Motorisch leren i.c.m. technologie/robotica · robotic gait trainer. Improve active participation...

A F F I L I AT E D W I T H U N I V E R S I T Y O F T W E N T E

ROESSINGH RESEARCH & DEVELOPMENT

Motorisch leren i.c.m. technologie/robotica

JAAP BUURKE, EDWIN VAN ASSELDONK

Disclosure – Jaap Buurke

(Potentiële) Belangenverstrengeling Betrokken bij de ontwikkeling van de LOPES

Voor bijeenkomst mogelijk relevante relaties met bedrijven

Sponsoring of onderzoeksgeld

Richtlijnen Revalidatie / Richtlijnen Fysiotherapie

Er is geen evidentie voor het hanteren van een bepaalde methode, ook niet voor het Bobathconcept.

Het is aangetoond dat neurologische oefenmethoden c.q. behandelconcepten (NDT/Bobath) op functie- en activiteitenniveau bij patiënten met een CVA niet effectiever zijn dan anderebehandelvormen. (niveau 1)

Richtlinen fysiotherapie 2014, blz 12

Loopvaardigheid

RMI

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FAC

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Walking Speed

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MI-LEG

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BI

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p < 0.000

p < 0.000

p < 0.003

p < 0.001

p < 0.002

Spiercoördinatie aangedane been

3 6 9 12 24 weken

Erector.Tr.

Glut.Med.

Glut.Max.

Rect. Fem.

Vastus Lat.

Semitend.

Tib.Ant.

Gastroc.

Conclusie

Loopvaardigheid wordt beter

Spiercoördinatie aangedane been verandert niet

Functioneel herstel van lopen kan dus plaatsvinden onafhankelijk van herstel van het aangedane been.

Buurke, et al. Neurorehabil Neural Repair

Restitutie Substitutie

Gedragsmatige compensatie +

Neurologisch herstel

HerlerenVaardigheden

Wat verandert er?

Training and monitoring of

daily-life physical interaction

with the environment after stroke

Veltink P.H, van Meulen F.B, van Beijnum B.J.F, Hermens H.J, De Rossi D, Lorussi F, Tognetti A, Buurke J.H, Reenalda J, Baten C.T.M, Simons C.D.M,

Luft A.R, Schepers H.M, Luinge H.J.5, Paradiso R, Orselli R.

../../My Videos/INTERACTION/Man_walking_blur.mp4

../../My Videos/INTERACTION/Man_combined_blur.mp4

Simulated ADL

Resultsmean CoP value of 13 stroke survivors during different tasks. Mean age of 63.9 (SD ±9.0) years and 2.3 (SD ± 1.8) years post stroke

Key aspects of Motor Relearning?

F.B. van Meulen, D. Weenk, J.H. Buurke, B.F. van Beijnum, P.H. Veltink. Ambulatory assessment of walking balance after stroke using instrumented shoes.Journal of NeuroEngineering and Rehabilitation201613:48.

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Richtlijnen 2014Motorisch leren

Het is aannemelijk dat verbetering van functionaliteit zoals zitten, staan, lopen en arm-handvaardigheid tot stand komt door het aanleren van adaptatiestrategieën. (niveau 2)

Het is aannemelijk dat functionele oefentherapie in een voor de patiënt zo relevant mogelijke omgeving (taak- en contextspecifiek) een positief effect heeft op de te leren vaardigheid zelf. Hierbij blijken elementen van variatie en voldoende herhaling (repetition-without-repetition) belangrijke aspecten te zijn voor een effectief leerproces. (niveau 2)

BWSTTFunctioneel

Taakspecifiek

Herhaling

Intensief

Variatie?

Vroeg

ROBOT AIDED GAIT TRAINING

Lokomat

Effectiveness of robot-aided gait training

No clear consensus

◦ Robotic gait training accelerates rehabilitation in SCI [Benito-Pelava et al 2012]

◦ Robotic gait training results in less improvement than conventional training in subacute [Hidler et al, 2009] and chronic stroke survivors [Hornby et al, 2008]

◦ Recent Cochrane review [Mehrholz et al., 2017] showed that stroke survivors who receive robot-aided gait training are more likely to walk independently

Challenge

“Do BWSTT and RAST enable learning? For example, can future robotic control algorithms be altered from moving the legs through a kinematically normal pattern to a more physiologically meaningful path

that permits errors of balance and step pattern that subjects can try to correct to better enable motor learning?”

Challenges

Improve active participation

Allow subject to make errors

Tailor to individual needs

More task specific

Improve ease of use

ROBOT AIDED GAIT TRAINING – CHALLENGES

Incorporate knowledge about motor learning/recovery in design and control of robots

Challenge Implication design and/or control robotic gait trainer




More task specific

Improve ease of use

Motor relearning / challenges




More task specific

Improve ease of use

Neuroscientific evidence underlying challenges for robot-aided gait training


Assist as needed

Only provide assistance on the impaired aspect of gait◦By an algorithm that automatically adjusts the amount of support

based on a performance metric (more restricted definition)

◦By manually adjusting the amount of support provided to the patient (this definition is getting more popular).

Full assistance enforces fixed trajectory ◦ little variation between

step and subjects

AAN provides support proportional to deviation from desired trajectory◦ Large variation between

steps and subjects

ASSIST-AS-NEEDED (AAN) VS ENFORCING FIXED TRAJECTORY IN ANIMAL MODELS OF SCI

Desired trajectory

Full assistance training

Assist-as-needed training

Lee C et al. J Neurophysiol 2011


AAN training results in larger improvement in muscle activity compared to full assistance

Training 5 days/week for 4 weeks (1000 steps per training)

Rats with severe mid-thoracic spinal cord contusion

Numberof bursts

BurstDuration

[ms]

Assist-as-needed

Fullassistance

Assist-as-needed

Fullassistance

Lee C et al. J Neurophysiol 2011

Motor relearning/ challenges




More task specific

Improve ease of use


Allow subjects to make errors

AssistedUnassisted

Assistance was given by springs attached to a hip beltthat applied restoring forces towards beam center

Physical guidance in learning to walk on a beam

Domingo & Ferris, Gait & Posture, 2009

Allow subjects to make errors:Physical guidance in learning to walk on a beam


PHYSICAL GUIDANCE (SMALLER ERRORS) DURING LEARNING RESULTS IN LESS IMPROVEMENT

Allow subjects to make errors:Physical guidance in learning to walk on a beam


Motor relearning/ challenges




More task specific

Improve ease of use



When constraining degrees of freedom in a robotic device, the subject might still exert forces in that degree of freedom [Neckel et al. J Neuroeng Rehabil, 2008.]

These forces do not result in movement when walking in the device but (theoretically) will again result in movement when walking overground.

AffectedNon-affectedControl

Stance Swing

Stroke survivors show abnormal abduction torques during swing while walking in Lokomat



Incorporate knowledge about motor learning/recovery in design and control of robots

Challenge Implication design and/or control robotic gait trainer

Improve active participation Only provide assistance on impaired aspects of gait

Allow subject to make errors Only provide as much assistance as needed and more degrees of freedom

Tailor to individual needs Only provide assistance on affected tasks and more degrees of freedom

More task specific More degrees of freedom so walking in the device better resembles walking outside the device.

Increase ease of use Reducing the amount of clamps

} Assist-as-needed

} Mechanical design

Technological Development to overcome challenges

Robot-aided gait training

• Robotic body weight support system

• Over ground exoskeletons (in combination with overhead suspension system)

• Fixed-base robotic gait training• Treadmill-based exoskeletons

(with additional degrees of freedom)

• End-effector

BWS for overground walkingAlong a track (i.e. Zero G, Rysen)

Challenge BWS overground

Wearableexoskeleton

Advanced treadmill

Increase activeparticipation

++


More task specific

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++

More task specific

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++

More task specific ++

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++


Tailoring training ±

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++



Ease of use ++


Different exoskeletons are commercially available (Ekso, Rewalk, Indego)

◦ All have actuated hip and knee flexion/extension actuation

Initially designed as assistive devices for paralyzed patients

WEARABLE EXOSKELETONS

Ekso Indego



Wearableexoskeleton

Advanced treadmill


+


More task specific

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


+


-

More task specific

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


+


-

More task specific +

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


+


-



Ease of use



Wearableexoskeleton

Advanced treadmill


+


-



Ease of use ±

Treadmill based robotic gait trainers with more degrees of freedom

First generation robot-aided gait trainers had limited amount of degrees of freedom (similar to current wearable exoskeletons)



Wearableexoskeleton

Advanced treadmill


++


More task specific

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++

More task specific

Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++


Tailoring training

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++


Tailoring training ++

Ease of use



Wearableexoskeleton

Advanced treadmill


++


++


Tailoring training ++

Ease of use +

Conclusion

• Robotic body weight support system

• Over ground exoskeletons (in combination with overhead suspension system)

• Fixed-base robotic gait training• Treadmill-based exoskeletons

(with additional degrees of freedom)

• End-effector

Conclusion


Wearableexoskeleton

Advanced treadmill


++ + ++


++ - ++

More task specific ++ + +

Tailoring training ± ± ++

Ease of use ++ ± +

Treadmill based robotic gait trainers with more degrees of freedom

BWS for overground walking

ROBOT-AIDED GAIT TRAINING

HTTPSWWW.YOUTUBE.COMWATCHV=MLUOHYQVBFM

Take Home Message

Adaptatiestrategieën

Motor relearning in stroke

Robotische systemen moeten beterinspelen op die adaptatiestrategieën

Motorisch leren i.c.m. technologie/robotica · robotic gait trainer. Improve active participation...

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