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DOI: 10.1007/978-3-642-34546-3_159 Springer-Verlag Berlin Heidelberg 2013
Clinical Application of a Robotic Device for Locomotion Markus Wirz 1 and Rdiger Rupp 2
1 Spinal Cord Injury Center, Balgrist University Hospital, Zurich/Switzerland mwirz@paralab.balgrist.ch 2 Spinal Cord Injury Center, University Hospital, Heidelberg/Germany ruediger.rupp@med.uni-heidelberg.de Abstract. Some considerations should be taken into account to facilitate the clinical application of a robotic device. The basis for the development should not be limited to the scientific concept and the technical feasibility. Practical input from patients and therapists adds important features relevant for daily practice. The informal knowledge exchange warrants successful developments and implementation. 1 Introduction This presentation is not based on systematic research work but rather on clinical observation and experience. This report is based on the application of the Lokomat, a robot for assisting locomotor training [1] , and it highlights factors that merit consideration for implementing robotic devices into an already existing framework of rehabilitation interventions. These factors can be divided into general considerations, human-related and technical aspects. The latter pertain to therapists and patients. 2 General Considerations The goal of rehabilitation interventions is that patients become as independent as possible in their daily life. Hence rehabilitation robots are applied on a temporary basis. It is without doubt that new technical developments will impact positively on rehabilitation procedures. With the help of robotic devices well-defined interventions can be used for both clinical and research purposes. Beside these interventions robotic devices are tools to measure and record the states and progress of the subject in an objective way [2]. For developing a rehabilitation robot the challenges are to unite a wide spectrum of requirements: scientific knowledge (from basic scientists); knowledge acquired by empirical experience (therapists); technical feasibility (engineers); regulatory requirements and patient safety, comfort and acceptance (patients) have to be regarded. It is likely that only those devices which are developed on a scientifically-based concept, whose mode of operation are comprehendible by clinicians and which can be operated safely 974 M. Wirz and R. Rupp
and conveniently may succeed in daily routine. Feasibility and effectiveness of robotic devices should be established by clinical trials [3]. It can be stated that at this time the development of rehabilitation robots is in an early stage. Experience from clinical application will lead to further improvements. 3 Human-Related Aspects 3.1 Patients Self-reported goals and requirements are important topics with regards to patients. Patients with neurological disorders have special needs, for example, muscles may be atrophic and sensation may be reduced both of which lead to a propensity for pressure lesions. In some circumstances patients experience an impairment of the vegetative nervous system resulting in orthostatic hypotension. Some patients may experience discomfort so it must be possible to stop training immediately. A patient may then refuse subsequent training sessions due to a single, harmful experience. Motivation is a key element in neurorehabilitation and can be facilitated by training scenarios which are relevant for the patients. Information about their performance and results are important elements which can provide an adequate amount of feedback. 3.2 Therapists Robotic devices as with any other new intervention are sometimes perceived as disrupting to well-established courses of action. To foster clinical acceptance the knowledge of therapists has to be taken into account throughout the development process. Such a bottom-up approach allows the user to feel ownership towards the device which leads to fruitful exchange of knowledge between clinicians and engineers. Therapists regard rehabilitation robots as tools to enable interventions that are otherwise not possible. They do not like to be regarded as the sole operators of the machines but rather want prefer to make use of the possibilities robots offer to therapeutic training sessions. An important feature of robotic devices is the capacity for measurement, for example, it is most useful for feedback modalities (e.g. virtual environment) during training and for documenting purposes. Rehabilitation robots can usually be adapted to a wide spectrum of patient capabilities. This fact, together with other features, makes the devices complex to fit to patients and to find an adequate operation mode. Thorough instruction courses allow users to safely and consistently operate the new device. 4 Technical Aspects From a clinical perspective usability is an important feature which should be considered from the start. In favor of usability some sophisticated technical features may not be realized. Clinical Application of a Robotic Device for Locomotion 975
In order to control forces and trajectories the hardware components of the robotic device must be designed in such a way that they can be firmly attached whilst simultaneously accounting for the special needs of the patients. Devices should be adaptable to a wide range of anthropometric properties. Also during operation the device should be adjustable to the stage of recovery, e.g. full or partial assistance. Assistance as needed is a prerequisite of a well-adapted training. In cases where patients experience discomfort or in patients with orthostatic hypotension it must be possible to exit the robotic device quickly. After an emergency stop motors should be backdrivable and the device itself must be removable thus enabling access to a potentially unconscious patient. Hardware and software components must be designed in a way that unambiguous operation is ensured. Although simpler solutions may be advantageous in most situations, hidden operation modes for advanced users and researchers can also be implemented. Robotic devices are able to deliver a large number of physiological movements with defined trajectories in a consistent and reproducible way. However, from a motor learning point of view it is important that subjects learn to master erroneous movements, to repeat movements with variations and that they are provided with adequate feedback [4]. In the near future technical devices will become more important components of rehabilitation. There are many areas of future developments e.g., additional degrees of freedom, learning self-adapting systems or home-training devices to name only a few. 5 Conclusion Early versions of rehabilitation robots have been implemented in clinical practice. They allow training in a scientifically relevant way whilst taking into account clinical preconditions. The knowledge exchange between engineers, researchers, clinicians and patients will pinpoint elements for further improvements. References [1] Colombo, G., Wirz, M., Dietz, V.: Driven gait orthosis for improvement of locomotor training in paraplegic patients. Spinal Cord 39(5), 252255 (2001) [2] Bolliger, M., Banz, R., Dietz, V., Lunenburger, L.: Standardized voluntary force measurement in a lower extremity rehabilitation robot. J. Neuroeng. Rehabil. 5, 23 (2008) [3] Wirz, M., Zemon, D.H., Rupp, R., Scheel, A., Colombo, G., Dietz, V., et al.: Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: a multicenter trial. Arch. Phys. Med. Rehabil. 86(4), 672680 (2005) [4] Krakauer, J.W.: Motor learning: its relevance to stroke recovery and neurorehabilitation. Current Opinion in Neurology 19(1), 8490 (2006)
A Robot and Control Algorithm That Can Synchronously Assist in Naturalistic Motion During Body-Weight-Supported Gait Training Following Neurologic Injury