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Technologies for enhancing movement therapy and combination therapies

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

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Technologies for enhancing movement therapy and combination therapies

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  1. Technologies for enhancing movement therapy and combination therapies Reinkensmeyer and Boninger

  2. 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

  3. 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

  4. 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) Sales of therapeutic technology by Hocoma A.G.

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. Technology for early mobilization after stroke: NeREBOT Giulio Rosati, University of Padua

  11. Lower cost devices Etienne Burdet, Imperial College

  12. 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 walking Incorporating BCI’s and MORE DOFs Herman van derKooij, Biomechanical Engineering University of Twente

  13. Incorporating BCI’s: http://www.iai.csic.es/better/ Prof. Jose Pons, Madrid BETTER Project

  14. Wearable RoboTs Prof. Jose Pons, Madrid BETTER Project

  15. Multiple degree of freedom elbow exoskeleton for rehabilitation Constrained degrees of freedom impairs rehabilitation MORE DOF ScuolaSuperioreSant’Anna

  16. MORE DOF + Better controller Schmidt, Fraunhofer Institute, Hesse, Charité Hospital, Berlin

  17. Multiple degree of freedom exoskeleton for rehabilitation MORE DOF ISIR Paris/Garches/CEA/Roby-Brami/Morel

  18. 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. More dof: Lokomat Hocoma, Zurich

  19. BETTER FEEDBACK (show video) ETH Zurich

  20. VIRTUAL REALITY + ROBOTICS AALBORG UNIVERSITY, DENMARK

  21. Robot-therapy of hemiparetic patients, with a minimally assistive & progressively decreasing strategy for tracking movements New control strategies: Adaptive assistance U. Genoa, Morasso, Masia, Sanguineti

  22. Integrated approach Charité Hospital, Hesse, Berlin

  23. 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

  24. Modeling human-robot interaction Prof. Etienne Burdet, Imperial College, London

  25. Modeling interaction forces between humans and robots

  26. Use spinal maps to identify how rehabilitation modifies muscle coordination in specific patients (e.g., stroke). SPINAL MAPS Monaco et al., J Neurophysiol, 2010 Prof. SilvestroMicera, Pisa and Zurich

  27. 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?

  28. Therapy+ plasticity treatment Prof. James Fawcett, Cambridge

  29. 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

  30. Therapy + Plasticity Treatment • Specific forelimb reaching rehabilitation (1 hour/day) with chondroitinase leads to a dramatic recovery of forelimb function

  31. Therapy + Plasticity Treatment • General environmental enrichment (1 hour/day) makes animals worse at skilled paw reaching

  32. 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

  33. 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.

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