technologies for enhancing movement therapy and combination therapies reinkensmeyer and boninger
TRANSCRIPT
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
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
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)
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Lokomat Systems Erigo Armeo Spring Armeo Boom
Sales of therapeutic technology by Hocoma A.G.
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
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
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
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
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
Herman van der Kooij, Biomechanical Engineering
University of Twente
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 walkingINCORPORATING BCI’S AND MORE DOFS
INCORPORATING BCI’S: HTTP://WWW.IAI.CSIC.ES/BETTER/
Prof. Jose Pons, Madrid BETTER Project
Scuola Superiore Sant’Anna
Multiple degree of freedom elbow exoskeleton for rehabilitation
Constrained degrees of freedom impairs rehabilitation
MORE DOF
ISIR Paris/Garches/CEA/Roby-Brami/Morel
Multiple degree of freedom exoskeleton for rehabilitation
MORE DOF
Hocoma, Zurich
MORE DOF: LOKOMAT
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.
NEW CONTROL STRATEGIES: ADAPTIVE ASSISTANCE
U. Genoa, Morasso, Masia, Sanguineti
Robot-therapy of hemiparetic patients, with a minimally assistive & progressively decreasing strategy for tracking movements
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
SPINAL MAPS
Prof. Silvestro Micera, Pisa and Zurich
Monaco et al., J Neurophysiol, 2010
Use spinal maps to identify how rehabilitation modifies muscle coordination in specific patients (e.g., stroke).
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?
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
Therapy + Plasticity Treatment
Specific forelimb reaching rehabilitation (1 hour/day) with chondroitinase leads to a dramatic recovery of forelimb function
Therapy + Plasticity Treatment
General environmental enrichment (1 hour/day) makes animals worse at skilled paw reaching
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
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.