1. Jenny Wang, PT, DPT, MS Swedish Medical Center Englewood, CO

2.  Discuss how robotics can enhance training, learning, and rehabilitation goals.  Selecting appropriate patients and outcome measures.

3.  Class of robots that can integrated into rehabilitation programs at home, in health care settings, at work, or in the community to enhance function.  Integrated as a tool to enhance the effectiveness of one on one therapy to promote recovery, independence, and maximal function.

4.  Learning based robotic systems include virtual reality, games for memory, and technology to improve physical performance  Enables patient to perform quality controlled, repetitive, progressive, task- oriented practice to improve learning  Bioness systems  Tibion Bionic leg

5.  Can be classified as non-wearable or wear- able

6. Robotic exoskeleton placed on patient’s leg during training.

7.  Provides mechanized assistance for patient initiated active movement  Flexible plantar pressure-sensing shoe insert  Loose fitting plastic ankle straps attaching the shoe insert without providing ankle support  Leg and thigh uprights  Single axis knee joint with angle sensors  Textile straps secured with zippers  Velcro and adjusting knobs  Onboard actuator motors with control panel housing  Rechargeable lithium battery

8.  Plantar pressure sensors detect gait phases through weight bearing  Angle sensors detect knee motion angles  Actuator torque sensors determine knee torque

9.  Maximizes neural plasticity and recovery of motor control, sensation, and physical skills through controlled, progressive repetition  Improves endurance, quality of movement, more complete task performance, independence, and quality of life  Task specific training focused on functional tasks like transfers, gait training, and stairs

10.  During stance phase, stair climbing, and sit>stand movements, knee actuator assists knee concentric extension.  During toe off and non-weight bearing conditions, actuator decouples and allows for free knee swing.  Patient initiated knee extension with weight bearing triggers mechanically assisted knee extension based on programming.  Resistance and timing parameters can be set by P.T. based on patient performance.

11.  Weight: 110-300 lbs.  Start force: weight on foot plate required to initiate powered assist  Assist factor: amount of knee extension assistance provided (concentric)  Resist factor: amount of knee extension assistance provided during flexion (eccentric)  Assist extension limit: degree of extension through which assistance is provided. Helps limit knee hyperextension when present

13.  Patient population:  Comprehensive Rehab unit (amputees, orthopedics/multi-trauma)  CVA*  Brain tumors  SCI  TBI  MS  PD

14.  Patient motivation  Physical/cognitive ability to use and follow multi-step directions  Height  Stroke patients with the most consistent outcomes

15.  59 yo female  Medical history: L pontine and cerebellar ischemic infarcts, basilar artery thrombosis s/p TNK and stent angioplasty  Past medical history: R femur fracture s/p IM nailing from auto accident 30 yrs ago, dyslipidemia, pre-HTN, migraines  Premorbid functional status: Independent with functional mobility and ADLs, working full time as dental assistant  Discharged from rehab unit after 4 weeks with supervision/assistance from family

16.  Impairments: Mobility and Strength  Bed mobility: Minimal assistance  Transfers: Minimal-Moderate assistance  Gait: Ambulate 2 steps forward w/out UE support, Min-Max Assist for balance and R foot placement. Trendelenburg and Genu Recurvatum on RLE.  Right leg strength Hip flexion 2-/5 Knee flexion 2-/5 Knee extension 2-/5 Dorsiflexion 0/5

17.  Functional status: bed mobility, transfers, gait, stairs  Five time sit to stand  Body structure and function Domain of ICF model of disability  Measures: Lower limb strength and function Balance and mobility Predictor of recurrent falls General test of physical performance  Correlates with DGI, TUG, Gait speed, BBS

18.  Gait speed  Activity Domain  Measures: Motor control Muscle performance Endurance and activity level Musculoskeletal condition  Correlates with discharge location, additional need for rehabilitation, functional status  Indicator for household ambulator, limited community ambulator, or community ambulator

19.  Projected functional goals at discharge established at initial evaluation  Bed mobility  Transfers  Gait  Stairs  Initial treatment aimed at quality of movement ie. trunk control, hip stability, midline orientation, safety with mobility, and lower extremity activation.

20.  Based on principles of motor control and learning, performed function based training using Tibion Bionic leg initially for standing weight shifting, sit><stand, then gait.  Tibion initiated on Day 9 for gait training, after interventions addressing safety, midline orientation, knee control, appropriate hip stability, and trunk control/alignment.  Continual intervention for functional mobility in conjunction with use of Tibion and Bioness L300.  Also participating in 1.5 hrs of OT and 1 hr of SLP services

21. ThresholdAssistanceResistance Day 1585High Day 2585Medium Day 31080Medium Day 41075Medium Day 51075Medium Day 61575Medium

24. Initial EvaluationDischarge Bed mobilityMinimal AssistanceIndependent TransfersMinimal-Moderate Assistance Stand by assistance Gait2 Steps Moderate- Maximal Assistance Cane, R AFO x 150 ft Contact guard assistance StairsNAUp/down 7 inch curb w/ cane and AFO, Minimal Assistance. 10 steps w/ rail, Contact guard assistance Five time sit to stand31 sec17 sec Gait speed0.4 m/s0.8 m/s RLE status Hip Flexion Knee Extension Knee Flexion Dorsiflexion 2-/5 0/5 3/5 2+/5 3/5 1/5

25. Long Term GoalsStatus Bed mobility: IndependentGoal Met Transfers: SBAGoal Met Gait: Ambulate with cane, SBA on indoor surface Goal not Met Stairs: Up/down flight of stairs w/ cane or rail, CGA Goal Met

26.  Challenges:  Not available for personal rental for home use  Difficult fit for smaller stature/petite patients