Rick Segal, PT, PhD, FAPTA

November 2, 2012

Man vs. Machine: Technology Meets SCI

Rehabilitation
Presentation Outline
1. Why are advances in technology being pushed in
rehabilitation?
2. Are we fully utilizing our collective resources to incorporate
(Assistive) technology to improve rehabilitation outcomes
and to improve the quality of life of people with SCI?
3. Does the evidence support the use of these newer and
more equipment driven approaches over more “traditional”
rehabilitation?
4. Are there evidence-based “hybrid” approaches that offer
promise?
Presentation Outline
1. Why are advances in technology being pushed in
rehabilitation?
2. Are we fully utilizing our collective resources to incorporate
(Assistive) technology to improve rehabilitation outcomes
and to improve the quality of life of people with SCI?
3. Does the evidence support the use of these newer and
more equipment driven approaches over more “traditional”
rehabilitation?
4. Are there evidence-based “hybrid” approaches that offer
promise?
International Classification of Functioning, Disability and
Health (ICF; WHO, 2001)
One of the ways for people with SCI to participate is by
standing and/or to be upright mobile. Mobility using a
wheelchair offers many opportunities but at times there are
participation limitations that occur. Accessing spaces that a
wheelchair cannot access is a challenge. For 20 years there
has been extensive study of and use of body weight support
systems in conjunction with treadmills to help train walking.
This is based on seminal work by Barbeau, Rossignol and
colleagues in Quebec.
Presentation Outline
1. Why are advances in technology being pushed in
rehabilitation?
2. Are we fully utilizing our collective resources to incorporate
(Assistive) technology to improve rehabilitation outcomes
and to improve the quality of life of people with SCI?
3. Does the evidence support the use of these newer and
more equipment driven approaches over more “traditional”
rehabilitation?
4. Are there evidence-based “hybrid” approaches that offer
promise?
Reinkensmeyer et al. Journal of NeuroEngineering and Rehabilitation 2012, 9:22

1. Assistive technologies are being designed to

integrate more closely with the user, decreasing user
burden while increasing user capability
2. Research on technologies for rehabilitation therapy
is growing rapidly and beginning to transform clinical
practice. At the same time, the need for therapy
technology that can be used at home is largely unmet
3. There is a fundamental need in mobility technology
research for better neuromusculoskeletal models that
can be personalized to predict on a case-by-case basis
optimal treatments for individuals
4. Wearable sensors and pervasive systems will improve
health and wellness monitoring, safety monitoring, home
rehabilitation, assessment of treatment efficacy, and early
detection of disorders for people with mobility impairment
Reinkensmeyer et al. Journal of NeuroEngineering and Rehabilitation 2012, 9:22
5. Improvements in actuators and power supplies have not
progressed as quickly as those in sensors; the invention of
a stronger, lighter, and more efficient actuator and more
compact power supply would accelerate assistive and
therapeutic technology advances as well as spawn many
new applications of mobility technology
6. Eliminating physical impairment will ultimately require
combinations of physical training and plasticity &
regenerative therapies
7. Multidisciplinary teams that work closely with consumers
and are embedded with scientists with an intimate
knowledge of disability are best positioned to produce
transformative mobility technology
8. Finally, government support for research in mobility
technology has led to substantial gains. Future and growing
support is essential to continued advancement
Presentation Outline
1. Why are advances in technology being pushed in
rehabilitation?
2. Are we fully utilizing our collective resources to incorporate
(Assistive) technology to improve rehabilitation outcomes
and to improve the quality of life of people with SCI?
3. Does the evidence support the use of these newer and
more equipment driven approaches over more “traditional”
rehabilitation?
4. Are there evidence-based “hybrid” approaches that offer
promise?
Edgerton and coworkers, Journal of Neurotrauma, 2006
1. Do newer technologically based rehabilitation
approaches make “traditional” rehabilitation
approaches obsolete based on improved
outcomes and cost effectiveness?
2. Is there a better physiological basis for these
newer technologically advanced approaches?
3. Are there key elements that can make both
general approaches successful?
 Body-weight Supported Treadmill Training

From the University of Washington Website

https://www.google.com/url?url=http://www.youtube.com/wa
tch%3Fv%3DPufPyEHDFpQ&rct=j&sa=X&ei=5XiQUPyNE4Sc9QT
F94DYCA&ved=0CCUQuAIwAQ&q=lokomat&usg=AFQjCNGkKYT
GA4h6nz1u2NpQ8LArxxiQeQ&cad=rja
Hidler et al., 2009
Hidler et al., 2009
Hidler et al., 2009
“Body weight–supported treadmill training
(BWSTT), robotic-assistive step training (RAST),
and associated techniques for locomotor training
(LT) have not proven superior to exercise and
progressive over-ground gait training (OGT)
to improve walking for motor impaired patients with
stroke, spinal cord injury (SCI), multiple sclerosis,
Parkinson’s disease, and cerebral palsy.” Dobkin
and Duncan, 2012, Neurorehabilitation and Neural
Repair
 Field-Fote and Roach,
Physical Therapy, 91:48
(2011)
Field-Fote and Roach, Physical Therapy, 91:48 (2011)
 Field-Fote and Roach,
Physical Therapy, 91:48
(2011)
 Field-Fote and Roach,
Physical Therapy, 91:48
(2011)
Field-Fote and Roach, Physical Therapy, 91:48 (2011)
 Changes in walking speed overall and by training group

Field-Fote and Roach, Physical Therapy, 91:48 (2011)

Westlake and Patten, 2009
Westlake and Patten, 2009
Westlake and Patten, 2009
Actively powered exoskeletons from Dr. Greg Sawicki’s
lab at NCSU
Presentation Outline
1. Why are advances in technology being pushed in
rehabilitation?
2. Are we fully utilizing our collective resources to incorporate
(Assistive) technology to improve rehabilitation outcomes
and to improve the quality of life of people with SCI?
3. Does the evidence support the use of these newer and
more equipment driven approaches over more “traditional”
rehabilitation?
4. Are there evidence-based “hybrid” approaches that offer
promise?
Kandel, Schwartz and Jessell, 2000
 The stretch reflex is a relatively simple behavior. It has been
used as a model for studying learning and memory.

Wolpaw, 1997
Stretch (SSR) and H-reflexes can be modified in human and
non-human animals

Evatt, Wolf & Segal, 1989

Wolpaw
Segal and Wolf, Experimental Neurology, 1994
Segal and Wolf, 1994
Segal and Wolf, 1994
Success dependent upon both technology and intense Physical Therapy
There is normally phase dependence for H-reflex during walking, but
this phase dependence can be altered with neurologic insults
A

Makihara et al., 2011

Stance Swing

Muir and Steeves Normal SCI SCI with sensory stim

 Sol_Gait1(PRE)
Little activity at push off

250
EMG (%MVC)

150

50
0
0 10 20 30 40 50 60 70 80 90 100
Sol_Gait2 (Intermediate)
Gait cycle (%)

More activity during stance

250
EMG (%MVC)

150

50
0
0 10 20 30 40 50 60 70 80 90 100
Gait cycle (%)
Trumbower, et al. 2011
Trumbower, et al. 2011
Trumbower, et al. 2011
Trumbower, et al. 2011
Trumbower, et al. 2011
From Kandel, Schwartz and Jessell, 3rd Ed
Wadsworth Labs, Albany, NY http://www.wadsworth.org/bci/index.html
From Stein and Mushahwar, Trends in Neuroscience, 2005
From Stein and Mushahwar, Trends in Neuroscience, 2005
From Stein and Mushahwar, Trends in Neuroscience, 2005
Theoretical robot to assist with activities of daily living from Ron
Alterovitz’s Website at UNC Computer Science
 Rick Segal, PT, PhD, FAPTA
November 2, 2012

Man vs. works with Machine: Technology

Meets and Shares with SCI Rehabilitation