Therapy Session

Please find the list of Indications, Contraindications and Risk Factors for Erigo Therapy here.

Please find the list of Indications, Contraindications and Risk Factors for Lokomat Therapy here.

Please find the list of Indications, Contraindications and Risk Factors for ArmeoSenso Therapy here.

Please find the list of Indications, Contraindications and Risk Factors for ValedoMotion Therapy here.

Please find the list of Indications, Contraindications and Risk Factors for Andago Therapy here.

Please find the list of Indications, Contraindications and Risk Factors for ArmeoPower Therapy here.

Please find the list of Indications, Contraindications and Risk Factors for ArmeoSpring Therapy here.

Do some of the patients you treat suffer from shoulder pain and subluxation grades 1-2*? Are you interested in some clinical tips on how to train these patients with the Armeo^®? Read this Q&A to find out more!

Armeo® therapy in patients with shoulder subluxation is possible and successfully applied in a number of clinics. However, shoulder subluxation is a risk factor for ArmeoPower and ArmeoSpring training and shoulder instability with uncontrolled shoulder displacement during training is a contraindication for ArmeoPower training, therefore special care from therapist’s side is required in order to ensure a safe therapy session. Remember that the clinician in charge is always responsible for decisions regarding whether Armeo therapy is indicated or not. Specifically, therapies must only be used if the potential benefits outweigh the potential risks for the individual patient in question. A few important  points should be considered before and during training:  

• Fixing or limiting the range of motion of the shoulder joints g. gleno humeral joint to focus on specific muscle training in order to reduce the risk of subluxation. (ArmeoPower: within the software– Fig1; ArmeoSpring manual adjustments – Fig2)

Fig. 1

Fig. 2

• Adjusting the arm weight support in order to ensure a correct shoulder alignment and to avoid overstretching of the soft tissues by the effects of gravity^2,3. E.g.  If the shoulder is distracted caudally due to the arm’s weight, you can increase the arm weight support to reduce the space between the head of the humerus and the glenoid cavity.
• Approximation (coaptation) of the gleno humeral joint to stimulate proprioception and a better joint alignment. This can be obtained by slightly shortening the length of the upper arm.
• Carefully adjusting the workspace with AROM and AMOVE keeping in mind that excessive ranges of motion (>90°) in flexion and abduction of the shoulder can be harmful² g. During AMOVE limit the painting on the ceiling and on the wall to the side of the impaired arm.
• Choosing specific exercises in accordance with the patient’s abilities e.g consider choosing exercises without challenge aspects related to the shoulder.

*Subluxation grades 1-2 according to Langenberghe and Hogan¹

1. Van Langenberghe HVK, Hogan BM. Degree and grade of subluxation in the painful hemiplegic shoulder. Scand J Rehabil Med. 1988;20:161–166.

2. Gresham, G. E., Duncan, P. W., & Staston, W. B. (1995). Post-Stroke Rehabilitation Guideline Panel. Post Stroke Rehabilitation. Clinical Practice Guideline No. 16 CAHCPR Publication No. 95-0662). Rockville, MD: U.S. Department of Health an Human Services, Public Health Service, Agency for Health Care Policy and Research.

3. Cailliet R. The shoulder in the hemiplegic patient. In: Shoulder Pain. 3^rd ed. FA Davis; 1991:193-226

Severe cognitive deficits are listed as contraindications for Armeo training. However, depending on the severity of the deficit, training may be possible if the following criteria are met:

• The patient is able to interact with the software and perform the exercises.
• The patient is able to understand the instructions of the therapist.

Below we have outlined a number of risks associated with limited cognitive abilities, and possible adjustments in order to ensure safe and effective therapy session with the ArmeoSpring.

Possible Training Adjustments for Possible Risks or Challenges

• If there is a risk that the patient could stand up while he is strapped into the Armeo, stay close to the patient in order to intervene if needed.
• If the patient forgets how to perform the exercise, select a simple training plan. Start with only one exercise and choose the easiest one for the patient.
• If the patient gets frustrated, dismayed or if he exhibits negativity, select a difficulty level where the patient is challenged but not overstrained.
• If the patient easily gets distracted, assess risk related to the patient’s lack of concentration. Divide training sessions into short sequences with breaks in between the exercises.

Please note that it is the clinicians’ responsibility to evaluate the possible risks and benefits for patients with impaired cognition and decide whether Armeo therapy is suitable.

Erigo training is not limited due to age but to the size of the patient. As long as it is possible to appropriately adjust the device to the patient it is possible to use the Erigo with patients of all ages.

The patient size for Erigo training is defined by:

• A maximum weight of 135 kg (297 lb)
• Leg length (measured from the foot sole to the greater trochanter) less than 69 cm (27 in.) or greater than 104 cm (41 in.)

Especially in the early stage of rehabilitation, moving into- and tolerating the upright position are important rehabilitation aims as shown in the integration reports. Various usage is seen ranging from 3 times per week to 5 times per week, sometimes even training twice per day (for example in the morning and in the afternoon). There are some remarks that you can keep in mind for increasing or decreasing the frequency of training:

Criteria for Increasing/Decreasing Frequency

• Increasing the training frequency/maintaining a high training frequency is recommended when improvements (e.g. muscle tone regulation, cardiovascular stability) during or after the therapy session are visible.
• Criteria for reducing the training frequency are: signs of fatigue, skin irritations (especially in the areas of the groin or thighs) or other negative effects which could result from the therapy itself.

Yes, it is possible to use the Lokomat with patients with spasticity, bearing in mind that spasticity that cause limitations in the range of motion and that cannot be reduced is considered a risk factor. Patients with high levels of spasticity require special attention while training on the Lokomat.

Aspects to Consider when Training Spastic Patients

With patients with high spasticity, please pay special attention to the following points. If any of these three points is the case, then Lokomat therapy is not suitable for the patient.

• The patient presents a contraindication resulting from maintained spasticity. For example, severe fixed contractures due to joint retraction.
• The level of spasticity is so severe and resistance constantly exceeds the safety threshold of the orthosis despite the adjustments to handle it, causing the Lokomat to stop. If this happens too often it may frustrate patients and make them feel “not good enough” for Lokomat training. Hence, this can affect their overall treatment motivation.
• The patient presents discomfort and pain during walking even when trained at a very slow speed and with the recommended adjustments.

Tips for Regulating the Spastic Response

• Air walking at slower speeds: Start the session with walking in the air at a slow speed (≤ 1 km/h) for a brief period of time before lowering the patient to come into contact with the treadmill. The spastic response is velocity dependent and is normally higher during the first movements; after a few repetitions the response usually regulates.
• Hip ROM and hip extension: Start with a reduced hip ROM. A greater ROM, particularly hip extension will more likely provoke a spastic response. If the patient’s spasticity response is still causing the device to stop even with reduced hip ROM, you can limit the hip extension either by increasing the hip offset value or by bringing the pelvic cushion backwards.
• Ground contact and loading: While contact with the treadmill can cause a spastic response, the weight loading will most likely contribute to muscle tone regulation. Thus, when you bring the patient down onto the treadmill, try to avoid foot contact without loading. Furthermore, reduce the BWS as much as possible later on in the session; this will contribute to muscle response/activation and at the same time regulate the muscle tone.
• Combination with conventional therapy: Interventions such as stretching exercises or standing and weight-bearing exercises in a standing frame device prior to Lokomat training may prepare the patient’s muscles for walk training.

Please Note

These recommendations are based on the feedback of experienced Lokomat users.

In many cases, patients with a neurological disorder spend a considerable amount of time sitting in a wheelchair or lying in bed, especially if they are unable to participate in an exercise or standing program. They have limited ability to complete activities involving axial weight bearing and the use of functioning muscle to preserve bone mass, and are thus at risk for osteopenia and osteoporosis. This forces clinicians to carefully consider the type and intensity of rehabilitation a patient can safely handle.
This document discusses specific aspects you may want to consider prior to deciding whether your patient is suitable for Lokomat training if they have a diagnosis of reduced bone density.

Possible Risks Versus Possible Benefits

Considerably reduced bone density (osteopenia or ) is a contraindication for Lokomat training. No Lokomat training may be conducted in patients where considerable bone density loss and an increased risk of fractures can be suspected from their history (for example in individuals who had prolonged reduced weight bearing), or in patients where considerable bone density loss has even been diagnosed. The repetitive axial loading and sheer forces exerted on the skeletal system during training can, despite the safety mechanisms, lead to fractures or other injuries in osteoporotic bones.

Most patients with a neurological condition display some level of osteoporosis or osteopenia. Reduced bone density is always a (i.e. training with the Lokomat is still possible under certain circumstances) and osteoporosis in its advanced stages is a contraindication and patients in this case must not train with the Lokomat. However, no clear cut-off value exists to include or exclude a patient from Lokomat training. This is a judgment call that must be made by the medical experts overseeing the patient’s treatment.

Therefore, the clinician has to decide whether the potential benefits outweigh the potential risks in each individual case

Aspects to Consider

There is one peer reviewed article [1] discussing guidelines and recommendations regarding Lokomat training in children. In addition to information from this article, and in the absence of further, evidence based guidelines and recommendations regarding osteoporosis and Lokomat training in adults, we have collected the following insights from a group of very experienced clinicians of the ARTIC [2] group (Advanced Robotic Therapy Integrated Centers) regarding how some of them handle Lokomat training with patients with reduced bone density:

1. If the patient has not walked or stood frequently as part of his/her training during the last six months, a bone density measurement is conducted prior to the initiation of Lokomat training. The decision if training can be conducted safely is then based on the results of this examination.
2. The following aspects of Lokomat therapy should be discussed with the treating physician:

• How much of his own body weight can the patient bear?
• Can the bone stand all forces (axial forces or sheer forces) applied by the orthosis? A demonstration of the Lokomat to the treating physician may be useful if he/she is not already familiar with the device.

3. The LokomatPro with pediatric orthoses is more sensitive and a safety stop is provoked sooner as a result of lower forces (e.g. evoked by spasticity) and gait pattern deviations compared to the adult orthosis. It is recommended to keep the sensitivity at the default setting (Value 2 = maximum selectable sensitivity) if the patient does not have daily over-ground walking training.

When carrying out Lokomat training with patients who may have reduced bone density, pay particular attention and consideration to the following factors.

• Correct hardware settings: Make sure that the orthosis is adjusted properly and the fixation is correct. The better the orthosis fits to the patient, the smaller the risk for undesired shear forces on the legs.
• Body weight support: Higher BWS will reduce the risk of injury. (The patient will be bearing less of his own body weight.)
• Speed and Orthosis Speed parameters: The more accurately the orthosis speed value is selected, the smaller the risk of overloading the leg and foot. Avoid strong impact or shear forces and choose a speed that is adapted to the patient and is physiological.
• Create the best gait pattern possible: The more accurately the gait pattern is selected, the lower the risk of undesired forces. The focus should be on a “smooth” and physiological gait pattern.

Keep in mind that the treating medical experts who prescribe and carry out Lokomat therapy are responsible for the patient. It is their decision as to what kind of treatment is appropriate for individual patients in their care; this includes whether Lokomat training is appropriate for a given patient.

Hocoma can only present items to consider when making the decision; Hocoma cannot make the decision as to whether Lokomat training is appropriate, especially without having any contact with the patients.

[1] Aurich, T., et al., Practical recommendations for robot-assisted treadmill therapy (Lokomat®) in children with cerebral palsy – indications, goal setting, and clinical implementation within the WHO-ICF framework. Accepted to Neuropediatrics, 2015.

[2] Craig Hospital, Denver, CO, USA / Spaulding Rehabilitation Hospital, Boston, MA, USA / Tan Tock Seng Hospital, Singapore / Rehabilitation Institute of Chicago, Chicago, IL, USA / Shepherd Center, Atlanta, GA, USA / University of Pittsburgh Medical Center, Pittsburgh, PA, USA / Rehaklinik Zihlschlacht, Zihlschlacht, Switzerland / Rehabilitation Center for Children and Adolescents Affoltern am Albis, Children’s University Hospital Zurich, Switzerland / Schön Kliniken Vogtareuth, Vogtareuth, Germany / Von Hauernsches Kinderspital München, München, Germany / Wellington Hospital, London, UK.

Orthopedic surgery in pediatric patients is often recommended when spasticity, stiffness, contractures or bone deformities are severe enough to make walking or moving difficult or painful.

After surgical intervention, a rehabilitation period is needed to achieve the functional goals. Lokomat therapy can be a rehabilitation tool for intensive gait therapy after surgery, but the parameters needed for successful therapy are not well established.

Before deciding if Lokomat is a suitable therapy approach for a patient, the clinician should carefully consider the contraindications and risk factors reported in the Lokomat User Manual.  

In this entry, we summarize the practical recommendations for Lokomat therapy after surgery as published by a group of physical therapists and physician experts in the management of patients with cerebral palsy.

General Recommendations for Robot Assisted Training (RAT) after Surgery

It is extremely important to define clear therapy goals after surgery. Lokomat therapy should only be carried out in accordance with the therapy goals of the patient. According to the recommendations from the experts, Lokomat therapy is not indicated after strong structural changes. Moreover, this group also recommends seeking out alternative therapies for patients whose goal is not to recover or rehabilitate gait after the surgery (Aurich et al. 2015).

Pain is a common problem after orthopedic surgery. Pain should be avoided during Lokomat therapy (Aurich et al. 2015). There are various factors that may lead to pain during a Lokomat session, and each cause should be considered individually. For example, pay special attention while fitting the harness (use additional padding if required), avoid friction between cuff and leg with proper tightening of the cuff, and adjust the range of motion according to the patient’s limits. These are a few examples of general recommendations on how to control or reduce the incidence of pain during a Lokomat session.

Recommendations in Accordance with Various Orthopedic Operations  

Lokomat therapy is possible after soft tissue surgery such as muscle/tendon transfer or myofasciotomy. The onset of Lokomat therapy is recommended 6-8 weeks after the surgery; although after percutaneous myofasciotomy, it is possible to start 4-6 weeks after surgery if the patient has free range of motion (ROM) without pain (Aurich et al. 2015).  

After surgery performed on a bone (pelvis, femur, foot, etc.) there is a general recommendation to wait 8-12 weeks before starting Lokomat therapy. Consolidation of the surgery needs to be sufficient and judged by the orthopedic surgeon as well as documented by x-ray. Free passive ROM (especially in hip and knee flexion) should be documented prior to the start of therapy. The amount of loading should be discussed with the orthopedic surgeon prior to the start of therapy. When the patient has been prescribed and/or fitted with an ankle-foot orthosis after surgery, it is recommended that the patient wear it during Lokomat therapy (Aurich et al. 2015). 

Lokomat therapy cannot be provided is contraindicated after hip, knee and ankle arthrodesis as a sufficient ROM in these joints is a basis for Lokomat therapy.  

Musculoskeletal Considerations after Surgery

Musculoskeletal deformities are a common secondary problem in children with cerebral palsy. General considerations apply for mild to moderate deformities. Lokomat therapy must not be provided in case of Sstrong structural abnormalities in the frontal or sagittal plane (e.g. genu varus, genu valgus) are contraindications for Lokomat therapy since the risk for secondary injuries due to possible shear forces is increased.   

Hip subluxation and dislocation is not a general contraindication. Training in an abducted hip position (by adjusting the frontal plane settings of the Lokomat) is recommended for such patients (Aurich et al. 2015).  

Asymmetrical leg length influences the position of the pelvis and/or the foot contact with the treadmill. Relevant leg length discrepancy should be corrected (e.g. using insole or shoe rise) in order to improve the pelvis position and the ground contact (Aurich et al. 2015), but it nevertheless constitutes a risk factor for Lokomat training.  

Scoliosis is not a general contraindication. The position of the patient during therapy should be considered and an upright position of the trunk (Aurich et al. 2015) shall be the goal. As an indication, experts point out that patients with a Cobb angle over 60-70° have a difficult time staying upright. Moreover, a trunk stabilizing orthosis needs to be used with caution to prevent pressure marks or disturbed blood flow in the upper limbs (Aurich et al. 2015). 

Lokomat therapy with patients after lumbosacral fixation / fusion must be discussed and agreed upon with the orthopedic surgeon (Aurich et al. 2015). 

For children with cerebral palsy and a GMFCS level IV-V (non-ambulatory), consider the bone density and the risk that osteoporosis presents. Significant osteoporosis is a contraindication for Lokomat therapy (Aurich et al. 2015).  

Keep in mind that the treating medical experts who prescribe and carry out Lokomat therapy are responsible for the patient. It is their decision as to what kind of treatment is appropriate for individual patients in their care; this includes whether Lokomat training is appropriate for a given patient. 

Hocoma can only present items to consider when making the decision; Hocoma cannot make the decision as to whether Lokomat training is appropriate, especially without having any contact with the patients. 

Do you have a different strategy when treating children in the Lokomat? Write a comment and share your experience! 

Aurich-Schuler, T., B. Warken, J. V. Graser, T. Ulrich, I. Borggraefe, F. Heinen, A. Meyer-Heim, H. J. van Hedel and A. S. Schroeder (2015). “Practical Recommendations for Robot-Assisted Treadmill Therapy (Lokomat) in Children with Cerebral Palsy: Indications, Goal Setting, and Clinical Implementation within the Who-Icf Framework.” Neuropediatrics 46(4): 248-260. 

The pediatric population has special individual characteristics which make a simple generalization from adults to pediatrics impossible. For that reason, a group of physical therapists and physicians met together and developed some practical recommendations for Lokomat therapy in children with Cerebral Palsy. The complete results are published in the 2015 article titled Neuropediatrics by Aurich et al.

Anthropometric Requirements

In order to ensure proper setup, the following recommendations were made by a group of experts: (Aurich et al. 2015)

• Body weight must be at least 15 kg
• The minimum femur length must be at least 21 cm
• Always use the Lokomat distal cuff to  fasten the exoskeleton better to the patients’ legs

Distal cuff bracket removed

Orthostatic Requirements

• The patient should be able to sustain a vertical position for at least 20 minutes as assessed by the therapist prior to initiation of therapy.
• Emergency exit strategies during therapy have to be set up in advance and it may be useful to practice these with a healthy volunteer in advance.
• The individual institution’s emergency call procedure must be familiar to all therapists.

Handling of Pain

• The condition of the patient must be monitored continuously during therapy.
• Mild occurring pain during the first therapy sessions (e.g. muscle pain, pain caused by pressure of the cuffs or by the belt system) is frequently observed. Any sort of pain, but most critically pain in bones, joints, or soft tissue during therapy, has to be analyzed immediately.
• Shear forces on the joins must be avoided. Consequently, an individual fitting and adaptation of the exoskeleton must be performed with great care on the current range of motion and the axes of the patient’s legs.
• The correction of existing anatomical abnormalities or deformities should be made only through small, gradual changes within the software setting.
• If complaints persist despite adjustments over the second or third therapy session, the indication of robotically assisted treadmill training as a therapeutic option needs to be critically reconsidered.

Keep in mind that the treating medical experts who prescribe and carry out Lokomat therapy are responsible for the patient. It is their decision as to what kind of treatment is appropriate for individual patients in their care; this includes whether Lokomat training is appropriate for a given patient. Hocoma can only present items to consider when making the decision; Hocoma cannot make the decision as to whether Lokomat training is appropriate, especially without having any contact with the patients.