Expanding Robotic-Assisted Gait Training into the Clinic:

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

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 2

Disclosures Nada Zip Zero None 3

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 4

A Robot?.For Therapy? https://www.medgadget.com/2016/04/ekso-gt-roboticexoskeleton-cleared-for-stroke-rehab-spinal-cord-injuries.html 5 https://exoskeletonreport.com/product/ekso-gt/

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 6

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: 7 Multiple Sclerosis Parkinson’s Traumatic Brain Injury Complex medical presentations

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 8

The What What is this robotics technology? 9

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 10

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 11

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 12

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;13:1303-1311. Published 2017 May 15. doi:10.2147/NDT.S114102 13

6 determinants of gait Pelvic rotation Pelvic tilt/Obliquity Knee flexion at stance phase Foot and ankle motions Knee motion Lateral pelvic displacement 14

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 – Research article 15

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 16

Robot vs. Human Are we just running a robot that does the work for us? Or Are we therapists that use a robot as a tool to more optimally support the skilled training and education we provide as licensed therapists? 17

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 18

The How: “It’s not the mask, but the man behind the mask” 19

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 20

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 . 21

WHERE Courage Kenny Locations – United Hospital (IP and OP) – Abbott Northwestern (IP and OP) – Golden Valley (TRP and OP) – Stillwater (OP) 22

Thank You! 23

References Belda-Lois JM, Mena-del Horno S, BermejoBosch 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. 24