Objectives

1. Expanding Robotic-Assisted Gait Training into the Clinic: Use, Frequency, and Additional Considerations for this Technology as an InterventionJennifer Steele, PT, NCS Kate Tobias, PT, NCSApril 26, 2019

2. Objectives • Improve awareness of use of robotic gait interventions for the stroke and brain injured populations • Expand on benefits of focused work on various aspects of the gait cycle with use of robotics, particularly stance control and intensity opportunities during gait • Additional clinical considerations for treatment with use of robotics for gait

3. Disclosures • Nada • Zip • Zero • None

4. What do Neuro Therapists do… • We gait train at high intensity • We complete intensive neurological movement re-education • Coordination training • Motor sequencing and task sequencing • Activation timing • We guide intensive strength and cardio training • We promote dual-task training

5. A Robot?...For Therapy?? https://www.medgadget.com/2016/04/ekso-gt-robotic-exoskeleton-cleared-for-stroke-rehab-spinal-cord-injuries.html https://exoskeletonreport.com/product/ekso-gt/

6. The 4 W’s and the H • WHOdo we use it for – population, off label uses, FDA approved uses • WHATis robotics technology • WHENdo I use technology for neuroplasticity • WHY do we want to use technology for neuroplasticity • HOW do we use technology for neuroplasticity

7. The Who • Who do we use it for – population, off label uses, FDA approved uses • By Diagnosis: • Stroke • Spinal Cord Injury • Can it be used for: • Multiple Sclerosis • Parkinson’s • Traumatic Brain Injury • Complex medical presentations

8. The Who • By Impairment/Physical Presentation • Hemi- or paraparesis • Spasticity management • Midline Alignment, weight shift impairment • Neglect/Inattention • Ataxia, coordination impairments • Motor timing impairment, synergy patterns • Festination • Global deconditioning, leg/trunk weakness

9. The What • What is this robotics technology?

10. Currently available: • Ekso GT, Gait Trainer, G-EO, Lokomat, Bionic Leg, eLEGS, ReWalk, and REX • Prototypes not yet available commercially: Lopes, Lopes 2, Knexo, Alex, Mindwalker, VanderBilt Exoskeleton, Hercule, i-Walker, Walkbot, Walk Assist Robot, Honda’s walking assist device, Anklebot, and Indego

11. Each brand offers its own unique way to support training goals • Weight shift sensors – provide real-time feedback • Movement initiation • Motor assist allows for increasing intensity of training** • This is a big one, gives therapist and patient time and repetitions needed to achieve actual motor learning • Varied “Free” options promote Proprioception/coordination training

12. The When • When do I use technology for neuroplasticity • Maximizing reps • Promote earlier initiation of therapy • When we “need more hands” • Isolate one area of mechanics • Stabilize everything else to address one area • To provide another learning “environment” • Those maxed on traditional efforts

13. A walking robot as a modality? • Morone G, Paolucci S, Cherubini A, et al. Robot-assisted gait training for stroke patients: current state of the art and perspectives of robotics. Neuropsychiatr Dis Treat. 2017;13:1303-1311. Published 2017 May 15. doi:10.2147/NDT.S114102

14. 6 determinants of gait • Pelvic rotation • Pelvic tilt/Obliquity • Knee flexion at stance phase • Foot and ankle motions • Knee motion • Lateral pelvic displacement

15. The Why • Why do we want to use technology for neuroplasticity versus something else • Because the research says it works! • Research supports robotics as a modality that promotes earlier rehab, more intensive rehab, and that task-specific training. • Research article • Research ongoing regarding improvement in outcome measures (i.e. TUG, gait speed) • Research shows that other technology modalities can achieve similar outcomes, but clinically they are harder to replicate • Research article

16. The Why • Why do robots make neuroplasticity training easier? • Motor adaptability allows for… • Earlier intervention • Whether cardio, strengthening, task specific training • Greater adaptability for patient specific intensity levels • Provides real time feedback for motor correction • Emphasizes problem solving • Provides sensory feedback for normal movement patterns • Creates multi-sensory stimulation

17. Robot vs. Human Are we just running a robot that does the work for us? Or Are we therapists that use a robot as a tool to more optimally support the skilled training and education we provide as licensed therapists?

18. The How:How do robotics support therapy? • Robotics are simply another tool to help therapists get the job done. • Therapist skills: • Clinical Assessment – visual and tactile • Clinical Judgement • Clinical Decision Making • Cueing techniques – physical, visual, verbal, auditory • Tools help us to deliver this skill-set • Treadmills, harnesses, weight machines, robots, electrical stimulation, our hands

19. The How: “It’s not the mask, but the man behind the mask”

20. Our Clinical “How” • Identify appropriate candidates • Measure for fit • Initial session of standing • Progression through optimal mode identification for area of focus • Training mixed with integration carryover • CPT Coding

21. Frequency and duration • How do we use technology for neuroplasticity • 10-12 sessions • 2 x per week care plan • 1 x per week in EKSO • For focused motor planning/emphasis work • Cardiovascular • Motor retraining/neuromuscular re-education • Strength training in functional context • Push off/weight shifting/initial swing/terminal swing-> gait mechanics • 1 x per week clinical visit • For integration and carryover • Working with primary therapist with direct communication on areas of difficulty noted • Can go both ways – primary notes area of opportunity to work on, EKSO identifies area to work on .

22. WHERE • Courage Kenny Locations • United Hospital (IP and OP) • Abbott Northwestern (IP and OP) • Golden Valley (TRP and OP) • Stillwater (OP)

23. Thank You!

24. References • Belda-Lois JM, Mena-del Horno S, Bermejo-Bosch I, et al. Rehabilitation of gait after stroke: a review towards a top-down approach. J NeuroengRehabil. 2011;8:66. • MasieroS, Poli P, Rosati G, et al. The value of robotic systems in stroke rehabilitation. Expert Rev Med Devices. 2014;11(2):187–198.