9/3/2013 Disclosure Information AACPDM 67th Annual Meeting October 16-­‐19, 2013 Back to Basics -­‐ Stretching combined with exercising Deborah Gaebler-­‐Spira, MD1,2 Theresa Clancy, PT1 Theresa Sukal Moulton, DPT, PhD3 1.Rehabilitation Institute of Chicago 2.Northwestern University 3.National Institutes of Health Speaker Name: Deborah Gaebler-­‐Spira I have the following financial relationships to disclose: Consultant for: Merz Grant/Research support from: NIDRR, NIH, NSF, CNS Therapeutics, Allergan, Ultraflex Pilot Study I will not discuss off label use and/or investigational use in my presentation Speaker Name: Theresa Clancy I have the following financial relationships to disclose: Grant/Research support from: Ultraflex Pilot Study, Ipsen Dysport Phase III Multicenter Study I will not discuss off label use and/or investigational use in my presentation October 18, 2013, Instructional Course 16 AACPDM 67th Annual Meeting, Milwaukee, Wisconsin Objectives Theresa Sukal-­‐Moulton 2. Intelligent stretching device development and use as a research tool Deborah Gaebler-­‐Spira 3. Translation into clinical practice I have the following financial relationships to disclose: Grant/Research support from: NIH Intramural Program I will not discuss off label use and/or investigational use in my presentation Skeletal muscle ʹ anatomy review 1. Review of muscle & evidence for stretching Speaker Name: Theresa Sukal Moulton Theresa Clancy ͻ Muscle > fascicles > fibers > myofibrils > sarcomeres Fibers can be white (Type I, fast twitch) or red (Type II, slow twitch) Fiber packing (pennation angle) can have an effect on line of force production, and therefore torque about a joint 1 9/3/2013 Exciting muscles for movement ͻ neuromuscular junction: electrical ͻ
ͻ
ͻ
signal stimulates the flow of calcium, causes thick and thin myofilaments to slide across one another sarcomere shortens, generates force many sarcomeres working together = muscle fiber contraction more muscle fibers are recruited as they are needed (small Æ large fibers) Typical stretch reflex ͻ Excitation of a stretched muscle, reciprocal ͻ
Stretching typical muscle ͻ begins with the sarcomere, ͻ
ͻ
ͻ
overlap decreases some fibers lengthen, but others may remain at rest Once the muscle fiber is at its maximum resting length (all the sarcomeres are fully stretched), additional stretching places force on the surrounding connective tissue during high speed stretch with active muscle, tendon may take much of the stretch Model of a muscle Neural reflex inhibition of antagonist Sensory information ʹ static component persists as long as the muscle is being stretched: nuclear chain fibers ʹ dynamic component lasts for only a moment, with sudden change in muscle length: nuclear bag fibers ͻ Motor output ʹ Short latencyʹ spinal reflex loop ʹ Long latency ʹ brain stem ʹ Volitional ʹ cortical awareness and response Passive muscle Active muscle contraction contractile Series elastic Parallel elastic (Lieber, 2010 pg 278) 2 9/3/2013 Short muscles in CP Short muscles in CP: depends on what you measure ͻ Photos and videos ͻ Passive range of motion often decreased, especially hamstrings, gastrocs, hip flexors ͻ Fascicle length reduction (Mohagheghi et al, 2007 & 2008, Gao et al 2009) or ͻ
ͻ
ͻ
the same (Shortland, 2002) ͻ Measured using ultrasound, Use of normalizing factor matters. Variability in fiber size is higher in CP, increased odd fiber shapes and extracellular space (Ponten 2005; Lieber, 2010) Fiber length same (Foran, 2005)͙ďƵƚƚŚĞŽŶůLJǁĂLJƚŽŵĞĂƐƵƌĞƚŚŝƐ
is via whole muscle preparations and dissection (Lieber, 2010) Increased sarcomere length in medial hamstrings (Smith, 2011), FCU (Lieber, 2004) Short muscles in CP: cellular changes?
[passive components] ͻ Increased stiffness of individual mm fibers, with Short muscles in CP: spasticity? [neural components] ͻ Measured as speed dependent increased resistance to passive circumstantial evidence for contribution of titin isoforms (Foran, 2005; Friden, 2003) ͻ extracellular matrix between mm fibers shows decreased ͻ
ͻ
quality and stiffness. Collagen concentration is increased in spastic mm, but the type distribution is unknown. (Foran, 2005) Individual mm fibers and titan were not stiff but that muscle bundles and extracellular matrices were (Smith, 2011) By 3 years of age, passive properties of the muscle cause changes between CP and typically developing (Willerslev-­‐Olsen, 2013) ͻ
stretch, but difficult to manually differentiate source of tightness (De Grongen, 2013) There is no animal model that mimics human muscle chronic spasticity (Foran, 2005) and unclear if spastic muscle is chronic use or disuse (Lieber, 2010) ʹ fibers can shift phenotype properties based on use, but spastic mm does not consistently change (Foran, 2005; Lieber, 2010) ͻ Adaptive collagen/inflammatory response in tendons from chronic activation (Gagliano, 2013) ͻ ΎΎĂůůƚĞƐƚƐĂƌĞĚŽŶĞĂƚƌĞƐƚ͙ĨƵŶĐƚŝŽŶͬĚĞƐĐĞŶĚŝŶŐŝŶƉƵƚŵĂLJ
ĂĨĨĞĐƚ͞ƐƉĂƐƚŝĐŝƚLJ͟ 3 9/3/2013 Short muscles in CP: motor problem? [active components] ͻ Decreased selective motor control Pediatric considerations ͻ Collagen turnover rates: 300 days in adults vs 80 ʹ Abnormal synergies, distal more impaired than proximal (Fowler, 2010) ͻ Muscle weakness and disuse ʹ Muscle atrophy (Shortland et al, 2004) ʹ voluntary torque generation is less than what can be maximally stimulated. (Rose, 2005) ͻ OVERALL ʹ these specific changes may be muscle or ͻ
ͻ
ͻ
days in children (Gorter, 2007) Growth in general, periods of growth spurts Compliance with stretching and exercise programs Access to rehab professionals during critical periods of development impairment specific Effects of shortened muscles Stretching as an intervention ͻ Seating and positioning challenges ͻ Limitations in activities of daily living ͻ Pain ͻ Apparent weakness due to length tension ͻ Cochrane review found little or no effect on ͻ
ͻ
relationship Gait and transfers deficits Changes in bone growth passive stretch on preventing contracture in people with neurological disorders (Katalinic, 2010) ʹ Only 5/35 trials included children, so extrapolation should be cautioned (Wallen, 2012) ͻ limited effects of passive stretching on ROM/spasticity, but recommend 30 min daily (Pin, 2006) ͻ More work must be done on dosage, modality 4 9/3/2013 Treatment flow chart ĐŽŶ͛ƚ Treatment flow chart ͻ Risk of abandoning stretching is ROM regression (Franki, 2012) ͻ should be used as part of an overall treatment plan (Gorter, 2007) (Gorter, 2007) Focus on the ankle joint Typical clinical measurements ͻ Passive interventions ʹ Manual stretch ʹ Botox ʹ Serial casting ͻ Active interventions ʹ Strengthening (McNee, 2009) ʹ Use of estim to improve ankle control during gait (Damiano, 2013; Prosser, 2012) ͻ Goniometric ROM ͻ Modified Ashworth/Tardieu ͻ Manual muscle test or hand held dynamometer ͻ Selective control assessment for the lower extremity (SCALE) ʹ Participation in clinic and community based fitness activities (Wiart, 2008) ʹ Motor training for the development & maintenance of CNS pathways and for recovery post injury (Damiano, 2009)͙ŐŝǀĞŽŶůLJƚŚĞĂƐƐŝƐƚ
needed to complete the activity 5 9/3/2013 World Health Organization International Classification of Function Cerebral Palsy Activities Impairment ‡ Impairment ‡ ROM limitations ‡ Walking restrictions ‡ Weakness Function Depends On ‡ Gross Motor Skills ‡ Mobility ‡ Basic functional skills Environmental Factors Personal Factors ‡
‡
‡
‡
‡
‡
‡
‡
‡
‡
Accessibility Opportunity/Availability Support Season Teacher/Peer attitudes Participation Involvement in daily activities at home, school, community with family/peers Response to BoNT-­‐A & PT Motivation Priorities and goals Maturation/age Safety concerns Interactions between components of the ICF NIH Taskforce on Childhood Motor Disorders Ͷ 2001-­‐2012 Terry Sanger, Mauricio Delgado, Jon Mink, Deborah Gaebler-­‐Spira, Mark Hallett ͻ Interplay of body structure and function-­‐
ͻ
ͻ
impairments Strength, tone, SMC, balance-­‐understanding each and quantifying allows us to target therapy programs Parse individual deficits contributions ͻ Goal: unify language ͻ Starting with hypertonia-­‐ create useful tools to ͻ
ͻ
quantify impairments Created the opportunity to work with the RIC engineers in earnest Began working on clinical tool to quantify spasticity 6 9/3/2013 (De Gooijer, 2013) Robots as an evaluation tool Clinical measurements ͻ Instrumentation can be used to ͻ Vary widely based on who performs the ͻ
evaluation and what scales are used There is a need for reliable, reproducible measurements of ROM, spasticity, and other biomechanical parameters ͻ Motors ʹ move the joint at an exact speed over a specific range of motion ͻ Position sensors ʹ what is the joint position ͻ Torque sensors ʹ how hard is it to move the (Ross, 2011) ͻ EMG ʹ monitor muscle activity ͻ Apply models to the torque/angle curves Technology That Improves Measurement and Quantification Robots as a treatment tool ͻ Continuous passive motion at constant velocity effects last up to 3 days (knee) (Cheng et al, 2013) ͻ Robotics can be utilized to give ͻ
2013; Ross, 2011) joint ʹ Evaluate a patient at baseline ʹ Determine if new treatments are effective repeatable/quantifiable stretch, and assistance as needed for motor training (Zhang et al, 2013) Biodex-­‐type motorized dynamometers allow strengthening isometrically or isokinetically quantify what we might feel during manual exam (Wu, 2011; Zhao, 2011; De Gooijer, ͻBody structure and function impairments ͻTeam concerns may vary Rutgers Ankle (Cioi, 2011; Burdea, 2013) ʹneed comprehensive measurement (Engsberg et al, 2006) ͻ Haptic feedback and gaming can be used to increase motivation (Wu et al, 2011; Cioi et al, 2011; Burdea et al, 2013) ͻ allows therapist to create patient-­‐specific protocol and progression 7 9/3/2013 Screen display Manual Stretch Evaluator (Peng et al, 2011) Angle Velocity Torque Typical torque-­‐angle curve (non-­‐CP) Torque-­‐angle curve (cerebral palsy) Reflex activity Four trials (Peng et al, 2011) (Peng et al, 2011) 8 9/3/2013 Effort to improve our definition Portable Intelligent Ankle Stretching (PIAS) Device ͻ Devised a robotic device to control for: Knows how hard to push, how fast, how long to hold ʹ speed of movement of a joint, ʹ torque magnitude, ͻ To measure: ʹ
ʹ
ʹ
ʹ
strength, active and passive range of motion Joint stiffness EMG of muscle activation of stretch reflex, and magnitude of response Intrinsic Mechanical Property Change Stiffness and Viscosity of calf muscles decreased after one session stretching (Zhang, et al. 2002) Reflex-­‐Mediated Responses Changes of muscle mechanical property results in decreased reflex excitability (Zhang, et al. 2002) 9 9/3/2013 Active ROM and Activation Increases Post Stretching Next Step: Rehabilitation Engineering Research Center on Technologies for Children with Orthopedic Disabilities ͻ Program Director: Gerald F. Harris, Ph.D., P.E ͻ
Marquette University/Medical College of Wisconsin/Shriners Hospital Co-­‐Director: Li-­‐Qun Zhang, Ph.D. Rehabilitation Institute of Chicago (Zhang, et al. 2002) Musculoskeletal changes in CP Typically developing child Child with cerebral palsy Could Alternative Robotic Rehab Program Help? ͻ
Hypothesis ʹ 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 ͻ
(Oberhofer et al., 2010) Objectives ʹ Develop the therapeutic robot and the training protocol to offer a more engaged and playful approach ʹ Examine the effectiveness of the robotic intervention ʹ Investigate how this approach impacts on the children with CP in the laboratory setting 10 9/3/2013 IntelliStretch Ankle Position (Deg)
Passive Stretching under Intelligent Control ‡ Knows how fast to move; ‡ How hard to stretch; ‡ How long to hold at the extreme Ankle Resistance (Nm)
Intelligent Stretching Profile Peak Stretching Velocity 15
ͻ
10
5
0
215
ͻ
230
Time (sec)
235
240
245
ͻ
ͻ
25Σ in dorsiflexion 15Σ in plantarflexion 20
ͻ
ͻ
10
0
-10
220
225
230
Time (sec)
235
240
245
15 Nm in dorsiflexion 3 Nm in plantarfflexion Note: Dorsiflexion reached torque limit/ plantarflexion reached position limit in this case ʹ Extra torque loaded for strengthening the dorsiflexors/plantarflex
ors ͻ
PR O
M
ͻ Resisted active Assisted-active
training within
PROM
Resisted-active
training within
AROM
ARO
M
real time as visual feedback for motor learning Device detects the ŵŽǀĞŵĞŶƚŽĨƉĂƌƚŝĐŝƉĂŶƚ͛Ɛ
foot and provides the assisted PR O
M
ͻ Positional parameter in Resisted-active
training within
AROM
225
Resisted Active Movement Training ARO
M
Assisted-active
training within
PROM
220
Torque limits -20
215
Assisted Active Movement Training 40 degrees/sec Position limits (with 5Σ extra) Combined feedback ʹ Sensory ʹ Motor ʹ Visual 11 9/3/2013 Experiment Protocol Laboratory Training Setup ͻ Study design-­‐ Before-­‐after trial ͻ Experiment time course Child sat comfortably on the sofa chair with the knee as extended as possible 18 sessions training (3 times/wk for 6 weeks) Pre-­‐training evaluation -­‐Biomechanical testing -­‐Ultrasound evaluation -­‐Plantar Pressure (Fscan) -­‐Clinical evaluation Post-­‐training evaluation -­‐Biomechanical testing -­‐Ultrasound evaluation -­‐Plantar Pressure (Fscan) -­‐Clinical evaluation Training Paradigm Passive Stretching Warm up stretching (~ 20 mins) Resisted-active
training within
AROM
Active Movement Assisted-­‐active (~ 15 mins) Resisted (~ 15 mins) Passive Stretching After exercise stretching (~ 10 mins) Assisted-­‐active movement To increase AROM Resisted-­‐active movement Strengthening within AROM 40 deg/sec max Passive stretching PR O
M
Assisted-active
training within
PROM
Robot detects the movement of ƉĂƌƚŝĐŝƉĂŶƚ͛ƐĨŽŽƚĂŶĚƉƌŽǀŝĚĞƐƚŚĞ
assistance Participants ARO
M
ͻ
ͻ
ͻ
Inclusion: Spastic diplegic/hemiplegic; GMFCS level I-­‐III; cognitive skills to participate Exclusion ʹ Fixed equines; surgical intervention within the preceding year; casting or Botox within 6 months prior to participation; selective dorsal rhizotomy or intrathecal baclofen Subject no.
Gender
Age
Subtype
Treated side
GMFCS
Dorsiflexion
Ankle MAS
1
F
5y
Diplegia
R
II
15.4
3
2
F
8y 8m
Diplegia
R
II
18.3
3
3
M
6y 1m
Diplegia
R
II
11.2
3
4
F
5y 4m
Diplegia
R
III
21.0
2
5
M
10y
Diplegia
R
II
26.0
3
6
F
9y 4m
Diplegia
R
II
20.0
3
7
F
7y 7m
Hemiplegia
R
I
24.9
1+
8
M
5y
Hemiplegia
L
I
24.1
2
9
F
8y 9m
Hemiplegia
L
I
22.0
3
10
M
8y 4m
Hemiplegia
L
I
26.5
2
11
M
15y 11m
Hemiplegia
R
I
16.7
2
12
M
10y
Hemiplegia
L
I
22.0
3
12 9/3/2013 Statistics ͻ Wilcoxon signed-­‐rank test (p<0.05) Outcome Evaluation-­‐ Clinical Evaluation ͻ Spasticity ʹ SCALE ʹ MAS ʹ PBS ʹ Modified Ashworth Scale ʹ Modified Tardieu Scale ͻ Selective Motor Control ͻ Paired t-­‐test (p<0.05) ʹ
ʹ
ʹ
ʹ
ʹ SCALE (Selective Control Assessment of the Lower Extremity) AROM PROM Strength Gait measures ͻ Functional outcome ʹ Pediatric Balance Scale ʹ 6-­‐min walk ʹ Timed up and go Results-­‐ Spasticity Results Ͷ Functional Outcome TUG
PBS
MAS Score
R1 (deg)
-10
-15
-20
-25
-30
-35
*
15
*
56
*
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
46
Time (sec)
Post
Score
Pre
0
-5
36
26
16
10
6
-4
Pre
Post
5
0
Pre
Pre
Post
Distance (m)
500
Modified Tardieu R1 and MAS score reduced significant after 6-­‐week intervention Post
6-min Walk
0 : 90 degrees between foot and shank *
400
300
200
100
0
Pre
Post
13 9/3/2013 Results-­‐ Selective Control Assessment of the Lower Extremity Results Ͷ selective motor control Hip
Knee
Ankle
Foot
Toe
ʹ Lock the footplate at neutral position (~10 degrees of plantarflexion) ʹ Visual feedback 7
+
*
*
*
*
-
+
*
*
+
+
*
*
*
*
-
+
*
*
+
*
*
*
+
*
+
*
*
+
*
+
+
* no changes + improved by one grade ++ improved by two grades -­‐ decreased by one grade +
+
*
*
*
*
*
*
++
+
+
*
*
*
+
+
+
++
*
*
+
*
*
*
*
*
*
*
-
+
*
*
+
*
*
*
*
*
+
*
+
+
improved maintained decreased Pre-training
Post-training
6
4
3
2
1
0
-20
*
0.25
5
Stiffness (Nm/deg)
ͻ Strength (3 trials) To
8
Resistance Torque (Nm)
ʹ Robot set as back-­‐drivable ʹ Visual feedback Foot
Joint Stiffness Decreases After Training device Passive ROM (5 cycles at several levels) ͻ Active ROM (3 trials) +
++
Ankle
9 among 12 participants showed improvement in ankle control Improvements in hip, knee and subtalar joints are also seen ͻ Biomechanical measures were obtained using the robotic ʹ Under velocity of 10 degrees/sec ʹ Within same torque limit before and after the intervention *
+
*
*
*
+
+
*
*
*
+
*
*
*
*
0
ͻ
ͻ
Biomechanical Measures-­‐ in the Sitting Position with Knee Extended +
+
+
++
SCORE
1
+
2
+
*
+
+
+
Knee
Toe
+
Foot
Hip
*
*
0
+
+
*
*
*
+
+
+
*
*
Post-
*
+
+
1
+
+
*
*
Pre-
*
*
2
0
ͻ
+
+
*
*
*
*
0
Ankle
4.3
*
*
+
+
*
*
*
+
*
*
*
*
2
Knee
6.0
+
Hip
4
1
*
*
SCORE
6
SCORE
(score)
*
+
*
*
*
+
+
+
*
*
2
8
*
*
+
+
*
*
*
+
*
*
*
*
Selective Movement Scale
-10
0
10
Ankle angle (deg)
20
30
0.2
0.15
0.1
0.05
0
PRE
POST
14 9/3/2013 Outcome Evaluation-­‐ Plantar Pressure Measurement During Gait Range of Motion Strength PROM
Dorsiflexor Strength
35
30
25
20
15
10
5
0
8
*
Torque (Nm)
Dorsiflexion (Deg)
Results Ͷ Biomechanical Measures *
6
ͻ Same shoes were wore at pre/post evaluations ͻ Child wore the shoes which they wore without braces on 2
Pre
Post
Post
Plantarflexor Strength
20
Torque (Nm)
25
15
*
10
5
0
Pre
20
15
10
5
Sensors calibration before walking trials 0
Post
Pre
Post
Gait Analysis Based on F-­‐scan Data ͻ
ĐŚŝůĚ͛ƐƐŚŽĞƐ 4
AROM
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 Force (lb)
ͻ
ͻ
ͻ
ͻ
ͻ
ͻ Sensor trimmed to fit the ʹ Resolution 3.9 sensels/mm2 ʹ 21 row/60 row ʹ 954 sensels 0
Pre
Dorsiflexion (Deg)
ͻ The Fscan sensor (#3000E) Results: More Symmetrical 40
Left
Right
35
Asymmetry 30
25
20
Stance Phase Swing Phase 0.16±0.13 0.06±0.04 p<0.05 0.33±0.24 0.19±0.20 p<0.05 15
10
5
0
0
ʹ Stance phase ratio between two sides ʹ Swing phase ratio between two sides ʹ Use the distance to 1 (1-­‐phase ratio) to measure symmetry. 0.5
1
1.5
2
2.5
Time (sec)
3
3.5
4
4.5
5
Pre-­‐ Post-­‐ Statistics Asymmetry Ͷ The value closes to zero means the participant spent the similar time on stance/swing phases of the two sides 15 9/3/2013 Biodynamics Lab
Results Ͷ COF Trajectory ‡
PostCOF Trajectory Distance (cm)
Pre-
*
14
Study neurological impairments and sports-­
related injuries, and develop state-­of-­the-­art rehabilitation robotics to address these clinical problems. ± Intelligent stretching using voluntary movement training (game interface) 12
10
8
6
4
2
0
Pre
Post
Discussion/Conclusions Discussion ͻ
ͻ The robotic approach offers several advantages: ͻ
ͻ
ͻ
ͻ
ͻ
All participants completed 18 sessions of training and demonstrated significant improvements Passive stretching was able to relax the stiff muscle: јWZKD јDŽƚŽƌĐŽŶƚƌŽů͗јZKD͕јƐƚƌĞŶŐƚŚĂŶĚј^>ŵŝŐŚƚďĞ
due to ʹ Better control after muscles became less stiff ʹ Biofeedback game-­‐playing and repetition (motor learning) ʹ Closed-­‐chain training (sensory input) Improvement of selective motor control also seen in foot and hip Strengthening adopted in the study did not increase spasticity Improved contact during stance might improve gait ʹ dŚĞƌĂƉĞƵƚŝĐƚĂƐŬƐĐĂŶďĞŵŽĚŝĨŝĞĚƚŽŵĂƚĐŚƚŚĞĐŚŝůĚ͛Ɛ
needs and interests. ʹ The robot can be used to engage the child to perform and learn new challenging tasks. ʹ Assistance by the robot allow the level and repetitions needed to facilitate beneficial neuro-­‐adaptations ͻ Limitations ʹ Self as control; Larger sample needed 16 9/3/2013 Home-­‐based Rehab ͻTo provide strenuous and safe stretching controlled by an intelligent-­‐control algorithm ͻTo train voluntary movement control of the patients. ͻHome-­‐based robot guided ͻTele-­‐assessment ͻTele-­‐Guidance Translation of research to the clinic Setting ͻ Outpatient pediatric department at an urban rehabilitation hospital 17 9/3/2013 Challenges to implementation Eligibility ͻ Distraction of the clinic environment ͻ Long sessions, overlap of patients ͻ Waiting list ͻ Staff schedules (clinician consistency) ͻ Reimbursement of intensive blocks of sessions ͻ Diagnosis of CP ͻ GMFCS level III, II or I ͻ Ability to understand the task/follow multi-­‐step ͻ
(prior approval required) Large range of impairment levels, broad group of kids Clinical Outcomes Measured Protocol ͻ 12 sessions, 2x/wk ͻ 30 minutes of intelligent stretch use Passive stretching
ͻ
ͻ
directions Ability to reliably signal pain, fear or discomfort. Ability to activate the tibialis anterior and gastroc-­‐
soleus Active assist game with
Active movement game
robot
with robot biofeedback
with or without resist
10 min
10 min
10 min
‡ Followed by 45 minutes functional activities ͻ GMFCS, FMS ͻ 6 min and flying 10 meter walk tests ͻ Timed Up and Go (TUG) ͻ Dorsiflexion ROM (R1/R2, knee flexed and extended) ͻ MMT: dorsi-­‐ and plantar-­‐ flexion ͻ GMFM ͻ SCALE ͻ Pediatric Berg Balance Scale ͻ BOT-­‐2 (for higher level kids) 18 9/3/2013 Functional Activities ͻ Treadmill training ͻ Stairs ͻ Balance activities Pilot Study ͻ Retrospective cohort study ͻ Participants: ʹ
ʹ
ʹ
ʹ
ʹ Static ʹ Dynamic ͻ Bicycle Riding n=28 (8.2 ц 3.62 years old) 19 male, 9 female 11 diplegia, 16 hemiplegia, 1 triplegia GMFCS levels I (n= 10), II (n= 17), and III (n=1) ͻ Outcome measures collected before and after training Results How does that compare to the lab? ͻ Significant differences found between pre and ͻ Comparisons with Wu, et al, 2010 results (Kruskal-­‐
post tests (Wilcoxen Signed Rank Test) ʹ
ʹ
ʹ
ʹ
ʹ
ʹ
ʹ
6 minute (p=0.013) 10 meter walk (p=0.001) TUG (p<0.001) BBS (p<0.001) SCALE (p=0.001) R1 (p<0.001) R2 (p<0.001) ͻ
Wallis test) Laboratory participants ʹ
ʹ
ʹ
ʹ
n=12 (7.8 ц 2.91 years old) 6 male, 6 female 6 diplegia, 6 hemiplegia GMFCS levels I (n=6), II (n=5), and III (n=1) ͻ Outcome measures collected before and after training 19 9/3/2013 How does that compare to the lab? ͻ statistically similar gains between clinic and research treatment types ʹ
ʹ
ʹ
ʹ
ʹ
6 min walk (p=0.215) TUG (p=0.655) BBS (p=0.842) R1 (p=0.359) R2 (p=0.824) ͻ significantly greater improvement in SCALE in the laboratory treatment (p=0.028) New focuses Closing Thoughts ͻ Use of the device is feasible in clinical practice ͻ The coupling of use of the Intelligent Stretcher ͻ
with functional activities demonstrated gains in functional outcome measures Specificity of training likely contributes to areas where differences are noted Future directions ͻ Position Changes, Different Joints, Multiple Joints ͻ Home program/use of device ͻ How long does effect last ͻ Serial casting/botulinum toxin measurements ͻ When to do the intervention? ͻ Dosage of the intervention 20