03-Reinkensmeyer2-WTEC-MobilityStudy ...

bouncerarcheryΤεχνίτη Νοημοσύνη και Ρομποτική

14 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

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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


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


TECHNOLOGY FOR EARLY
MOBILIZATION AFTER
STROKE:
NEREBOT

Giulio Rosati, University of Padua

Etienne Burdet, Imperial College

LOWER COST DEVICES

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
walking


INCORPORATING BCI’S AND MORE DOFS

INCORPORATING BCI’S:
HTTP://WWW.IAI.CSIC.ES/BETTER/

Prof. Jose Pons, Madrid BETTER Project

WEARABLE
ROBOTS

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

Schmidt,
Fraunhofer

Institute,
Hesse
,
Charité

Hospital,
Berlin

MORE DOF + BETTER CONTROLLER

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.

ETH Zurich

BETTER FEEDBACK
(SHOW VIDEO)

VIRTUAL REALITY + ROBOTICS

AALBORG UNIVERSITY, DENMARK

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

INTEGRATED APPROACH

Charité

Hospital,
Hesse
, Berlin


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


MODELING HUMAN
-
ROBOT INTERACTION

Prof. Etienne Burdet, Imperial College, London


Modeling interaction forces between
humans and robots


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


Prof. James Fawcett, Cambridge


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.