MN* Stratlang WItilndaIN Is trectla ebto to move aavves =Shifty the jOint?

Treatment flow chart can't

is Ow, Cad Wet, rnove Ord thP evaiN010

tame of 'notion?

yes -41 No

Yen No

Active on CuPPOrted mcwelnert Cl Imre

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I

sus:also passhm strolcn no

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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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„.. . °RIC Tech4PODED

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)

RIC Tech4PODEM----.—

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

RIC Tech4POORD Nativnin Intting. of 1-4,1t

6

renc et al. 20111

MU

Screen display

Velocity

Torque

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1-1-- t

Angle

Typical torque-angle curve non-CP) 12

Ant11•M

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Torque-angle curve cerebral palsy)

° Refine activity

("n' "425211 2-60 -4.0 -.3.0 :20 io io ao Angle (9

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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)

Subject B

•//* • — 2 •

1,5

51 -20 -10 0 10 20

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zhr

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,

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200

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11/4/2015

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

qDRIC Tech4POD

101ral Iracti lituar

7

Reflex-Mediated Responses

Changes of muscle mechanical property results in decreased reflex excitability

110 011

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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

PJC Tech4POD

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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

RIC Tech 4 POD In>

8

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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f. 221I 210 ./

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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

PJC Tech4 pop iztID WL.P.Z1 111.411. or Health

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

Ao

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.

WOKS III re. 1 GAWCS lfl nr, 2

LirTreulcd side 51415 9 Right 6141 & 9 Right

: • semoro Jib

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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PBS

—

Changes of Clinical Scales

in Home-based & Lab-based •

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11/4/2015

10

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

nacioma Imdituies of Homer Ccntc.C.n.t,

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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•-•—• • '•

11

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).

RIC Tech4POD onti 1,1,11U:tics of sr./carts

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

Tech4POD Ma)) tis-Astal Imaituls. 11,arli-arra

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).

Ri C Tech4POD

,rJorul Itt.I.Itutettut HwItt

12