JAHRESTAGUNG DER Ö. WACHKOMA GESELLSCHAFTin Kooperation mit der Ö. Gesellschaft für Neurorehabiliation

„WACHKOMA UND IMMOBILITÄT – Lasst mich bloß in Ruhe!“„Robotics – sich gehen fühlen“L. Saltuari

Locomotion

Locomotion is a complexstructurised function which isorganised in a hierarchy, startingfrom the spinal level and controlledby brain stem, extrapyramidal and cortical structuresThis complex motor control is also expressed in the development of gait in children

Control System for Locomotion

The Hierarchy of Motor Control

Local spinal cord reflexes triggered by myotacticstretch receptors localized to the point of stimulus, are highly stereotyped, and have an onset time of 35 – 40 msecs.Automatic brain stem and subcortical reflexescoordinated among the leg and trunk muscles, stereotyped but adaptable, and coordinatemovements across joints. Onset time ist 85 – 95 msecs.Voluntary responses that generate purposefulbehaviors and have longer onset itme latencies of 150+ msecs, sometimes called proactive balancecontrol systems. Vision and attention are the keysto the early detection of potential balance threats.

CortexCortex

A A

(Lateral) (Lateral)

(+)

Reticularextensorfacilitatory area

Reticular extensorfacilitatory area

Reticular extensorinhibitory area

(Medial)

Anterior lobe of thecerebellum

B B

Level of transection forclassical decerebrate state

To alpha and gamma (extensor) motorneurons

Fromascendingpathways Vestibular

nuclei

Fastigialnuclei

(+) (+)

(+)

(+)

(+)

(+)

(+)(-)

(-)

Additional lesionwith anemicdecerebration

Vestibularnerve

(-)

Supraspinal Supraspinal ControlControl

Higher „motive“ centers

• Substantia Nigra

- To the Mesencephaliclocomotor region

• Ventral Pallidum (aka InternalGlobus Pallidus)

- To Substantia Nigra

• Nucleus Accumbens (NA)

- Projects to Ventral Pallidum

• Hippocampus

- Projects to NA

Cerebellum

•Vermal and paravermal regions(and associated nuclei are involved)-Hemispheres contribute minimally

•Influences locomotion indirectly•Red nucleus-Swing phase

•Lateral vestibular (Dieter‘s) nucleus-Stance phase

•Medial Medullary reticular formation-Coordination of gait

-Through ventral spinocerebellar tract

„Upper motor neuron Syndrome“

Muskular weaknessspasticityhyperreflexiairradiation of reflexessynergismsprimitive motor patternspyramidal signs

Scientific evidence in Neurorehabilitation

RepetitionConstrained-induced TherapyEndurance

Functional magnetic resonance imaging beforemotor cortex stimulation for phantom limb painNervenarzt. 2007 Sep 12

Koppelstaetter F, Siedentopf CM, Rhomberg P, Lechner-Steinleitner S, Mottaghy FM, Eisner W, Golaszewski SM.Univ.-Klinik für für Radiologie II, Medizinische Universität,

Innsbruck, Österreich.This study deals with the diagnostic value of functional

magnetic resonance imaging (fMRI) in a patient withphantom limb pain following traumatic amputation of theright arm. After failure with medication, resection of stump neurinoma, and spinal cord stimulation, fMRI withevidence of cortical reorganization was performed. Tactilestimulation of the perioral region and motor imagery withcranial, tactile stimulation of the stump led to a caudalshift in fMRI activity. Subsequent motor cortex stimulationbrought relief from the pain. By detecting corticalreorganization, fMRI contributes to the indication formotor cortex stimulation for phantom pain and aids in electrode positioning.

Errigo

Lokomat

ParaCare – Balgrist ZürichAutomated gait orthesis with4 independent PD position controllers(reference hip and knee joint-angles)and 8 precision potentiometers (actualjoint-angles)

Lokomat

Evaluation of Efficacy of Lokomat Training in Comparison to Conventional PhysicalTherapy

RandomizedProspectiveDouble blindU-Test and Wilcoxon-Test

Methods

Number of patients: 16Sex: 6 male, 10 femaleAge: mean 63.4 years

Etiology: Strokecerebral ischemic: 13cerebral hemorrhagic: 3

Side: 8 right side, 8 left sideOnset time: 2.8 months

Design

A Lokomat

B Konvent PT

A Lokomat

B Konvent PT

A Lokomat

B Konvent PT

GruppeABA

GruppeBAB

3 Wochen 3 Wochen 3 Wochen

4 Untersuchung

Time Walking Test

TWT 10 mWie lange braucht Patient für 10 Meter

TWT 6 minWie weit geht Patient in 6 min

Rivermead Motor AssessmentSit unsupportedWithout holding on, on edge of bed, feet unsupportedLying to sitting on side of bedUsing any methodSitting to standingMay use hands to push up. Must stand up in 15 sec and stand for 15 sec, with an aid ifnecessaryTransfer from wheelchair to chair towards unaffected sideMay use handsTransfer from wheelchair to chair towards affected sideMay use handsWalk 10 m indoors with an aidAny walking aid. No stand-by helpClimb stairs independentlyAny method. May use bannister and aid-must be a full flight of stairsWalk 10 m indoors without an aidNo stand-by help. No caliper, splint or walking aidWalk 10 m, pick up bean bag from floor, turn and carry backBend down any way, may use aid to walk if necessary. No stand-by help. May useeither hand to pick up bean bag.Walk outside 40 mMay use walking aid, caliper or splint. No stand-by help.Walk up and down four stepsPatient may use an aid if he would normally use one, but may not hold on to rail. Thisis included to test ability to negotiate curb or stairs without a railRun 10 mMust be symmetricalHop on affected leg five times on the spotMust hop on ball of foot without stopping to regain balance. No help with arms.

Sit unsupportedWithout holding on, on edge of bed, feet unsupportedLying to sitting on side of bedUsing any methodSitting to standingMay use hands to push up. Must stand up in 15 sec and stand for 15 sec, with an aid ifnecessaryTransfer from wheelchair to chair towards unaffected sideMay use handsTransfer from wheelchair to chair towards affected sideMay use handsWalk 10 m indoors with an aidAny walking aid. No stand-by helpClimb stairs independentlyAny method. May use bannister and aid-must be a full flight of stairsWalk 10 m indoors without an aidNo stand-by help. No caliper, splint or walking aidWalk 10 m, pick up bean bag from floor, turn and carry backBend down any way, may use aid to walk if necessary. No stand-by help. May useeither hand to pick up bean bag.Walk outside 40 mMay use walking aid, caliper or splint. No stand-by help.Walk up and down four stepsPatient may use an aid if he would normally use one, but may not hold on to rail. Thisis included to test ability to negotiate curb or stairs without a railRun 10 mMustMust bebe symmetricalsymmetricalHopHop on on affectedaffected leg leg fivefive timestimes on on thethe spotspotMustMust hophop on ball of on ball of footfoot withoutwithout stoppingstopping to to regainregain balancebalance. No . No helphelp withwith armsarms..

EU-Walking

Sum score of relative changes

-50

0

50

100

150

200

250

300

350

400

Weeks

Perc

enta

ge

1-3 3-6 6-9LokomatPT

Prospective blinded randomized crossover study of gait rehabilitation in stroke patients using the Lokomat gait orthosis

Mair, Kofler, SaltuariNeurorehabilitation and Neural Repair, May 2, 2007

Summary

Significant improvements in function, strength and reduction of spasticityPatients profit more from ABA than BABPatients in low remission phases seemto profit more in improvement of spasticity, functional and nursaryoutcomeThe wide range of remission phases and clinical pictures with relative lownumbers of patients reduce thereliability of the data.

Clinical trial

EU-Walking Scale

Sco

re

6

5

4

3

2

1

0

-1Group 2Group 1

A

*

RMA Scale

Sco

re

12

10

8

6

4

2

0

-2

*

B

Group 2Group 1

10m-TWT

Seco

nds

500

400

300

200

100

0

-100

*

C

Group 2Group 1

6-min TWT

Met

ers

300

200

100

0

-100

D

Group 2Group 1

Motricity Index Leg

Sco

re

120

100

80

60

40

20

0

-20

E

Group 2Group 1

MRC Scale

Sco

re

60

50

40

30

20

10

0

-10

*

F

Group 2Group 1

*

Ashworth Scale

Sco

re

40

30

20

10

0

-10

G

Group 2Group 1Figure 2A-G

Conclusion

Clinical trials support the utility of Robotics in neurorehabilitation. Beneficial effects include reduction of muscletone, increase of endurance, dexterity and earlierautonomyRobotics cannot substitute hands-on therapy, especially in treatment for trunk control, thereforeshould be used as supplementary therapy

How complex must engineering of Robotic devicesbe in oder to be beneficial on an optimal level?