Exoskeletons for rehabilitation - Hooray for Indego
In rehabilitation the "ideal" scenario that people often describe is that situation (often elusive) where a rehabilitation intervention is frequent, intensive and functional-activity based. This makes sense and would be a positive step in most clinics to some extent but of course the devil is in the detail. In my mind this is an incomplete picture - something important is missing.
Consider this scenario for a minute. If I want to improve my golf drive I might go to the driving range twice every day and set out to hit 100 golf balls as far as I can. This meets the criteria of frequent, intensive and functional but the end result in my golf game still might be a disappointment. This is because of lack of attention to skill develpment in the mix - if my adopted pattern of behaviour is not consistently good then all that will happen is that I will be training and reinforcing bad habits.
So it is with rehab - we want frequent, intensive and activity based focus on movement but with attention to the quality of movement and patterns of behaviour. As humans we pick up habits and behaviours very quickly whether these are good or bad. In order to develop good habits and true rehabilitation of potential we need to carefully restore as much function as we can and then compensate for what we cant seem to recover. Neuroplasticity is at work and it can produce determental results just as easily as positive ones if we get this wrong.
Im a great advocate of technology in rehabilitation as it can amplify the beneficial effects of skilled therapy and therapists, Another important enabling factor of course is how these technical and people resources are deployed in the total care processes (the subject of a future article)
My experience with rehab started a long time ago when we used passive orthoses (made with metal and leather and eventually with carbon fibre or engineering plastics) for example with spinal cord injured persons.
These orthotic systems were heavy, passive, systems often with locked joints at the ankle and knees that achieved some functions but greatly compromised others. The price for stabilising a leg joint so a person could stand was extra weight and greatly increased effort to move. Control was being compromised by the constraints being created by the orthoses.
Most users eventually gave up trying to walk or stand because they worked out that it was more efficient to get around in a wheelchair. However much the clinicians encouraged "standing and walking for health", practicality always won out in the end. There wasn't much point in thinking about restorative efforts in this scenarion and neuroplasticity had never been heard of.
Today things are different aren't they?
The arrival of the Indego and other exoskeletons could and should sweep away some of the obsolete thinking and outdated practices that constrained what we could expect of rehabilitation in the past.
An Indego can be an effective assistive device but it is also an increasingly capable tool for rehabilitation and an effective assistive device. Consider the image below.
This (obviously stylised) recovery pattern shown above has lower extremity motor function on the "Y" axis versus Time on the "X" axis.
Intially we could imagine motor function is absent and the patient is unable to walk as there is no conscious ability to move his or her limbs. I shouldn't have to sell you on the idea that early intervention here is good. Immobilisation is very corrosive to recovery so if you are in a clinic with the Indego Therapy Kit you can start thinking about mobilising the patient at an early stage.
With MOTION+ software the therapist can give "Full Assist" to the patient. With the smallest shift of balance the patient can initiate gait with full assistance from the exoskeleton. With frequent and intensive practice the therapist can move to adjust the degree of assistance so that as restitution takes place the patient contributes more to the movement and the Indego does a bit less.
With the new THERAPY+ software the stylised gait pattern of MOTION+ can become more physiological. Natural gait has some variation to it - we don't normally take exactly the same stride length or motion pattern each gait cycle. As the patient follows the path of recovery the THERAPY+ software facilitates finding the balance between support and mobility.
This is revolutionary when we compare this with the old days of passive orthotic systems. The therapist can strive in each session to find that sweet spot that gives just the right amount of challenge and support. Think about the golf swing example above. We don't want "unskilled" practice which reinforces bad habits. Using the Indego the therapist can use his or her skill to efficiently and effectively establish the best motor learning environment for the patient.
Of course, the potential for recovery varies from patient to patient but this is not going to be constrained by the Indego. At whatever level of function the patient will plateau the correct degree of safety and support is implicit in the design.
The Indego Therapy kit enables truly individualised gait therapy for patients with lower extremity weakness. It can provide the blend of restitution and compensation strategies that every patient really needs - whatever their starting point or functional prognosis.