TECHNOLOGIES FOR ENHANCING MOVEMENT THERAPY AND COMBINATION THERAPIES

Reinkensmeyer and Boninger

Overview

Rationale Analysis of current state of the field Promising directions for technology-

enhanced therapy – European insights Combination therapies

Defined as strategies that combine drug or cell-based therapeutics with technology for therapy

Conclusions

Rationale – “the theory”

There is use-dependent plasticity in almost all motor system injuries and diseases

Technology has the potential to allow: More therapy with less supervision Better quantification of therapy and its

outcomes New types of therapy, improving outcomes

State of the Field – “the practice”

Rapid growth of technology for therapy

However, results are mixed, picture unclear Three examples from robot-assisted therapy

Estimate of number of articles on robotic therapy devices, as a function of year (from Marchal et al. JNER 2009)

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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Lokomat Systems Erigo Armeo Spring Armeo Boom

Sales of therapeutic technology by Hocoma A.G.

State of the Field – “the practice”

VA MIT-MANUS study (Lo et al., NEJM 2010)

Chronic stroke patients, n = 127 Robot-assisted therapy is about as effective

as dose-matched, intense therapist-delivered training

However, effect size was small (~3 Fugl-Meyer points)

Surprisingly, cost of delivery was similar

State of the Field – “the practice”

Lokomat stroke study (Hornby et al. Stroke 2008)

Chronic stroke patients, n = 48, ambulatory at study start

Training with the Lokomat was less effective than therapist-delivered training

Perhaps due to patient slacking

State of the Field – “the practice”

T-WREX/ARMEO Study Chronic stroke patients, n = 28 (Housman et al.

2009 NNR)

After 1 week of training, patients achieved 60 minutes of therapy with 4 minutes of therapist supervision

Patients much preferred training Therapy was marginally more effective than

conventional, self-supervised training

Comparing “theory” with “practice”

There is use-dependent plasticity in almost all motor system injuries and diseases

Technology has the potential to allow: More therapy with less supervision

But machines can be expensive, limiting cost-benefit X Better quantification of therapy and its outcomes

New science emerging, therapy with technology more motivating

New types of therapy improving outcomes X? In many cases, technology is equal or even inferior to

conventional training

Promising directions for technology-enhanced therapy: European insights

Earlier after injury Lower cost devices Incorporating BCI’s Wearable robots More degrees of freedom Improved feedback and control Integrated approach of Charité Hospital Computational modeling

TECHNOLOGY FOR EARLY MOBILIZATION AFTER STROKE: NEREBOT

Giulio Rosati, University of Padua

Etienne Burdet, Imperial College

LOWER COST DEVICES

Herman van der Kooij, Biomechanical Engineering

University of Twente

Less constrained robotic lower limb trainer

Investigate coupling between paretic and not paretic joint

Combination of exoskeletal walker and EEG/EMG control to substitute for walkingINCORPORATING BCI’S AND MORE DOFS

INCORPORATING BCI’S: HTTP://WWW.IAI.CSIC.ES/BETTER/

Prof. Jose Pons, Madrid BETTER Project

WEARABLE ROBOTS

Prof. Jose Pons, Madrid BETTER Project

Scuola Superiore Sant’Anna

Multiple degree of freedom elbow exoskeleton for rehabilitation

Constrained degrees of freedom impairs rehabilitation

MORE DOF

Schmidt, Fraunhofer Institute, Hesse, Charité Hospital, Berlin

MORE DOF + BETTER CONTROLLER

ISIR Paris/Garches/CEA/Roby-Brami/Morel

Multiple degree of freedom exoskeleton for rehabilitation

MORE DOF

Hocoma, Zurich

MORE DOF: LOKOMAT

With university collaborators, Hocoma is adding the following enhancements to the Lokomat:

• Active actuation of the ankle joint.• Frontal plane trunk and pelvis

motion (more physiological than sagittal plane motion alone).

• Force rather than position control of joints.

Orthopaedic rehabilitation viewed as a potentially big future market.

ETH Zurich

BETTER FEEDBACK (SHOW VIDEO)

VIRTUAL REALITY + ROBOTICS

AALBORG UNIVERSITY, DENMARK

NEW CONTROL STRATEGIES: ADAPTIVE ASSISTANCE

U. Genoa, Morasso, Masia, Sanguineti

Robot-therapy of hemiparetic patients, with a minimally assistive & progressively decreasing strategy for tracking movements

INTEGRATED APPROACH

Charité Hospital, Hesse, Berlin

Modeling motor learning due to interactions between humans and robots

We saw very little work focused on modeling learning in response to robot-assisted therapy

However, one model seems quite significant for predicting response to therapeutic robot forces

MODELING HUMAN-ROBOT INTERACTIONProf. Etienne Burdet, Imperial College, London

Modeling interaction forces between humans and robots

SPINAL MAPS

Prof. Silvestro Micera, Pisa and Zurich

Monaco et al., J Neurophysiol, 2010

Use spinal maps to identify how rehabilitation modifies muscle coordination in specific patients (e.g., stroke).

Combination therapies

Defined as strategies that combine drug or cell-based therapeutics with technology for therapy

Arguably, this is the future of rehabilitation therapy

Focus in context of NSF/WTEC study: Is there an important role for technology to play

in the development of combination therapies? Is there a scientifically interesting interaction

between the training and the drug- or cell-based therapy?

THERAPY+ PLASTICITY TREATMENT

Prof. James Fawcett, Cambridge

Therapy + Plasticity Treatment

Chondroitinase ABC is a bacterial enzyme that digests molecules that form cartilage-like barriers to axonal growth

Chondroitinase without training is not very effective

Therapy + Plasticity Treatment

Specific forelimb reaching rehabilitation (1 hour/day) with chondroitinase leads to a dramatic recovery of forelimb function

Therapy + Plasticity Treatment

General environmental enrichment (1 hour/day) makes animals worse at skilled paw reaching

Therapy + Plasticity Treatment

Plasticity treatment induces sprouting; rehabilitation prunes and connects

Enhancing one form of behavior can impact negatively on the learning of other behaviors

What does this mean for rehabilitative technology? Technologies may provide control over which

functions are reprogrammed, given the limited new potential of the restored network

Need technology and models for understanding capacity of new sprouting

Conclusions

There is rapid growth in new technologies for rehabilitation therapy

We are in a sort of second phase in which there are many approaches to make this technology better

However, there is still very little scientific insight into how technology can best promote plasticity

Significantly, there will be a “science of combination therapies”. It will be important to base technological design on this science.