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J.L. Pons et al. (Eds.): Converging Clinical & Engi. Research on NR, BIOSYSROB 1, pp. 973975.

DOI: 10.1007/978-3-642-34546-3_159 Springer-Verlag Berlin Heidelberg 2013

Clinical Application of a Robotic Device for
Markus Wirz
and Rdiger Rupp

Spinal Cord Injury Center, Balgrist University Hospital, Zurich/Switzerland
Spinal Cord Injury Center, University Hospital, Heidelberg/Germany
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
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
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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
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.
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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
[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
[4] Krakauer, J.W.: Motor learning: its relevance to stroke recovery and
neurorehabilitation. Current Opinion in Neurology 19(1), 8490 (2006)