1. Expanding Robotic-Assisted Gait Training into the Clinic: Use, Frequency, and Additional Considerations for this Technology as an Intervention Jennifer Steele, PT, NCS Kate Tobias, PT, NCS April 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??

6. The 4 W’s and the H
WHO do we use it for – population, off label uses, FDA approved uses
WHAT is robotics technology
WHEN do 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: Published 2017 May 15. doi: /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

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?
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 Neuroeng Rehabil. 2011;8:66.
Masiero S, Poli P, Rosati G, et al. The value of robotic systems in stroke rehabilitation. Expert Rev Med Devices. 2014;11(2):187–198.