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Jenny Wang, PT, DPT, MS Swedish Medical Center Englewood, CO
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Discuss how robotics can enhance training, learning, and rehabilitation goals. Selecting appropriate patients and outcome measures.
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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.
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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
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Can be classified as non-wearable or wear- able
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Robotic exoskeleton placed on patient’s leg during training.
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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
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Plantar pressure sensors detect gait phases through weight bearing Angle sensors detect knee motion angles Actuator torque sensors determine knee torque
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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
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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.
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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
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Patient population: Comprehensive Rehab unit (amputees, orthopedics/multi-trauma) CVA* Brain tumors SCI TBI MS PD
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Patient motivation Physical/cognitive ability to use and follow multi-step directions Height Stroke patients with the most consistent outcomes
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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
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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
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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
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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
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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.
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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
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ThresholdAssistanceResistance Day 1585High Day 2585Medium Day 31080Medium Day 41075Medium Day 51075Medium Day 61575Medium
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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
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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
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Challenges: Not available for personal rental for home use Difficult fit for smaller stature/petite patients
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