Finally on Monday was Arun Jayaraman with What to Expect and Not Expect from Lower Extremity Robotic Technology.
Arun first wanted us to understand what all goes into making the therapeutics robots. The designers, engineers, etc. have a lot of back and forth with clinicians and patients… about 10-15 YEARS worth before they become commercially available. And also why they cost so much– a lot of work and precious time of many people have gone into them. But the difference they could make in recovery after a neurological injury could be astounding.
Being wheelchair bound or using long leg braces for mobility vs. a combo of stem cell treatment with robotic assisted mobility? Sounds good to me!
Right now the robots can: 1) assist in providing therapy diagnosis, 2) assist with higher intensity treatment options (robots don’t get tired like therapists do), 3) promote functional recovery by doing solely functional training , 4) potentially serve as assistive devices. However, we need to careful of what Arun called the “Pokémon” effect. “Gotta catch ’em all” all the robots! Just because they’re cool doesn’t mean that they are appropriate for every patient. In fact, if we as clinician scientists don’t reach out to the developers in the production phase, the developers will just make the robots on how they think they will be used. Which may not line up with what we as clinicians and patients need.
We’ve been seeing robots like these in other fields for years, but they are only just now being applied to therapeutics. Robots build our cars. Exoskeletons were first commissioned to be built for use by soldiers on the battle field, so they could keep going longer, under heavier work loads. There are some very rich people that are wanting to take the robots on marathons, so they can say they’ve run a marathon! The robots we have now have come a long way, but they have a ways to go. Arun likened therapeutic robotics current state to this phone in the evolution of cell phones.
Compared to today’s standards, this is a dinosaur. LONG way to go.
There are currently 3 types of lower extremity robots:
- Full body
2. Modular/single joint like the stride management assist seen here starting at 0:45
3. Soft Suits
There are currently 65 different companies out there working on these things.
Before we put a patient in a exoskeleton, we need to consider their pathophysiology, standing tolerance, ROM or rather lack there of due to strength deficits of hypertonicity/contracture issues, skin integrity and how the device will fit them. They are still working out exactly who will benefit the most from this tech. Which is important to know to avoid “the Pokémon effect.” The patient will progress through 4 levels of proficiency with the robot: 1) the therapist manually triggers the activity, 2) the patient manually triggers the activity, 3) the robot detects when the activity is intended, 4) the robot provides variable assist– as the patient’s ability to actively move improves, the robot’s assistance decreases. The therapists’ job would be to train the patient through those levels, to where they could safely don/doff and operate the robot at home. In 1 case Ajun mentioned, a stroke patient was provided with traditional care and went to a nursing home wheelchair bound. Then he got trained with a robot about 1 year post stroke. In 24 sessions, the patient was walking contact-guard assist with a single tip cane. That’s amazing! However, they are finding that typical outcome measures (6 minute walk, Berg) aren’t working well with the robots, so we would need to come up with something different to measure these folks with.
All great advancements do have their limitations. These things have NO balance reactions, so once you start to fall, you better yell, “TIMBER!” because you’re going down. And once you get down there, the robot probably won’t be able to help you get up. Bummer. They are also slower than natural gait speed and do not yet provide a natural gait pattern. Also, these things run on batteries; what would happen if you’re out and about at the mall let’s say and you run out of battery. What then? You’re just stuck there? Skin integrity may become a huge issue for wearers as many folks that have movement impairments have accompanying sensation impairments as well. What if the robot causes a blister? They’re also rather difficult to donn/doff and take a lot of time to do so. Would that make them impractical?
Robotics is advancing on quickly. They are currently looking into the whole balance issue with infrared cameras that map the terrain you’re on to adjust. They’re also looking a gyroscopes to sense if you fall, so that the suit can be signaled to make a correction. They’re also looking at an implant into the brain, so that the suit can be controlled by just thinking about moving. Now we’re getting all sci-fi movie.
Last thing Arun had to say was that if you think you have a patient who would benefit from an exoskeleton, mostly they are only available through clinical trials. So search for an appropriate trial at clinicaltrials.gov
That wraps up Monday!