Post on 23-Jan-2018
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Sustained caseneotretdIng
(Goner; 2007)
Clinically
• inferences about a spastic muscle's extensibility have been made based on the assumption that changes in RoM would be reflective of muscle length changes.
• increases in RoM can be due to the extensibility of tendons and other passive structures.
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Manual Stretch Evaluator
11/4/2015
Typical clinical measurements
• Goniometric ROM
• Modified Ashworth/Tardieu
• Manual muscle test or hand held dynamometer
• Selective control assessment for the lower extremity (SCALE)
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Clinical measurements
• measurement of spasticity varies based on who performs the evaluation and what scales are used
• There is a need for reliable, reproducible measurements of ROM, spasticity, and other biomechanical parameters
- Evaluate a patient at baseline
- Determine if new treatments are effective
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Focus on the ankle joint
• Passive interventions
- Manual stretch - Botulinum toxins
- Serial casting - Surgery-common for equines
• Active interventions
- Strengthening (Mriter, 2009) - Use of estim to improve ankle control during gait (Ionian°, 2013: Prosser.
1012) - Participation in clinic and community based fitness activities (05on,
zoos) - Motor training for the development & maintenance of CNS pathways
and for recovery post Injury (Mogan°, 2007).- give only the assist needed to complete the activity
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Screen display
Velocity
Torque
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Angle
Typical torque-angle curve non-CP) 12
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Robots as an evaluation tool
• Instrumentation can be used to
quantify what we might feel during
manualO,,er ,
eaxi ( W u, 2011; Zhao. 2011; Dc
s
• Motors- move the joint at an exact speed over a specific range of motion
• Position sensors - what is the joint position
• Torque sensors - how hard is it to move the joint
• EMG -monitor muscle activity
• Apply models to the torque/angle curves
Intrinsic Mechanical Property Change
Stiffness and Viscosity of calf muscles decreased after one session
stretching
Subject B
150
g 100
50 -20 -10 0 10 20
Plentarlororkeque(slm)
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Effort to improve our definition
• Devised a robotic device to control for:
— speed of movement of a joint,
— torque magnitude,
• To measure:
— strength,
— active and passive range of motion
— Joint stiffness
— EMG of muscle activation of stretch reflex, and
magnitude of response
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Reflex-Mediated Responses
Changes of muscle mechanical property results in decreased reflex excitability
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Active ROM and Activation Increases Post Stretching
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Robots as a treatment tool • Continuous passive motion at constant velocity
effects last up to 3 days (kneel Owns et 01,2013)
• Robotics can be utilized to give repeatable/quantifiable stretch, and assistance as needed for motor training Ki.g roll, 20131
• Biodex-type motorized dynamometers allow strengthening isometrically or isokinetically lcnobercne al. 20061
• Haptic feedback and gaming can be used to increase motivation nwv501,2011: Clot et al, 20111 Flutde. ts 31,2013)
• allows therapist to create patient-specific
protocol and progression
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IntelliStretch Passive Stretching under Intelligent Control
• Knows how fast to move;
• How hard to stretch;
• How long to hold at the extreme
11/4/2015
Assessment of Muscle and Tone
• Very difficult to clinically determine stiffness from spasticity, even for experienced practitioners.
• De Vlugt et of: quantitatively discerning between neural and non-neural origins
— Instrumented foot plate to displace the joint In the dersilleron/plantarfldlon axis
— torque vs. angle measurements correlated with DAG data oldie plantar flexors and dersilletors.
• Willersev-Olsen et al demonstrated that delivering passive stretch a slow angular velocity enables stiffness to be measured independently from active tone.
• de Goojler et al: Constant torque, ramp and hold — Stiffness measured at lowe.A angular velocity (IS depfsec) — Refleeeve stiffness I:past:city) measured at higher velocity 1120 deg/secl
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Could Alternative Robotic Rehab Program Help?
• Hypothesis — Combining passive stretching and active movement training
using the rehab-robot along with biofeedback game play improves lower-limb motor function in children with CP and improve the patient experience of stretching
• Objectives
— Develop the therapeutic robot and the training protocol to offer a more engaged and playful approach
— Examine the effectiveness of the robotic intervention
— Investigate how this approach impacts on the children with CP in the laboratory setting
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Intelligent Stretching Profile
PaukStretchIng Velocity
• 40 degrecs/sec
Position Smits (with roan' • 251n dorslflexIon
• IS In plantarfladon
Torque Sings • iS Nm In doashimtlen
• 3 thn In plontarfflation
NotcDorajlealon leached WrOVe 11.14/Plentorflorlon reached positlon Rmit In this ease
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Assisted Active
Movement Training
• Positional parameter in real time as visual feedback for motor learning
• Device detects the movement of participant's foot and provides the assisted
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Resisted Active Movement Training
• Resisted active
— Extra torque loaded for strengthening the dorsiflexors/plantarflex ors
• Combined feedback — Sensory — motor — Visual
movement AROM
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Training Paradigm Objectives
• To test borne-based robotic therapy using a portable rehab robot and evaluate the effects of passive/active movement training on the ankle joint of children with CP
• To conduct 6-week home-based and lab-based passive stretching and active movement training on children with Cl'
• To evaluate/compare the effectiveness of home-based and laboratory-based robotic therapy
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Participants
N. 17
13 boys 0014 girls
912.6 years of age
lloniplegia 59 Diplegia
N. IS
I> boys and 4 girls
10.6.3 wurs of age
5 Ilemiplegin 57 Dipkgia
Croup
Sample tire
Condor
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Diammais
Home-based Group I Lab-based Group
GARCS I.>- 10 Gh11,CS I n'Il Motor impairment (MKS n"6 Lihtl•CS 11; tr.
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11/4/2015
9
Lab-Based Rehab
Experimental setup • Subject sat comfortably with the
knee tretended • A portable rehab robot
• Strautom and safe stretching under intelligent control
• Voluntary movement training with robot assistance or resistance.
• Mont ming guises
Home-Based Rehab
• User-friendly interlace
• Passive stretching with intelligent control
• Active movement training
• Audio-visual interface
• Tele-interactions
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Evaluation Measures and Time Points
Fouo„.„„
Clinical invasstivi • Bsominhanical oictviurini - Madilltel Ashworth Seale (INAS) - '441BetiVp CoolestASnuSin,lit
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- Pediatric balance male (PBS) c-nbe cock tee.
- Timml Up-and-Go (TUG) -
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- l'vtir ROM (PROM)
- Wale strength tdorsifletror and p)untarflevar)
Statistics & Results
• 2-way ANOVA with repeated measures (p<0.0S) — Signiflont change: anew the evaluations — No significent difference found between the groups
• Paired t-test within group (p<0.05)
— SCALE (js bOth grocPs) — MAS (+In lab group)
— PBS (Is In both groups)
— MOM In both groups)
— PROM (Is in both group)
— Strength ris In both groups)
— Galt measures (TLIG a 6MWT) (1.* In both groups
1‘ indicates improved
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Changes of Clinical Scales Home-based & Lab-based
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Changes of Clinical Scales
in Home-based & Lab-based •
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Biomechanical Changes Home-based & Lab-based
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PROM ln Of • ".
Outcome Evaluation-
Plantar Pressure Measurement During Gait
• The Fscan sensor (#30000 — Resolution 3.9 seriss4s/rimi2 — 21 row/60 row — 954 senuls
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• Sensor trimmed to fit the child's shoes
• Same shoes were
wore at pre/post evaluations • Child wore the shoes which they wore without braces on
Sensors calibration before walking trials
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Gait Analysis Based on F-scan Data • Stance phase • Swing phase
• Double-leg support • Cadence (steps/min) • COF trajectory within stance
phase • Phase ratio (trained
side/untrained side) before and after intervention — Stance phase ratio between two
sides — Swing phase ratio between two
sides — Use the distance to 1(1-phase ratio
to measure symmetry.
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Results: More Symmetrical
Asymmetry
Stance Phase Swing Phase
Pre- 0.16±0.13 0.33±0.24
Post- 0.06±0.04 0.19±0.20
Statistics p<0.05 p<0.05
Asymmetry — The value close, to zero means the participant spent the similar time on stance/swIng phases of the two skies
ORIC Tech 4 POD 0> ,r,lthIles of HeAJIII
11/4/2015
Discussion & Conclusion
• User-friendly, portable, suitable for home setting
• No adverse events reported
• Strength training did not increase spasticity
• Passive stretching and active movement training is effective in improving functional and biomechanical measures of motor function in both lab &home settings. — Better control after muscles became less stiff — Biofeedback game-playi ng and large B of repetitions — Closed-chain training (sensorY ',Vet]
• Improvement of selective motor control also seen in other joints
• Home-based training more convenient, comparable rovgn3ents as lab-based
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Limitations
• Only the more severe side treated for diplegic patients
• Other joints may need to be treated
• Non-weight bearing training
• Group randomization affected by subject availability to lab-based training
• Dosage and timing need to be optimized
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Repeated Sretching may provide the necessary
stimulus for the muscles adaptive process exact mechanism for sarcomere addition and longitudinal growth in the muscle is unknown, previous research has indicated that muscle stretching is a very powerful stimulant (Williams. 1990).
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Function Depends On
• Interplay of body structure and function-
impairments
• Strength, tone, SMC, balance-understanding each
and quantifying allows us to target therapy
programs
• Parse individual deficits contributions
RJc Tech4POD N:Ttigna I mittuluts of Health cs.Coss
Closing Thoughts
• Use of the device is feasible in clinical practice and
can be used in home or for more precise
quantitative research
• Can be used for bouts of therapy or as part of
ongoing therapy
• Utilized to provide elongation to the most
adaptable tissues in the BODY
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Future directions
• Home program great option
• Determine how long effect lasts-when to do
intervention
• Serial casting/botulinum toxin —to augment
effects
• Dosage of the intervention-can determine
learning curve and decay of change and
improvement
ORIC Tech4POD It:Ur-ma Inslitutes of FILN:lth Mr,Carst
11/4/2015
Argument for stretching
• Repeated stretching reduces passive tension and allows greater elongation through small changes
in the viscoelastic properties of the muscle—
tendon unit (Ryan et al., 2008).
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