitation. The reasons for this are that this technology already requires a good balance system as well as good coordination, which is limited in many patients with neurological disease. In addition, these systems often require a long preparation time, which is lost to the effective therapy time.

Overview of robot-assisted devices and their evidence

Standing board with step function (e.g. Erigo®)
Even patients who are still wakeful and severely impaired in their sensorimotor system can benefit from the gradual verticalization [1, 2].
Early mobilization with Erigo is not superior to mobilization with a conventional standing board [3], although there are indications that the step function is beneficial in circulatory disorders, so that standing becomes more tolerable [2, 4].

Robot-assisted gait therapy (RAGT)
Patients who are unable to walk can train to walk while relieving their weight, using an exoskeleton or footplates to enable step movements. In addition, depending on the device, knee braces can be fitted if there is no knee control. Robot-assisted gait trainers support the patient as much as is necessary to get into function. There is moderate evidence that electromechanical gait training in combination with physiotherapy improves independent walking ability. Every seventh non-ambulatory patient could benefit from this offer [5].

Overground weight relief systems (OBWSS) (e.g. LiteGait® / Andago® / Float®)
There are now various weight relief systems that enable walking or balance training in everyday life. They support the patient in gait and balance training so that they can train everyday situations, such as climbing over obstacles / steps, without the risk of falling. A distinction is made between stationary (e.g. Vektor®, Float®) and mobile systems (e.g. LiteGait®, Andago® etc.). Stationary body weight support systems allow free movement through 360 ° in space, while mobile systems have the advantage that the patient can move from room to room. There is evidence that additional gait training with weight relief promotes independent walking in patients who have had a subacute stroke [6].

Treadmill
Treadmill training (with and without weight relief) is particularly suitable for patients who are already able to walk (Functional Ambulation Category (FAC) 3) to improve walking speed and endurance [7].

Robot-Assisted Arm Therapy (RAAT)
Various technologies are available for robot-assisted arm training (e.g. ArmeoPower®, ArmeoSpring®, Amadeo®, Diego, BI-MANU-Track®), which emphasize the patient from passive to assistive, proximal or distal, unilateral or bilateral, selective or support complex, stationary or mobile. In particular, patients in the first three months after a stroke seem to benefit in terms of everyday performance, arm function and arm strength [8, 9]. It remains to be seen which device is best suited for which patient group [10].

Benefits and opportunities of robot-assisted devices

An important goal in rehabilitation is to regain lost functions. Here, robot-assisted devices support and relieve both the patient and the therapist, so that intensive repetitive training can be carried out at the respective performance limit of the patient. Especially for severely affected patients, such as after amputation, this form of training opens up new perspectives, since the systems serve to relieve weight and can replace lost functions, whereby the therapist is also physically relieved. In addition, weight-relieving systems offer safety for patient and therapist and reduce the risk of falling, so that the patient can explore his limits and benefit from the training. Thanks to the integration of feedback systems or virtual reality, many patients find the training motivating, stimulating and entertaining. Electromechanical or robot-assisted devices thus have a supportive, relieving and complementary effect, so that the most intensive, goal-oriented and efficient training possible can take place.

Motor learning and robot-assisted devices

As early as 1996, Nudo was able to demonstrate that apes with induced strokes needed around 600 repetitions in order to regain lost functions and thus promote neuroplasticity in terms of cortical reorganization [11, 12]. Observational studies in the field of neurorehabilitation show that the intensity within a therapy deviates far from the number of recommended repetitions [13]. As early as 2003 [14] it could be shown that with treadmill training with weight relief up to 1000 steps were possible for 20 minutes, while with conventional therapy (neurophysiological approach) only 50-100 repetitions were performed. It is now accepted that the intensity of therapy has a direct impact on the outcome [15]. In addition to the intensity, another factor for motor learning is the task specificity [16]. This is how Stefan Hesse coined the saying: "If you want to learn to walk, you have to go." The only question is which patient will benefit best from which robot-assisted device.

When is which device used in the rehabilitation clinic in Bellikon? A summary table for gait rehabilitation with devices

Based on the guideline of the German Society for Neurology (DGN) and on systematic reviews [5, 7], an overview of gait rehabilitation was created that serves both therapists and medical professionals as a basis for decision-making. The starting point is the patient's current ability to walk, which is determined using the Functional Ambulation Category (FAC). The acquisition of the FAC is very simple, quick and precise.

Conclusion

For the therapist, the robot-assisted gait therapy represents a complementary service, which on the one hand offers physical relief so that the therapist can focus on qualitative aspects of the therapy. On the other hand, particularly with robotics, highly repetitive training is made possible. The patients are usually highly motivated and appreciate the use of the equipment, as it allows them to train at their personal limits without worry, often directly
Receive feedback on their performance and experience the playful training as varied.

bibliography

  1. Frazzitta, G., et al., Safety and Feasibility of a Very Early Verticalization in Patients With Severe Traumatic Brain Injury. J Head Trauma Rehabil, 2015. 30 (4): p. 290-2.
  2. Taveggia, G., et al., Robotic tilt table reduces the occurrence of orthostatic hypotension over time in vegetative states. Int J Rehabil Res, 2015. 38 (2): p. 162-6.
  3. Krewer, C., et al., Tilt Table Therapies for Patients with Severe Disorders of Consciousness: A Randomized, Controlled Trial. PLoS One, 2015. 10 (12): p. e0143180.
  4. Luther, M.S., et al., Comparison of orthostatic reactions of patients still unconscious within the first three months of brain injury on a tilt table with and without integrated stepping. A prospective, randomized crossover pilot trial. Clin Rehabil, 2008. 22 (12): p. 1034-41.
  5. Mehrholz, J., et al., Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev, 2017. 5: p. CD006185.
  6. Brunelli, S., et al., Early body weight-supported overground walking training in patients with stroke in subacute phase compared to conventional physiotherapy: a randomized controlled pilot study. Int J Rehabil Res, 2019. 42 (4): p. 309-315.
  7. Mehrholz, J., S. Thomas, and B. Elsner, Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev, 2017. 8: p. CD002840.
  8. Mehrholz, J., et al., Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev, 2018. 9: p. CD006876.
  9. Veerbeek, J.M., et al., Effects of Robot-Assisted Therapy for the Upper Limb After Stroke. Neurorehabil Neural Repair, 2017. 31 (2): p. 107-121.
  10. Mehrholz, J., et al., Systematic review with network meta-analysis of randomized controlled trials of robotic-assisted arm training for improving activities of daily living and upper limb function after stroke. J Neuroeng Rehabil, 2020. 17 (1): p. 83.
  11. Nudo RJ, et al., Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. Journal of Neuroscience, 1996. 16 (2): p. 785-807.
  12. Nudo RJ, et al., Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science, 1996. 272: p. 1791-1794.
  13. Lang, C.E., et al., Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil, 2009. 90 (10): p. 1692-8.
  14. Hesse, S. and C. Werner, Poststroke motor dysfunction and spasticity: novel pharmacological and physical treatment strategies. CNS Drugs, 2003. 17 (15): p. 1093-107.
  15. Schneider, E.J., et al., Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review. J Physiother, 2016. 62 (4): p. 182-7.
  16. French, B., et al., Does repetitive task training improve functional activity after stroke? A Cochrane systematic review and meta-analysis. J Rehabil Med, 2010. 42 (1): p. 9-14.

 

Correspondence address

Stephanie Hellweg | Specialist in physiotherapy, neurological rehabilitation
MSc Neurorehabilitation, MSc ZFH Physiotherapy, Dipl. Physiotherapist
Bellikon Rehabilitation Clinic | 5454 Bellikon

[email protected]
Tel +41 56 485 56 83 | Fax +41 56 485 52 57

www.rehabellikon.ch