Therapy Session

The C-Mill C-Gait assessment is a test to visualize the functional walking performance (or adaptation ability while walking). The C-Gait assessment is intended for all patients that are indicated for C-Mill therapy, that can walk and perform gait adaptability tasks for over 18 minutes as this assessment lasts approximately 18 minutes (depending on the patient’s speed).

The C-Gait assessment consists of 7 different tasks: visually guided stepping, tandem walking, obstacle avoidance, slalom walking, reaction to unexpected situations, speed adaptations and, if applicable, walking while performing an auditory, cognitive dual task[i].

Figure 1: Task evaluation

Each task should be executed twice at different degrees of difficulty, once at an easy degree and once at a higher degree (level 2 and level 4).

Each task ends with a pop-up window containing some evaluation questions (figure1).

The questions are:

-Rate the level of challenge

-Has the client supported oneself during the section.

-How often was the handrail used

Figure 2: Final evaluation

When the protocol is finished, all the tasks are completed, then a pop-up appears with the following questions ( figure 2):

▪ How tiring was the training? Please rate from 6-20, with 6 being ‘not tiring at all’ and 20 being ‘maximum exhaustion’.

▪ How afraid are you to fall when you walk outside? Please rate from 1-10, with 1 being ‘not afraid’ and 10 being ‘extremely afraid.

Figure 3: C-Gait assessment Outcome measurement

After the assessment, the scores of each task will be presented using the spider diagram (figure3).

The C-Gait scores are based on the performance on each task and the difficulty level at which the task is executed (difficulty level * 2 * performance (%) / 100). Five is the highest difficulty level, but only possible to choose for the C-Gait Training[ii]. The score that is displayed in the spider diagram is the highest score achieved on one of the two levels. The maximum score that can be achieved for each task in the C-Gait assessment, therefore, is eight (100% performance on level four).

[i] The auditory, cognitive dual task is an auditory Stroop test. The patient hears the words “low” and “high” in a certain pitch. Just like the visual Stroop test, the patient needs to say out loud whether the pitch is high or low. This task can only be performed with additional hardware and software for speech recognition. The software skips the Cognitive tasks in the C-Gait assessment because they are not available.

[ii] The C-Gait assessment has been released; however, the C-Gait training is only available for customers that participated in the C-Gait study.  It won’t be developed further.

The Biofeedback Graph is an interactive tool to confirm that your patient remains active during the Lokomat session. In combination with the high number of repetitions achieved during a training session, this effort results in high training intensity.

The purpose of Biofeedback is to enable both the clinician and the patient to visualize objectively the amount of effort the patient is contributing during a gait cycle. Thus, to provide feedback on the performance of the patient.

How is it displayed?

Biofeedback Graph can be displayed at any moment of the Lokomat session on the therapist screen if you click on the button Biofeedback Graph on the bottom tab of the Lokomat training screen (Figure 1).

Figure 1: Biofeedback Graph icon on therapist screen.

To display the Biofeedback Graph on the patient screen and therewith enhance the patient’s attention and motivation, choose the Biofeedback Graph on the Library and add it to the therapy plan of your patient (Figure 2).

Figure 2: Biofeedback Graph on patient’s Therapy Plan

In both situations, the Biofeedback Graph is represented as a group of four graphs corresponding to the hip and knee activity for the left and right legs. Every graph has two lines: an orange line that indicates the level of activity during swing phase and a blue line indicating the level of activity during stance phase. On the vertical axis of the graphs (y axis), we can observe the amount of biofeedback units (the Lokocontrol software converts the force measured at the hip and knee joints), while on the horizontal axis (x axis), we can see time in seconds (Figure 3). On a functional level, this allows both the clinician and patient to know whether the patient is active at the appropriate time in the gait cycle.

Figure 3: Biofeedback Graph display with 4 graphs.

Some recommendations for its application:

Based on the experience of Lokomat Users, here are some recommendations on how to benefit from the Biofeedback when treating a patient.

• Observing the baseline: When starting the training and while the patient is still relatively passive, visualize the Biofeedback Graph to see what a “passive” graph looks like.

It is important to remember that the absolute values of the Biofeedback Graph on the y axis may be different from session to session, that is why we recommend observing the session’s baseline during this passive phase.

• Assess the patient’s ability to increase effort: Once you have set a baseline, you can assess your patient’s ability to generate more gait-phase-appropriate force i.e., the patient helps with the movement (graph line goes up), or more gait-phase inappropriate activity, i.e., the patient resists the movement (graph line goes down).
• Use during training: Use the biofeedback screens during training to maximize your patient’s effort. Some examples:
• Adjust the Biofeedback Graph to show only 1 joint in 1 gait phase and get your patient to focus on that particular movement (Figure 2 and 4).

Figure 4: Biofeedback Graph showing 1 joint on patient’s screen.

• Monitor your patient’s effort. You can use the Biofeedback Graph to make sure that your patient is training throughout the entire Lokomat session.
• Monitor the effects of your training adjustments. You can use the Biofeedback Graph to monitor any activation changes in relation to other treatment parameters (speed, loading, guidance force).

On the LokomatPro there is an algorithm called Path Control which is used for training patients at low Guidance Force (GF). When you select a GF below 50% (on both legs), the Path Control algorithm is activated. In this post we will explain you more about the differences between GF and Path Control and how to use the advanced settings of this feature. 

REFERENCES

• Aurich-Schuler T, Grob F, van Hedel HJA, Labruyère R. (2017) Can Lokomat therapy with children and adolescents be improved? An adaptive clinical pilot trial comparing Guidance force, Path control, and FreeD. J Neuroeng Rehabil.
• van Kammen K, AM Boonstra, LH van der Woude, HA Reinders-Messelink, and R den Otter. (2016) The combined effects of guidance force, bodyweight support and gait speed on muscle activity during able-bodied walking in the Lokomat. Clin Biomech (Bristol, Avon).
• Duschau-Wicke A, vJ Zitzewitz, A Caprez, L Lünenburger, and R Riener. (2010) Path Control: A Method for Patient-Cooperative Robot-Aided Gait Rehabilitation. IEEE Transactions on nneural systems and rehabilitation engineering.

Download the ArmeoPower Clinical Troubleshoot Document here:

ArmeoPower Clinical Troubleshoot Document

Download the ArmeoPower Setup QRG here

ArmeoPower Quick Reference Guide

Many therapists want numerical data from training sessions for research or clinical applications. The Lokomat offers a recording function that records biomechanical and technical signals in every session to monitor your patients’ progress.

With software version 6.5 the data are no longer automatically recorded; to record follow the procedure below:

1. Select the icon System Settings on the bottom of the main menu of the software.
2. Select SYSTEM SETTINGS in the Lokomat options.
3. Select CONFIGURATION on the bottom of the page.
4. Check the box “Record all signals for each session”.
5. The system will ask you to restart the software (Lokocontrol). Press “OK” to restart.

The data recorded during training are saved by default in D:\Hocoma\Recorder as text files called “Recording_YYMMDD_HHMMSS.txt”. The second half of the file name is a timestamp with two digits for Year, Month, Day, Hour, Minute and Second.

There are many applications that will open the recording .txt file but many therapists use Microsoft Excel for this purpose. Below is a brief instruction on how to open your recorded data in Excel:

1. Open a Blank workbook in Excel
2. Select Data > From Text/CSV
3. Find and select desired Recording .txt file
4. Click “Import”
5. Select in a preview the delimiter Semicolon
6. Press “Load”.

Now the data are ready to be viewed and analyzed.

Download the Overview of the Recorded Signals in Lokocontrol V6.5 here

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.

Definition

At its core, the fall limit is a way to customize the training for your patient. During gait, balance and step-up exercises, the patient’s center of mass moves vertically and with the fall limit you can adjust the allowable range of vertical displacement.

Figure 1: Default fall limit. Patients can move downward 7 cm for physiological gait or go over a step or obstacle up to 13 cm in height.

Figure 2: High fall limit. Patients can perform balance exercises and move downward up to 20 cm.

The fall limit can be adjusted by either pressing and holding the default fall limit button or by pressing the lift button to achieve the desired position.

NOTE: If the body weight support (BWS) is set to 0, adjusting the fall limit is not possible.

Why Adjust the Fall Limit?

Adjust the fall limit to give your patient flexibility in his training depending on his therapy goal.

• For gait and step training, use the default fall limit (suspension carrier arrow at the dot in Figure 3). The default fall limit allows your patient to safely displace himself downward 7 cm and upward 13 cm.

Figure 3: Default fall limit. Adequate for physiological gait. Press and hold the default fall limit button until the arrow is at the dot.

• For balance and squat training use a high fall limit (suspension carrier arrow toward the upper mechanical limit in Figure 4). The patient can perform downwards movements (like squats) of up to 20 cm. Adjust it to a position where your patient can perform the activity while still being able to recover in case he falls.

Figure 4: High fall limit. Adequate for balance exercises and squats. Use the lift button to adjust the fall limit to the desired height.

Other Considerations

• The fall limit will be asymmetric when applying asymmetric body weight support. Adjust the fall limit so the side that is closer to the lower limit is at your desired position.
• When the upper limit is reached, the Andago will automatically switch to straight line mode. Once the suspension carriers are no longer at the upper limit, the Andago will switch back to the mode it was in.
• If the patient often reaches the lower limit during gait, adjust the fall limit manually to a higher position by pressing the down arrow
• Also check if you can help your patient by adjusting the BWS or by manually providing more trunk stability.
• If the patient reaches the lower limit when turning or walking in a curved path, adjust the fall limit manually to a higher position. Give verbal and manual feedback to your patient to keep a stable trunk posture.

Andago Body Weight Support (BWS) unloads a portion of the patient’s weight, thus decreasing the amount of weight they need to support themselves. This weight unloading is also dynamic in that it provides constant unloading despite any vertical movement during the gait cycle and therefore ensures the most physiological unloading and afferent input.

How Much Body Weight Support is Enough?

In general there are two things to check when applying body weight support:

• Does the patient exhibit a stable standing position?
• Is the patient’s knee extending correctly during stance phase?

If possible, talk to your patient and involve them in the decision of increasing or decreasing BWS. Below we offer some tips for BWS adjustment during training.

• When adjusting the BWS symmetrically or asymmetrically, do it in small intervals (~5%) to ensure a level where the patient is able to accomplish the tasks while still being challenged. Providing too much BWS can produce changes in the gait pattern and hamper the patient’s ability to walk.
• The total amount of unloading is the sum of both BWS modules.
• Correct the fall limit (or to set it to the default value) after changing the BWS.

Things to Consider Before Adjusting Body Weight Support

Body weight support during overground training is a great way to help patients and with the Andago it can be adjusted during training by pausing the session and using the BWS button to increase or decrease the amount of unloading. However, too much BWS can be counterproductive and training can be improved by looking at other aspects before automatically reaching for the handheld.

• Check if providing pelvis and trunk stability contributes to knee stability. If so, consider using therabands or other standard therapy material to provide stability at the pelvis. Also consider giving your patient trekking poles or your hands to avoid the patient using the handrails and to stimulate specific movements.
• Check if specific verbal indications (“keep your leg as straight as possible”) helps the patient understand what is required. Place them in an everyday environment to facilitate the transfer of skills and give explicit feedback (e.g. “walk to the corner and collect the ball”).
• Training in front of a mirror can also help the patient correct his posture and improve stability prior to gait training and gives the therapist a broader view of the patient while correcting some movements.
• Check for muscle contractures in the hips, knees or feet that might be responsible for the knee flexion and treat them separately in addition to the Andago training.
• Ask your patient to walk faster if possible to reduce stance time and therefore reduce demand on quadriceps. If this is not possible, start training static positions with the Andago and work on weight shifting and weight transfer from one leg to the other.

Should I use Symmetric or Asymmetric Body Weight Support?

Andago BWS can be applied symmetrically or asymmetrically in order to compensate differences in loading ability of the patient on both sides (e.g. for stroke patients). Increasing BWS unilaterally can help your patient by supporting pelvis stability and postural control.

• Check the pelvis lateral tilt to identify if additional unloading is required on one side of the body.

Figure 1: In order to apply BWS asymmetrically, select the side on the handheld before adjusting the amount of unloading.

Clicking the symmetric unloading button after setting asymmetric BWS will distribute the total unloading symmetrically.

Example: if you unload the right side by 15 kg and the left side by 5 kg, clicking symmetric unloading button will set both sides 10 kg unloading.

This document provides a quick overview on all training categroies of the C-Mill and their corresponding treatment goals.

Quick Sheet - Therapy Goals

This guideline describes the clinical workflow on the C-mill system and explains the different categories Stand, Step and Walk with their corresponding treatment goals, assessments and training for patients with balance and walking impairments.

C-Mill Therapy Guide

For patients with little or no motor function, robotic support on the ArmeoPower allows the patient to conduct movements in a 1D, 2D or 3D environment. To engage the patient and to have him use his arm as much as he can, robotic support is provided with “assist-as-needed” mechanisms. This means if the patient can only partially make the desired movement, the ArmeoPower will support him for the rest of the task.

In general there is the option to select four levels of robotic support. Each level of support offers different advantages depending on whether the exercise is a 1D (single-joint) or 2D/3D exercise.

Choose the correct level of robotic support according to the patient’s ability and therapy goal in order to:

• challenge the patient (bring him out of his comfort zone and encourage him to use the complete motor function) and
• avoid frustrating moments of unsolvable movement tasks (see Figure 1).

Figure 1: Amount of robotic support depends on patient motor function.

On the therapy plan screen, you have a library on the left (holds all of the exercises and assessments) and the therapy plan on the right. From the library on the left you can choose which items you want to include in your therapy plan.

On the top of the library you have the filter options. The first box is a simple click filter where you can switch whether the list is showing exercise or assessments.   The second box is a dropdown menu that sorts the exercises by therapy goal and the third box is a dropdown menu that sorts the exercises by active joints or arm segments. With these filters you can quickly narrow down the list of exercises to only those that serve the patient’s needs.

There are two ways to add items from the library to the therapy plan. You can drag and drop—that is holding the mouse button down after you’ve clicked an item and then moving it over to the therapy plan or you can use the two arrows between the library and the therapy plan. To do so, click the item you wish to add to the therapy plan and then click the right arrow. Removing items from the therapy plan is done in the exact same way. You can drag and drop back into the library or select an item from the therapy plan and then click the left arrow.

To automatically remove all items from the therapy plan you can always click the trash can arrow.

Once you have items in your therapy plan you see the scope of your plan at a glance. Here you can see how long the plan is and how many items you have. The time only counts exercises because assessments are not timed. You can also easily change the order of the items in the therapy plan. Click the item you’d like to change the order of and then click either the up or down arrow to move it up or down in order. You can also drag and drop the items within the therapy plan to change the order.

Check also the instruction video to get more information.

A-ROM is an assessment that measures the patient’s maximum range of motion (ROM) of the upper extremities for all degrees of freedom. A-ROM is mandatory in the initial assessment step and the software will prompt you to carry out the A-ROM assessment. In addition, you can carry out the assessment as many times as you like by adding it to the patient’s therapy plan. By running it through the therapy plan, you can also select single degrees of freedom and measure them.

A‑ROM can be carried out actively or passively: active means the movements are generated solely by the patient with no intervention by the therapist; passive means the therapist guides the arm of the patient to carry out the assessments.

On the ArmeoPower, the initial A-ROM assessment is passive. If you carry out the A-ROM assessment through the therapy plan, you can do so either passively or actively. Passive A‑ROM assessments carried out through the therapy plan overwrite the values of the initial A‑ROM assessment, which influence the workspace of the 1D-exercises. Active A‑ROM assessments carried out through the therapy plan do not overwrite any values and are used only in reporting.

On the ArmeoSpring, the A-ROM assessment is active, though you can carry out a passive A‑ROM assessment if you wish to log the passive ROM of your patient. If you carry out the A-ROM assessment through the therapy plan, you can do so either passively or actively. Active A‑ROM assessments carried out through the therapy plan overwrite the values of the initial A‑ROM assessment, which influence the workspace of the 1D-exercises. Passive A‑ROM assessments carried out through the therapy plan do not overwrite any values and are used only in reporting.

For more information please check the instructional video.

A-MOVE is an assessment of the patient’s capability to move and explore the reachable space around him with his arm. The software measures the position of the hand in two and three dimensions and calculates the patient’s 3D workspace. This is important because defining the workspace influences the placement of targets in the exercises and the placement of the targets relates to the difficulty of the exercises. What is more, the Armeo software will only place targets within the patient’s reach as assessed by A-MOVE; this prevents frustration and the patient from “pushing” or overcompensating to reach targets placed outside of his reachable area during the exercise.

A-MOVE is mandatory in the initial assessment step; though you can carry out the assessment as many times as you like by adding it to the patient’s therapy plan.

On the ArmeoPower, the initial A-MOVE assessment is passive, but you can choose to do it actively or passively when you access A-MOVE from the therapy plan. “Passive” means the therapist guides the arm of the patient to carry out the assessments.

On the ArmeoSpring, the A-MOVE assessment is always active. “Active” means the movements are generated solely by the patient with no intervention by the therapist. Furthermore, you have to set patient zones at the end of A-MOVE for ArmeoSpring. Please make sure to set the two zones as close as possible to the patient’s body (1. Place the hand module next to patient’s knee and press space bar, 2. Place the hand module just in front of patient’s lower abdomen and press space bar).

To get more information, please check the instruction video.

In general a session is divided into several parts:

• Prepare the Armeo in advance
• Set-up the patient on the Armeo
• Adjust parameters individually to the patient needs and abilities
• Conduction of the training session (running the therapy plan)
• Bring the patient out of the Armeo
• Check the patient

Focusing on these parts, we have to differ between an initial session (first Armeo session with each patient; this is needed to personalize the therapy plan to the individual patient needs) and follow-up sessions. For the initial session it’s mandatory to adjust several parameters for the first time accurately (setting the workspace, creating a therapy plan). Thus, the duration of this part is increased compared to follow-up sessions (Table 1). Nevertheless, it’s recommended to adjust theses parameters gradually during the rehabilitation due to the progress of the patient.

In addition, the set-up settings like arm length and arm weight compensation of the initial session are saved in the software. Therefore, you could prepare the Armeo in advance of the training session in order to reduce the set up time for the follow-up sessions (Table 1).

Furthermore, you should check precisely the patient after the initial session (e.g. skin irritations) in order to plan further treatments with the device.

All in all, the duration of an Armeo session is dependent on the conditions of the clinic (e.g. staff resources or treatment intervals). The training session should at least last 20 minutes in order to get the desired results. Please keep also in mind:

• The intensity of a training session in terms of duration, repetitions, difficulty task or frequency, is influencing the outcome of rehabilitation (Kwakkel et al., 2004)
• As a clinician you will gain experience about the set-up of patients and adjustment of parameters over the time, which further reduce the setup time.

Jerky movements during ArmeoPower therapy occur in response to inappropriate settings. A number of simple adjustments are sufficient to prevent this.

Patients 3D-workspace should not overlap with patient’s safety zone

• The safety zone, that has to be created at the beginning of the therapy session, should be defined as close as possible to the body of the patient. If not, the safety zone may overlap with the 3D-workspace which can lead to jerky movements.

Starting position for movements should be within the 3D-workspace

• Please check if the patients arm position is within the workspace before starting any exercise with the ArmeoPower ( = before pressing the acknowledge button). Otherwise the robotic device will move the arm into this predefined area, often perceived as a jerky movement of the arm.

For single joint exercises, all other joints should be in an appropriate position to prevent interference with the safety zone.

• For example, if the exercise is for shoulder horizontal abduction-adduction, like “Rain Mug”, it is recommended to place the arm: extended as much as possible, 90° shoulder flexion neutral pronosupination and neutral wrist flexoextension. In this way, the desired movement (shoulder horizontal abd-add) can be performed without getting into the safety zone .

Hocoma AG has exercised great diligence in the selection of the materials that are in contact with the patient, these materials that have been assessed for its biocompatibility. Nevertheless, individual patients may under some exceptional circumstances experience adverse reactions. Abrasions or skin irritation are possible side effects of Lokomat training, to minimize these effects consider the following:

• Ensure that the patient is wearing suitable clothing. Wearing appropriate pants can reduce the risk of skin irritation. We suggest long pants or track suit pants made of soft cotton. Leggings are also suitable. Thick, rough fabrics with thick seams, very loose-fitting pants or pants with lots of zippers, studs or rivets are unsuitable. Synthetic materials can cause mild irritation or chafe the skin. Shorts are not suitable either because they allow the cuffs to rub directly against the skin.
• Avoid folds under the cuffs. When the patient is set up, wrinkles and folds in the pants under the cuffs must be avoided. These wrinkles and folds can cause abrasions while the patient is walking.
• Choose the proper cuff size. The cuffs should fit snugly but should not be so tight that they re-strict the patient’s circulation or cause skin lesions. If the cuffs are too loose, they can move up and down while the patient is walking and cause abrasions or chafing.
• Use padding. Hocoma provides two types of padding with the Lokomat: the groin padding (helps prevent irritation in the groin area) and shin guard (helps prevent irritation of the patient shins). Neo-prene is also an optional padding material; consider using neoprene pads between the patient’s legs and the cuffs. Another option would be to bandage the patient’s lower legs.

• Ensure patient is correctly set up in the Lokomat. The Lokomat’s axes must be well aligned with the patient’s joints to minimize cuff travel as the patient trains. If the cuffs move from their initial setup position, they might not fit the patient’s legs properly risking abrasion or restricted circulation. Make sure the orthoses are well fixed and do not slip down. Do not allow the lowest cuff to come in contact with the external malleolus.
• Avoid shear forces: With the FreeD module on the Lokomat, the pelvis can translate left and right and also rotate during gait. Therefore, the cuff mechanism that guides the patient’s legs also needs to allow this left-right movement of the legs to avoid shear forces. If you block the cuff movement in the frontal plane, make sure you don’t allow the pelvis lateral movement- no FreeD.
• Consider the patient population and comorbidities. There are populations with sensitive skin and comorbidities that impact the skin.
  • Patients with Spinal Cord Injuries experience decreased sensation because of their injury or medical condition. Impaired sensation can lead to the development of pressure sores be-cause the patient is unaware of any problem. They cannot tell the therapist if something hurts or does not feel right.
  • Older adults have gone through intrinsic changes, among them: reduction of collagen type I, elastin, fibroblasts and sebum secretion.
  • Pediatric patients have thinner skin that is more easily damaged.
  • Bariatric patients have less vascularization of the adipose tissue and are associated with other comorbidities.
  • HIV and AIDS patients are immuno-suppressed.

Comorbidities that impact the skin:

• Diabetes with microvascular and neurologic changes (prolonged wound healing)
• Altered nutritional status
• Altered hormone levels (estrogen, testosterone, GH)
• Anemia
• Atherosclerosis, decreased perfusion
• Venous insufficiency
• Any source of edema: lymphedema, venous stasis, hypoalbuminemia
• Colonization of skin with fungus and pathogenic, multiple resistant bacteria
• Pharmacologic compromise: corticosteroids, immunomodulators (Jeffrey et al., 2015)

Examine patients, especially new ones, on a regular basis for any possible skin irritations and signs of allergic reactions.
When bringing the patient out of the Lokomat check the patient’s shins and groin area for possible skin abrasions. Should there be signs of skin irritation or an allergic reaction, further training is not permitted. Have the situation first clarified by a dermatologist.
Skin lesions that cannot be protected appropriately constitute a Lokomat contraindication.

References
Jeffrey et al., Considerations in Special Populations: Patients with vulnerable skin, National Pressure Ulcer Advisory Panel, 2015; www.npuap.org

Would you like to increase therapy intensity, especially over the weekend and during after work hours, even when the therapists are not available?

Did you know that with the Armeocontrol 2.2 software release, among other features, you will be able to offer a limited supervision ArmeoSpring therapy to your patients? This way, the patients are empowered to train also outside of their scheduled therapy!

Over the weekend and during after-work hours the patients may have the possibility to train under supervision of a trained therapy assistant, using patient-specific therapy plans previously created by the therapist! This will increase intensity and frequency of patient activity and decrease the idle time, without increasing therapist workload

The Armeo software has been adapted so that the patients will be able to login with a patient-specific password, will be easily guided through a step-by-step setup, and will automatically start their therapy plan. An intuitive navigation within the therapy plan allows the patients themselves to use the Armeo exoskeleton to easily pause, skip an exercise or end the session.  The results of the session will then be integrated into the patient report, similar to normal therapy sessions.

Read the recommendations below regarding some aspects to consider when setting up the Armeo Extra Time concept in your clinic.

• The Armeo Extra Time therapy must be supervised for safety reasons, however this can be done within a group setting. Therefore, we suggest to position the ArmeoSpring in an environment where a supervision of patient activity is already in place. As an example this could be within a “therapy gym” (medical training therapy) environment supervised by a lay ”supervisor” who does not need to be a therapist. The ArmeoSpring can be positioned among other fitness, endurance and strength training machines.
• It is important that the supervisor be specifically trained on the basic use of the ArmeoSpring as for example the change of sides of the device, correct patient setup and some troubleshooting. Specific indications on what to train the supervisor on are provided in the User Manual Chapter 4, section 3.6. In order to facilitate this, some Quick Reference Guides have been created specifically for the supervisor (User Manual Appendix A) and can be stuck to the wall/desk.
• Each patient who will train with the Armeo Extra Time will have a login password which will allow him/her to log into their own personalized therapy plan. A default password is created for the patient, but can be changed by the therapist (User Manual Chapter 4, page 45). Please also consider writing the patient password in a safe place where the patient will not lose it (e.g. on the patient schedule).
• To ensure a smooth process and organization, we suggest establishing a sign up system where patients can choose a time slot and indicate their impaired arm. This enables the supervisor to prepare the correct setting for patient therapy (e.g. left-right arm change) and prevents conflicts between many patients who may be eager to exercise on the Armeo at the same time. One way to implement the signup system is a white-board, managed by the therapists but placed in a visible place (e.g. hallway) next to the therapy gym.
• The Armeo Extra Time therapy can also be conducted in the presence of a caregiver (relative of the patient, friend etc.). This can serve as motivational factor for the patient and provides a means to facilitate the patient setup without needing hospital personnel.

Refer to the User Manual for more info, including step by step Quick Reference Guides for the lay supervisor.

Keeping medical devices clean and disinfected is a crucial topic for hospitals and clinics.

Together with the support of external hygiene experts, we’ve elaborated on the Cleaning and Disinfection Recommendations for the Armeo.

Please find the document below.

Please note that these are only recommendations! The hospital or clinic that operates the Armeo is always responsible for the hygiene of their devices. The list of recommended disinfectants in the document does not claim to be exhaustive.

Armeo Cleaning and Disinfection Recommendations

Would you like to quantify, monitor and visualize information regarding your patient’s performance and activity during Armeo therapy? With the Armeo 2.x software, there are multiple levels of information you can retrieve, from basic results displayed on the screen, to more complex research features. Please consider that some features are intended exclusively for research purposes.

Advanced Options for Scientific Researchers

Please contact us at clinical.research@dih.com for additional advanced interface options that are available for research teams with their own software development capabilities.

*Available for Armeocontrol 2.2 onwards. Please contact your Hocoma Sales representative to schedule an upgrade.

**Please note these features are research features, which are not part of standard Armeo delivery and are provided without any guarantee and further support.

Achieving therapy goals is directly related to challenge the patient. Therefore, as your patient ability progress, settings and tasks on the Armeo^® need to be adjusted. Each patient as well as each patient group behaves and progresses in a different way. However, there are a number of progression characteristics, which you can use as a criteria for further challenging your patient.

Criteria to Recognize you Should Increase the Challenge for your Patient

• The given exercises can easily be done before the time runs out
• The patient always achieve 100% of the tasks. You can also check this under “Scores”
• The patient can easily reach the boundaries on the screen during the exercise
• There is an obvious progression discernible for the Assessment tools within the Armeo software (A-Goal, A-ROM)
• There is an obvious progression discernible for additional conventional Assessments (e.g. Fugl-Meyer-Test, Manual Muscle Testing (MMT)
• Within the over-all therapy (conventional therapy) you realize improvements in conditional skills like coordination, agility, endurance, motor function and force

Adjustments for Challenging your Patient

Any of these criteria are a sign that the patient can be further challenged. Some adjustments might be more suitable than others according to which criteria is observed. Below, we recommend you which adjustments to make:

• Select more complex exercises, which challenge the patient according to demanded movement tasks. Armeo software offers exercises with different dimensions (1D, 2D, 3D) as well as different movements (single joint exercises, combined movement exercises). If you want to increase challenging the patient, you have to select more demanding exercises within the therapy plan.
• Additionally, you can increase the difficulty level within each exercise (settings). Each exercise provides four different difficulty levels (very easy – easy – medium – hard), which modify the movement tasks according to amount of targets or size of objects for example. Therefore, the given movement tasks will be much more challenging for your patient.
• Furthermore, increasing the workspace results in increased challenge. Armeo users often use this tool of challenging in order to increase patient’s range of motion. But, avoid patient’s movement compensation during adjusting the new 3D-workspace.
• Decreasing the arm weight support is also a challenging factor for your patient. This tool you can select, if you want to enhance training the strength of your patient. We recommend to decrease the arm weight support gradually to find the appropriate value and also avoid fatigue. Make sure that your patient is able to repeat the demanded movement tasks several times with the new arm weight support.
• Increasing the amount or duration of Armeo sessions The duration of training sessions could be adjusted through adding exercises to the therapy plan or increasing the time within each exercise (settings). You can also increase the amount of training sessions per week.

Please Note:

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

The intention of ArmeoSpring therapy is not that the clinician provides assistance throughout the training. On the contrary, one of the advantages of the ArmeoSpring therapy is that it allows patients to practice independently at the limit of their present capabilities and with a high amount of repetitions.

The device includes the following features which allow the therapist to setup the device at the beginning of the therapy session according to each patients strength and abilities and allow independent training:

• Adjustable weight support: Counterbalances the weight of the patient’s arm. This allows even severely impaired patients to initiate and practice movements by themselves.
• Workspace: Allows you to set up a 3D working area in which the exercises are performed. It can be adjusted for each patient individually in advance, according to his movement ability.
• Automatic sequence: Allows you to design a therapy plan comprising the Augmented Performance Feedback exercises for the individual patient in accordance with his abilities and training goals. Then, the exercises run one after the other automatically in the defined order.

However under certain conditions it could be helpful if you support the patient:

• At the beginning of the session in order to demonstrate the correct movement pattern or prevent compensatory movements as well to get familiar with the exercises.

• A-ROM in passive mode: A-ROM assessments can be performed actively or passively. In the active mode, the patient should perform the movement on his own. In the passive mode, you should assist the patient in performing the movement.

Combination with conventional therapy: Since the Armeo provides patients with the possibility to practice movements independently of any external support; you could use this opportunity to combine Armeo therapy with other therapy techniques (e.g. facilitation techniques).

As in any other therapy it is recommended to define individual, patient specific therapy goals with the Armeo with a focus on his/her functional limitations and improvements relevant for daily life and profession.

Therapy goals that can be achieved with the Armeo include improved strength, function or coordination. The expertise of the therapist is to use the features or adjust parameters of the Armeo in such a way that the selected therapy goals can be achieved.

Figure 1: Adjustments related to therapy goal

• To focus on strength training, you can select either a rather low arm weight support or gradually decrease the arm weight support over time. Additionally, we recommend using a small 3D-workspace and rather single joint exercises in order to focus on the implementation of muscle force during the desired movements.
• To focus on functional training, it is recommended to choose a challenging 3D-workspace. by exploring the limits of the patients functional workspace. Arm weight support plays a minor role.  Select exercises that focus on functional movements the patient requires to train. For example, to focus on grasping, you can select the egg cracking exercise.
• To focus on coordination, select a more “complex” exercises in order to provoke joint coupling, this means, at least two joints involved in a kinematic chain of the arm movement. The 3D-workspace can be rather small and the arm weight support rather high.

The Armeo provides a wide set of exercises to create the therapy plan for your patient. The selection of the exercises should be done individually according to the patient’s diagnose, capability and therapy goal. To know which exercises to select for your patient, here we give you some recommendations on how to do this:
First, perform the exercises yourself as clinician to learn the characteristics and differences between them. With the information of both, the patient and the exercises, you can select the most appropriate exercises.

Individual Aspects to Consider

• Therapy goal: Functional training helps to recover – to relearn a specific movement, you need to train this movement. Thus, those exercises which will challenge the patient in the functions or movements you want the patient to improve should be selected. E.g if you want to focus explicitly on a specific movement or joint, a single joint exercise should be selected; or 1D-exercise to focus on coordinative aspects or joint couplings a more complex exercise or 2D/3D-exercise should be selected.
• Pathology: Patient’s pathology also influences the selection of exercises. For example, patients with cerebellar alteration the therapy goal will be more focused on coordination exercises among others, while the goal of traumatic brain injury patients could be to connect the patient with the environment and to stimulate his/her cognitive functions.
• Motivating exercises: Motivation is a key factor for successful recovery. Therefore, ensure that you also select exercises, which enthuse your patient with the task. Patients might have different preferences and demands according to their age, gender and cultural background.
• Movement limitations: If your patient exhibits some movement limitations (e.g. contracture or pain), we recommended to avoid exercises which require this limitation. Within the therapy plan, it is possible to filter exercises according to the movements and tasks which they involve.
• Cognitive aspects: Some exercises require a higher cognitive level. Thus, if the patient’s cognitive level is affected, exercises with simple movement tasks are recommended.

Training Progression 

It is possible to add or delete exercises of the therapy plan very easily. The aim is to increase difficulty of the exercises and to keep the patient motivated and committed with the treatment. In addition, the patient should be challenged in the maximum level he/she can reach, increasing the difficulty of the exercises according to the patient’s improvement.

Please Note:
These recommendations are based on the feedback of experienced Armeo users.

It has come to our attention through a number of questions and customer requests that the patient workspace and training region concept can be confusing and difficult. Furthermore, erroneous setup can sometimes lead to undesirable behaviors in the exercises. The goal of this document is to provide you some solutions to some of the most common problems and to allow you to distinguish between a technical issue (software bug or limitation) and improper or erroneous setup.

Definitions (see figure 1)

• Workspace: The workspace is the patient’s movement capabilities as measured in A‑ROM and A‑MOVE. The workspace is represented in the training region editor as the yellow area. Access the training region editor by clicking the settings button during an exercise.
• Training region: The training region is used to specify an area where you want your patient to focus his training during an exercise. You can define the training region in the training region editor. The overlap between the workspace and the training region is the area in which the exercise will place items. The training region is a square (or cube in 3D exercises) represented as the space contained within the boundaries as marked by the black arrows

Figure 1: Workspace and training region as viewed in the Training Region Editor during a 3D exercise.

The training region define the boundaries of the exercises:

Figure 2: Training region fully contained in the workspace (in the frontal plane) and how it corresponds to an exercise.

As you can see in Figure 2, the training region is fully contained within the workspace, therefore, the items (balloons and bombs in this case) can be placed anywhere on the screen. In Figure 3, instead, the overlap between training region and workspace is not complete and the targets will only be placed in the intersection between the two areas.

Figure 3: Training region which only half overlaps with the workspace. The area in white will not have any items.

Find below a file that contains “Common Issues, Their Explanation and Solutions” regarding the workspace

Common Issues, Their Explanation and Solutions

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 has to be fitted into the patient’s and the clinic’s daily routine. Therefore, it is important to know, how long it takes to do an Erigo training.

A standard Erigo session takes between 30-60minutes. Thus, most clinics schedule the patients on the Erigo every 1 hour.  To provide a short insight on how to be able to integrate it into the overall therapy, below we describe how a standard therapy session looks like, based on feedback received from experienced Erigo Users.

Content of an Erigo Session

An Erigo session includes 4 main parts:

• Preparing the patient and the Erigo
• Setup
• Training
• Bringing the patient out.

Preparing the Patient and the Erigo: 2-3- minutes

• Enter new patient data or select the patient within the Erigo software
• Select and prepare the orthopaedic material (harness and cuffs)
• Adjust the appropriate position and height for transfer

Session Setup: 5 minutes

• Patient’s transfer: Transfer the patient to the Erigo. Place the patient into a horizontal position such as matching the patient’s hip joint in relation to the Erigo and fasten the patient.
• Select leg loading by adjusting leg length, adjust knee lifter and foot plates. Close all buckles and velcro strips. Use the additional pads if required.
• Adjust the movement pattern (sinus/gait/alternate) and the range of motion (ROM).
• General Monitoring: heart rate monitor, blood oxygen, assisted breathing, etc.
• Additional adjustments if necessary: (e.g. Arm rest option)

Training: 20-50 Minutes

During the training, adjust the parameters gradually according to the patient’s condition and therapy goals: Set “Cadence” (stepping speed) “Guidance Force” and “Degree of verticalization” as well as the FES parameters*. Please find more detailed information on how to challenge a patient during the Erigo training by adjusting these parameters in other Erigo Entries.

Bringing the Patient out of the Erigo: 2-3 Minutes

• Bring the Erigo gradually into a horizontal position
• Open all buckles and Velcro strips
• Transfer patient and check his/her condition (e.g. ensure no skin irritations)

Please Note:

These recommendations refer to a standard Erigo therapy session and are based on the feedback of experienced Erigo users.

These recommendations need to be adjusted to the individual condition of the patient and the organization of the center (e.g. the training time or the time required to prepare the patient in case you need to bring the Erigo to the patient’s room or to the ICU).

*only ErigoPro

The Erigo offers the possibility to switch between three movement patterns: sinusoidal, gait and alternate. The appropriate pattern depends on the therapy goal set by the therapist.

• The sinusoidal pattern provides the most comfortable movement since both legs are moved simultaneously through the complete therapy range of motion (ROM) to simulate stepping movements. This very simple pattern is suited for maintaining or improving the patient’s ROM. The muscle pump effect and, therefore, the venous return from the lower limbs is strongly stimulated. As such, the sinusoidal pattern is specifically useful already in very early Erigo therapy.

Sinus

• The gait pattern simulates the movement of the legs during walking. This pattern is more complex than the sinusoidal pattern and is thus intended for advanced Erigo patients to prepare them for Lokomat^® or other types of locomotor training.

Gait

• The alternate pattern is well suited for those patients for whom it might be easier to concentrate solely on one leg at a time (e.g. patients with hemiparesis). This pattern is also used to help patients relearn to stand in the upright position.

Alternate

Always take the patient’s reaction into consideration. If a movement pattern is not perfectly aligned with the therapy goal yet is tolerated better by the patient, consider using it. Moreover, no matter the movement pattern, the patient can be verticalized dynamically which will provide adequate stimuli for therapeutic benefit.

Note: If you are using an ErigoPro with Functional Electrical Stimulation (FES), the FES can only be active if sinusoidal pattern is selected.

The range through which the patient’s legs are moved during an Erigo® session is an important parameter in order to ensure an adequate challenge for the patient.

The range of motion (ROM) of the Erigo’s leg drives is adjustable individually for each leg from 0° to 46°. Prior to every therapy session on the Erigo, the therapist measures the patient’s passive (pain-free) maximum values for knee flexion and extension. The default therapy ROM is set at 80% of the measured maximum ROM. You can adjust the therapy ROM throughout the therapy session.

It is important to find the individual maximum flexion and extension without causing any pain. If you notice any sign of discomfort you will have to adjust the ROM or even stop the Erigo. Consider that the ROM often differs between the two legs (especially in patients with hemiparesis), or can even change during a therapy session. For example, the ROM may increase in some patients because of decreasing muscle tone. Therefore, continuously adjust the therapy ROM throughout the session to the patient’s condition and needs. Another factor for how or how much to adjust the therapy ROM is the therapy goal, which is set by the therapist.

Some Aspects to Consider

• Refer to communication methods established by the patient’s relatives, other therapists or doctors in order to communicate with the patient about the sensation of the used ROM. For example, yes-or-no communication by closing the eyes, communication with the thumbs, gestures or other movements are known non-verbal communication methods.
• Observe the patient’s facial expression and gestures during the Erigo session, especially if you increase the ROM.
• Be conservative in the first session and try to increase ROM later on.
• After you’ve learned to interpret the reactions of a specific patient, slowly try to increase the challenge bit by bit.

To apply functional electrical stimulation (FES) during an ErigoPro training there are several parameters that must be adjusted during the setup. All parameters can also be adjusted during the session.
The parameters frequency, pulse width, and ramp are adjusted for all channels simultaneously. There are no standard values that are optimal for all patients, but the default values (see table below) are a good starting point to find the appropriate values.

The parameter amplitude needs to be adjusted individually during each setup. For each channel, the amplitude needs to be increased individually during the setup starting at 0 mA until the desired stimulus intensity is reached (palpable or visible muscle contraction).

Erigo Parameters Overview

* Note that it is the treating therapist’s sole responsibility to choose appropriate values for all parameters      for each individual patient.

** Ramp defines the number of pulses to reach the target pulse width.

If you want to learn more about the FES parameters, please refer to the user manual (chapter 4, section 4.2).

When attaching and removing the FES cables to and from the ErigoPro and the electrodes, some details must be considered in order to guarantee the lifespan of your Erigo and your FES cables.

Attaching the FES Cables to the Erigo

• When plugging the FES cables into the FES module of your Erigo, always consider the colour code. E.g. the blue plug corresponds to the blue jack of the Erigo.
• To plug into the jack, the cable needs to face vertically upright.

• Always hold the plug at the lower, horizontal end, not at the cable.

Removing the FES Cables from the Erigo

• When removing the cable from the jack on the Erigo, pull on the horizontal part of the plug. There is a spring mechanism which releases when the horizontal part of the plug is being pulled outwards straight.
• Don’t pull on the vertical part of the plug nor on the cable itself!

Removing the Electrodes from the FES Cables

• When removing the electrode from the FES cable, pull on the plugging ends of the cables. Don’t pull on the cables!

Avoid Tension on the Cables or Plugs at Any Time

• In order to avoid damaging the FES cables or plugs, make sure that there is no tension on the cables at any time during the Erigo session, especially in the flexion phase of the patient’s stepping pattern

Many times, therapists would like to improve upper extremity positioning during Erigo sessions in patients with lack of motor control.

The two main problems reported by clinicians are:

• Higher risk of thrombosis due to decreased venous return.
• Risk of shoulder subluxation due to the hanging position of the arm.

To prevent this problems, we recommend you to use the Erigo arm rest. Thus, the arms are in a raised position to support venous return and relieve the shoulder joint from tension.

Erigo Armrest

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.

It is imperative that patients are challenged and that they participate actively throughout the whole Lokomat training session. This is important for the following reasons:

• High therapy intensity (high number of repetitions, long therapy durations, frequent training sessions, and high patient activity during each of the repetitions) is crucial when trying to reach a patient’s optimal recovery potential (Spiess et al. 2018).
• A key aspect in motor learning is to challenge people during training according to their skill level.  Too low a level of challenge can make a treatment boring, and not encourage motor learning. On the other hand, too high a level of challenge can be frustrating or overwhelming (Guadagnoli and Lee 2004).
• Aerobic training has been shown to improve the cardiorespiratory fitness, as well as physical and psychosocial domains (Winstein et al. 2016), and to promote brain plasticity (Cramer et al. 2011).

Below there are some tips from experienced Lokomat users on maintaining patient engagement throughout the training session.

Adjusting Parameters

You can adjust the training parameters to increase active patient participation leading to a challenging training session.

• Increase the gait speed to the maximum value where the patient still presents a good gait pattern.
• Decrease the Body Weight Support and support the patient only as much as he needs thereby ensuring the highest loading.
• Reduce the Guidance Force and challenge the patient himself to maintain the gait pattern.

Using Lokomat Features

In addition to changing the parameters in order to further challenge the patient, the Lokomat includes three important features designed to increase active participation:

• Training Programs: Add variety to the training and (a) keep the patient motivated throughout the training session, (b) challenge him to react and adapt to the changes the program creates, and (c) increase the variety of required movements to improve motor learning.
• Biofeedback graphs clearly illustrate phase appropriate and inappropriate activation; this information helps to pinpoint problem areas for the patient.
• Augmented Performance Feedback / Virtual Reality Exercises motivates patients by giving real-time feedback on the screen where they can see the effects of their effort in the gait training as they move their character through different challenging games and tasks.

Additionally, some Lokomat users support the use of external cues from the clinicians like, “hit my hand”, “kick this ball”, and “stand up straight”.

Some Considerations

• While keeping a patient’s active participation up is vital to promoting recovery. It is also important to let the patient perform enough repetitions of the gait pattern. Therefore, pay close attention to the patient’s fatigue level, especially during the initial sessions in the Lokomat.
• If upright mobility is new to your patient, make sure to monitor his physiological response to the training.

Spiess, M. R., F. Steenbrink and A. Esquenazi (2018). “Getting the Best out of Advanced Rehabilitation Technology for the Lower Limbs: Minding Motor Learning Principles.” PM&R 10(9, Supplement 2): S165-S173.

Guadagnoli MA, Lee TD (2004). “Challenge point: a framework for conceptualizing the effects of various practice conditions in motor learning.” J Mot Behav. 2004 Jun;36(2):212-24. doi: 10.3200/JMBR.36.2.212-224. PMID: 15130871.

Winstein, C. J., et al. (2016). “Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.” Stroke 47(6): e98-e169.

Cramer S. C. et al. (2011). “Harnessing neuroplasticity for clinical applications”, Brain, Volume 134, Issue 6, June 2011, Pages 1591–1609, https://doi.org/10.1093/brain/awr039

Initial configuration and ongoing adjustments of the BWS level during Lokomat sessions are key variables of gait training. The aim is always to provide a challenging training in a safe environment. In terms of BWS, this means finding the value where, enough support is provided to allow an upright position, yet reduced to a minimum to provide as much loading as possible.
The default starting value is 50% of the patient’s total body weight. This is based on the experience of Lokomat users who determined that most patients can start a training session at this value. However, it should be adjusted according to the patient’s ability and condition.

What are the criteria for determining the appropriate BWS value?

Whenever possible the maximal load should be applied to the patient. This maintains the appropriate sensory input during the gait cycle and challenges the patient’s entire body. Once a safe walk is achieved, we recommend reducing the BWS to <40% of total weight.

• Patient’s Knees: The main indicator to recognize if the value is correct is the patient’s ability to extend his knee. A sufficient amount of BWS should be maintained to allow the patient to achieve the appropriate gait pattern; pay attention to his ability to extend his hips and knees in stance phase and maintain his trunk upright during the gait cycle.

Training Progression: Once you find a level of BWS that allows for a good gait pattern with good kinematics, it is important to continue challenging your patient. This can be done either by gradually decreasing the amount of BWS, or by changing other gait parameters (e.g. speed, guidance force).

How do I define the BWS value at first?

During the first session you may not know how much support the patient needs, we therefore recommend the following:

1. Start with walking in the air at the default value (50% of the patient’s body weight).
2. Bring the patient down onto the treadmill until you reach a dynamic range of the BWS.
   If, when lowering the patient, you cannot reach a dynamic BWS because the patient cannot carry 50% of his weight and the training session would not be safe (i.e. the knee does not extend during stance phase), then increase the BWS value.
3. Once the patient is walking in a dynamic range, you can gradually reduce the BWS value while taking care to monitor the patient’s ability to extend his knees. The goal of reducing the BWS value is to support the patient only as much as he needs: we want maximum challenge for the patient but always in a safe training environment.

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

The Lokomat starts with a default value of 1.5km/h. However, the optimal speed value in order to challenge patients during Lokomat therapy is different for each patient depending on his overall health condition, experience with the Lokomat as well as the individual training goal. Here we provide recommendations to support you defining the optimal speed for each patient.

How do I choose the appropriate speed value for the start if therapy and during training progression?

For the first training session the speed value should not be chosen too fast so that the patient has the ability to accustom to the device and follow the correct gait pattern; it should not be chosen too slowly to enable smooth movements. According to the feedback from experienced Lokomat users for the first training session a speed value between 1.5 and 2.0 km/h seems to be selected most frequently. For children the value is smaller, ranging from 1.0 to 1.5 km/h.

As soon as a safe and nice walking pattern has been established and the patient has been accustomed to walking in the orthosis, increasing the speed value is recommended to challenge the patient during the entire training session. We therefore recommend selecting the highest speed value at which the patient is still able to maintain a nice walking pattern. At the same time the speed should be chosen in accordance with the patients abilities to train for a complete training session.
When does it make sense to select higher or lower speed values?

Higher Speed Values

• Should be chosen when the gait pattern seems not physiological due to a low speed; increasing the speed might help the walking pattern to look “smoother” (Reisman et al., 2009; Tyrell et al., 2011)
• Imply more number of repetitions and increase the challenge for the patient during the training session. A challenge point optimization is required to provide sufficient afferent feedback and positively influence neuroplastic events in particularly early after injury (Pohl et al., 2002; Lamontagne & Fung, 2004; Miller et al., 2008; Outermans et al., 2010; Wada et al., 2010; Kuys et al, 2011).
• Make sure that the speed value is continuously increased over training progression to ensure a challenging walking session and support each patients potential for functional recovery (Andriacchi et al., 1977; Wagenaar & Beek, 1992; Wagenaar & van Emmerik, 1995)
• When the training goal is to enhance an “automatized” gait pattern during over ground walking a high speed value during the training session is required (Hesse et al., 2001; Kwakkel & Wagenaar, 2002).
• If patients are already able to walk but the training goal is to further increase their comfortable walking speed overground an increased speed value during Lokomat assisted training is required.

Lower Speed Values

Despite the fact that a high speed value is required in order to sufficiently challenge patients during their walking session lower speed values may be recommended:

• During the first training sessions, so that the patient can accustom to the orthosis and the walking pattern.
• The speed value needs to be reduced if it is too high for a patient to endure a whole training session.
• When the training requires time to focus on a specific movement for example consciously extending the knee during stance phase (Nogueira et la., 2013).
• For consciously activating muscle contraction and recruiting muscle fibers for specific muscle strength training.
• In patients with spasticity when starting the training session until the muscle tone regulates and adapts to the movement. A high speed can enhance a spastic reaction which could cause the orthosis to stop for safety reasons (Bohannon & Andrews, 1990).

What do I need to consider when changing the speed value?

• The step length should be adapted to the speed.
• The orthosis speed value should be adjusted (you can also us the automatic setting).
• The hip offset may require adjustments (towards extension).
• If the quality of the movement will be affected, e.g. heel strike at initial contact.
• The joints need to be able to support the increasing impact.

References:
Tyrell CM, Roos MA, Rudolph KS, Reisman DS (2011) Influence of systematic increases in treadmill walking speed on gait kinematics after stroke. Phys Ther; 91(3):392-403
Hesse S, Werner C, Paul T, Bardeleben A, Chaler J (2001) Influence of walking speed on lower limb muscle activity and energy consumption during treadmill walking of hemiparetic patients. Arch Phys Med Rehabil ; 82(11):1547-50
Bohannon RW, Andrews AW (1990) Correlation of knee extensor muscle torque and spasticity with gait speed in patients with stroke. Arch Phys Med Rehabil 1990,71:330–3.
Lamontagne A, Fung J (2004) Faster is better: Implications for speed-intensive gait training after stroke. Stroke. 2004;35:2543-2548
Nogueira LAC, dos Santos LT, Sabino PG, Alvarenga RMP, Thuler LCS (2013) Factors for lower walking speed in persons with Multiple Sclerosis. Multiple Sclerosis International, 1-8.
Reisman DS, Rudolph KS, Farquhar WB (2009) Influence of speed on walking economy poststroke. Neurorehabil Neural Repair. 2009 Jul-Aug;23(6):529-34.
Miller EW, Combs SA, Fish C, Bense B, Owens A, Burch A (2008) Running training after stroke: a single-subject report. Phys Ther, 88:511–522.
Pohl M, Mehrholz J, Ritschel C, Ruckriem S (2002) Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke 2002, 33:553–558.
Wada Y, Kondo I, Sonoda S, Miyasaka H, Teranishi T, Nagai S, Saitoh E (2010) Preliminary trial to increase gait velocity with high speed treadmill training for patients with hemiplegia. Am J Phys Med Rehabil, 89:683–687.
Outermans JC, van Peppen RP, Wittink H, Takken T, Kwakkel G (2010) Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. Clin Rehabil, 24:979–987.
Kuys SS, Brauer SG, Ada L (2011) Higher-intensity treadmill walking during rehabilitation after stroke in feasible and not detrimental to walking pattern or quality: a pilot randomized trial. Clin Rehabil, 25:316–326.
Kwakkel G, Wagenaar RC (2002) Effect of duration of upper- and lower-extremity rehabilitation sessions and walking speed on recovery of interlimb coordination in hemiplegic gait. Phys Ther; 82:432-448.
Andriacchi TP, Ogle JA, Galante JO (1977) Walking speed as a basis for normal and abnormal gait measurements. J Biomech;10:261–268.
Wagenaar RC, Beek WJ. (1992) Hemiplegic gait: a kinematic analysis using walking speed as a basis. J Biomech;25:1007–1015.
Wagenaar RC, van Emmerik REA (1995) Relearning dynamics after stroke. In: Van der Kamp, et al, eds. Movement Disorders: Proceedings on the First Symposium of the Research Institute for Fundamental and Clinical Human Movement Sciences: 51–77.

As you have probably experienced, some patients lack knee extension during stance phase. Lack of knee extension may be caused by different reasons. The Lokomat provides a number of adjustments to ensure proper gait kinematics during walking; the challenge is identifying the cause so as to properly adjust. Below are a few considerations in order to make sure the patient has good knee extension during stance phase.

1. Are the cuffs properly tightened?

Check if the cuffs are loose, particularly the upper cuff. They need to be properly tightened.

2. Is the height of the Lokomat knee axis properly adjusted to the patient?

Double check the knee height. If the knee axis of the Lokomat is below the knee axis of your patient this may cause your patient to be “pushed down” during stance phase. If this is the case, double check (a) that the hip axis height is correctly aligned and (b) whether you set the upper leg too long.

3. Did you properly adjust the sagittal plane setting?

When the Lokomat orthosis is fully extended, the patient’s knee should be too. This is particularly visible at the end of the swing phase. If this is not the case, lift the patient, click on “stop” and re-adjust the sagittal settings by moving the lower cuff forwards. Before starting again, check the knee extension by manually moving the orthosis.
A patient’s knee can be extended during stance phase by moving the upper cuff backwards. As you are adjusting the cuffs, ensure that you are not hyperextending the patient’s knee.

4. Is the BWS value appropriate?

It might be the case that either the BWS value is too high or too low. If it’s too low, the patient cannot support his own weight and his knees will buckle. If the BWS value is set too high, the patient won’t have enough loading to activate a muscle response.

5. Is the patient walking with dynamic BWS enabled?

Make sure the patient is walking within the dynamic range of the body weight support. This is necessary for the patient to have enough loading. Using a static range means he is still “lifted”. This is also important to ensure constant support, as vertical displacement on the gait cycle needs to be adapted in order to avoid extreme variations on the value.
You can ensure the patient remains in a dynamic range by using the automatic dynamic function (“dyn”). This is particularly useful when changing the value of BWS.

6. Is the patient not actively participating or getting tired?

Make sure the patient stays alert and maintains effort during walking. Your patient must remain as active as possible in the Lokomat orthosis during stance phase. Verbal and physical cues to “stand up” or “be tall” might be helpful.
If the patient is tiring out, you can increase the body weight support or guidance force. If that doesn’t work, it might be time to end the session.

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.

Keeping medical devices clean and disinfected is a crucial topic for hospitals and clinics.

Together with the support of external hygiene experts, we’ve elaborated on the Cleaning and Disinfection Recommendations for the Lokomat.

Please find the document below.

Please note that these are only recommendations! The hospital or clinic that operates the Lokomat is always responsible for the hygiene of their devices. The list of recommended disinfectants in the document does not claim to be exhaustive.

Lokomat Cleaning and Disinfection Recommendations

We have all heard that “intensity matters” and there is several evidence for this fact (Veerbeek et al. 2014, Spiess et al. 2017). However, it is not always easy to provide enough intensity on clinical settings (Spiess et al. 2017).

The Lokomat can provide intensive therapy while supporting the patient with a physiological gait pattern. In order to adjust the patient effort and keep the challenge, parameters like guidance force (amount of robotic support), treadmill speed and amount of body weight support can be adjusted during the session. Additionally, goal-oriented exercises and automatized training programs can be used to increase patient motivation and participation.

These practical recommendations have been created by consensus of a group of experts to support clinicians on the use of the Lokomat to adjust the intensity of the therapy to their patients. They do not intend to be a guideline, but to provide a general basis of knowledge on this topic. In addition, they will provide some helpful tips that expert clinicians use to determine dosage of Lokomat therapy.

Frequency

Frequency is the amount of Lokomat sessions per week that a patient receives. It is influenced by different factors like age, fatigue level or skin fragility. However, general recommendations are:

• (Sub) Acute patients (as soon as patient is cardiovascularly stable): > 5 sessions per week of 45-60min (at least 30 minutes gait).
• Chronic patients (>6 months): at least 2-3 sessions per week of at least 30 minutes (the more the better)

Fatigue: patients with increased fatigue (like patients with multiple sclerosis) can benefit from reduced frequency of sessions with adjusted intensity. The training should follow the recovery process of the patients and fatigue can guide the training intensity to avoid triggering pathologic reactions.

Age can also condition the frequency of the therapy, as it influences patients’ general physical condition. Ensure they have enough rest between sessions to let the muscles, tendons, skin etc. recover properly.

Number of sessions

The number of sessions or therapy duration very often depends on the general length of the medical treatment. However, general recommendations can be done on when a patient can be discharged from Lokomat therapy and transferred to overground gait training:

• Lokomat therapy is no longer needed (but not contraindicated) when the patient has a symmetrical walking pattern in terms of times of stance and swing (on a chronic phase).
• Lokomat therapy is no longer needed (but no contraindicated) when alternative options for overground training are available to ensure the intensity of the therapy (for instance, Andago)
• Lokomat therapy is no longer needed and contraindicated in case of any worsening of physical condition.
• Lokomat therapy frequency can be reduced when the patient has ability to walk overground to cover all therapy goals

Adjusting intensity

Adjustment of intensity during a therapy session is critical to challenge the patient beyond capabilities while ensuring the patient can participate actively in the session for at least 20 minutes or 1000 m walking distance.

• Body weight support (BWS) can be reduced as much as possible while the patient can maintain knee extension during stance phase. Reduce BWS to increase the amount of weight bearing of your patient and train muscle strength, knee stability and extension, hip stability and extension. Change BWS in intervals of 5% to challenge your patient. BWS training program can be used to challenge the patient with automatic changes on BWS. Use intervals of low BWS (at threshold for the patient) with intervals above threshold for recovery.
• Speed can be increased as much as possible as long as the patient can maintain a physiological gait pattern and ensure active participation. Speed can be increased to provide more repetitions, to reproduce the normal gait pattern and to train activity timing. Change speed in intervals of 0.1 km/h. Speed training program can be used to challenge your patient with random changes of speed. Use intervals of speed at the maximum threshold for the patient with intervals of speed above threshold for recovery. Reduced speed can also be beneficial for some patients, since stance phase time is increased and time for unilateral stance is longer. Reduced speed in combination with reduced BWS can contribute to strength and knee extension training.
• Guidance force (GF) can be reduced as much as possible while the patient can maintain a physiological gait pattern, temporo-spatial parameters are preserved, and symmetric gait pattern is achieved. Guidance force can be reduced to train gait variability, motor control and adaptability of the gait. Reduce GF in intervals of 5-10%. Asymmetric guidance force can be used to increase attention on the affect leg on patients with neglect.

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.

Veerbeek, J. M., E. van Wegen, R. van Peppen, P. J. van der Wees, E. Hendriks, M. Rietberg and G. Kwakkel (2014). “What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.” PLoS One 9(2): e87987.

Spiess, M. R. and G. Colombo (2017). “Intensity: What Rehabilitation Technology Can Add to the Subject.” Neurol Rehabil 23(1): 53-56.

Acknowledgement to: Dr Andreas Mayr (Tirolkliniken, AT); Corrado Melegari (Elias Neurorehabilitatione, IT); Debora Campos (AASDAP, BR), Chih-Chao Hsu (Taipei Medical University Hospital, TW), Dr Nicolas Buffagni (Clínica San Andrés, AR) for their clinical input and contributions to these clinical recommendations.

Have you ever performed Lokomat L-STIFF? Do you want to learn more about it? Lokomat L-STIFF provides you a reliable tool to measure patient leg stiffness (Cherni et al., 2019).

What is measured?

L-STIFF measures the mechanical resistance to displacement so called stiffness of the hip and knee joint during passive flexion and extension movements. This measurement is performed at three different speeds: 30°/s, 60°/s and 120°/s for the knee and 22.5°/s, 45°/s and 90°/s for the hip. The movement pattern is preset in the software. The range of motion can be adjusted by the therapist according to the patient’s abilities.

What conclusions can be made from the measurements?

L-STIFF can support you in understanding impairments of the patient and gives you information about the joint resistance against mechanical displacements – stiffness. Keep in mind that stiffness can be caused not only by spasticity but also by other factors such as muscle contractures, joint deformities or neuromuscular pathologies. Therefore, L-STIFF values have to be interpreted carefully and complemented with other clinical evaluations performed by educated and skilled therapists.

How do L-STIFF values compare to clinical measures of spasticity (MAS)?

L-STIFF was clinically validated by measuring both L-STIFF values and Modified Ashworth Scale (MAS) values across multiple patients. Statistically speaking, the higher the L-STIFF value, the higher the MAS value (Lünenburger et al., 2005). However, it is important to have in mind that the L-STIFF assessment does not measure spasticity or MAS values per se.

How is the L-STIFF data presented?

To see the measurements obtained from L-STIFF perform the following steps:

1. Tap [Assessments] from the [Main Menu] or [Assessments] after ending a training session.
2. Select the patient (if necessary).
3. Go through the [Prepare Device] screens and lift patient (remove foot lifters).
4. Tap L‑STIFF from the [List of Assessments].
5. Tap [Start]. The knee and hip joints are moved alternately at three speeds (30, 60, 120°/s and 22.5, 45, 90°/s respectively) with two repetitions. The patient should be completely relaxed during these movements. The Lokomat calculates a regression line for the two measurement repetitions per movement. The L‑STIFF value in Nm/° displays the slope of the regression line and indicates how much the resistance changes depending on the angle.
6. Save the results if you wish.

Single graphs are shown for the individual joints and movement directions of flexion and extension. The bars represent stiffness in Nm/° for each tested velocity. (Colors indicate the different velocities of the measurement.) If the L‑STIFF value is negative, it is possible that the patient actively supported the movement.

How do I ensure the concurrent validity of the L‑STIFF measurements? Recommendations on the applicability in clinical practice.

The L‑STIFF algorithm relies on assumptions about biomechanical parameters of the patient (e.g. leg mass) which are estimated from the mass (body weight) and leg lengths of the patient and a mechanical model of the Lokomat legs (friction, masses, length, etc.). This measure is considered reliable as long as the following are observed.

• The assumptions are based on the values entered in the Lokomat Patient settings (weight, height, upper and lower leg length); therefore, always make sure these values are correct.
• Use the same hardware settings, legs, cuffs and length settings for all measurements if you want to compare them.
• Make sure that the straps are not readjusted between measurements.
• The L‑STIFF assumes that the patient is in a relaxed state. If the patient is moving or co-contracting during the evaluation, it will affect the measure. Encourage the patient to relax during the measurement.
• Make sure that the upper body position of the patient does not change between or during measurements.
• Make sure the patient is not wearing stiff clothes (e.g. thick jeans) or very heavy shoes (heavy shoes increases the mass of the leg segment, which affects the estimation of stiffness, especially at high velocities).
• Perform the measurement during the same stages of the training across multiple sessions.
• Compare the values and trends across multiple sessions (ideally >3).

Is there any documentation on expected values for unimpaired subjects and/or patients with neurological impairments?

No list of reference values is available at the moment. To date we are not aware of clinical studies that compared L‑STIFF values for unimpaired subjects and patients. We are currently looking for clinics that would be interested in conducting such a study in patients with neurological impairments and work in collaboration with us to further improve the L‑STIFF software and readout.

After the measurement, I see a plot on the therapist screen. What does it represent?

Just after the measurement, if you click on Results raw data will be displayed on the therapist screen. The line graph shows the joint angle (horizontal axis) vs. resistive torque (vertical axis) when the selected joint is moved at particular speed. Please, remember than at this stage, the information displayed is raw data, and computations are not yet applied.

References

Cherni Y, et al., Intra- and inter-tester reliability of spasticity assessment in standing position in children and adolescents with cerebral palsy using a paediatric exoskeleton, Disability and Rehabilitation. 2019; 1:1-7.

Riener et al., Human-centered robotics applied to gait training and assessment, J Rehabil Res Dev. 2006; 679-94.

Lünenburger et al. Clinical assessments performed during robotic rehabilitation by the gait training robot Lokomat, Proceedings of the 2005 IEEE 9^th International Conference on rehabilitation Robotics. 2005; 345–348.

Report Example

Q: Is the width between the projected steps, that are projected onto the belt for standing balance applications and assessments, specific for each patient?

A: Yes. The width between the projected feet is based on the length of the patient.

Q: Why is there no score for the cognitive dual task of the C-Gait assessment?

A: The cognitive dual task requires additional hardware (a special headset). The patient needs to indicate if the words ‘high’ and ‘low’ are spoken with a high or low pitch.

Q: Is a harness required during the execution of a balance assessment?

A: Yes, a patient should always wear a safety harness, that is attached to a safety portal via a safety line.

Q: What can be deducted from the shape of the butterfly?

A: The butterfly can visualize relative differences between left and right steps, or difficulties in weight assumption from one leg to the other. Furthermore, it can visualize step width and gait asymmetries. Absolute values for step length cannot be visualized with the butterfly, because the butterfly reflects the CoP (Center of Pressure) trajectory on the belt surface and this is also depended on the treadmill speed.

Q: Track images: some images can only have a positive or negative score. What is the underlying logic per image?

A: Cues can only have a positive score. Animals can both have a negative as well as positive score and obstacles can only have a negative score.

Q: How are the default width and height of the stepping stones/ obstacles determined? And where can I find the exact dimensions?

A: The width and height are based on the foot dimensions that need to be stored for each patient/subject in the database. The exact dimensions of the stepping stones or obstacles can be seen in the CUEING.csv file, which is created when the measurement is exported.

Q: What types of training/services/support does Motek provide?

A: Motek provides different services, for example additional or advanced training, research services or on-site support during the clinical usage of a system with patients (companionship). We can also consult you during the implementation phase of your system or share experiences regarding reimbursement.

For a complete overview of our services, please send an email to clinical.applications@motekforcelink.com.

Q: Where can I find other centers to exchange experiences?

A: Please contact us via clinical.applications@motekforcelink.com and we will try to put you into contact with other centers. If applicable, please describe the specific characteristics/requirements of the centers you are looking for.

FreeD is an optional module of the Lokomat that provides a more natural and physiologic gait pattern while supporting lateral transition of the body weight. In order to setup a patient on a safe and efficient way with the new FreeD module we recommend you to read this entry. Below, you will find a detailed description of a patient setup with and without FreeD.

LokomatPro

LokomatPro with FreeD

1.  Measure upper and lower legs, adjust the orthoses and enter the values in the software.
2. Select the cuffs and attach them to the orthoses. The upper cuffs are delivered in sizes 9 and 7 and should fit most patients. If this is not the case, the middle cuffs can be used.
3. Select the harness and leg loops. Fix the harness on the patient.
4. Attach the patient to the support frame and lift the patient. Close the swivel door and lower the orthoses. Open the pelvic orthosis to its maximum width.
   

   Opening pelvic orthosis to maximum width

5. Adjust the height of the Lokomat by aligning the greater trochanter with the white plastic indicators.
   

   Alignment of the white indicator with the greater trochanter

   Adjust the pelvic depth by turning on the hand wheel and the pelvic width by pushing inwards on the pelvic cushions (to open, push button and pull). Attach the patient harness to the orthosis by buckling the pelvic straps on the harness.

6. Close the upper cuff and check the knee axis, adjust lower leg length if necessary. Close the middle and lower cuffs.
7. Adjust the upper cuff bracket so that the “Lokomat femur” is aligned with the patient’s femur. Adjust the lower bracket so that an imaginary lines through the lower leg falls behind the lateral malleolus. Adjust the middle bracket and check the knee extension.
8. Fasten the foot lifters.
9. Adjust the lower cuff so as to set the track width (frontal plane alignment). Set the amount of lateral and medial translation of the upper and middle cuffs and close the blocking mechanism screws.
   
10. Check that each leg does not collide with the foot lifter bar of the opposite leg at any time during the gait phase.

Handout: Setup Differences Between FreeD and non-FreeD

A proper setup will increase comfortable for the patient in the Lokomat. Here we provide some practical tips.

Minimize “Hang” Time

When you set your patient up, be as efficient as possible to minimize the time he is fully suspended. Be systematic in your setup; this will help you be quick and thorough.

Positioning the Harness

• Groin padding: The Lokomat offers two groin pads. Make sure they are placed in such a way as to cover the sensitive groin area. Take into consideration that the most of the pressure is anterior rather than posterior, so ensure that the padding is placed forward enough to provide good protection.

Groin Paddings

• Selecting the leg straps: Two different options are provided, a triangular pelvic harness or two separate straps. Some patients will prefer one option over the other. When using the triangular harness, we recommend placing one groin pad horizontally. Make sure the leg straps are long enough to cover the patient’s sensitive area and that they are tightened symmetrically on both sides.

Pelvic Harness

Leg Straps

• Attaching the leg straps: The leg straps can be attached to the harness in two different ways. If your patient feels uncomfortable with the medial position, try the lateral position. This position may affect superior translation of the harness on your patient, but it may be more comfortable.
• Placing the harness: Check that the harness is straight and symmetric. If the weight is not evenly distributed, the harness might put more pressure on one specific area, which will cause discomfort. Make sure the harness is not too high, especially on women, to avoid pressure on the breasts.

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.

Please note that this video shows the physiological walk adjustments with the Lokocontrol Software V6.2 with the FreeD module.

If you are using a different software on your Lokomat, the adjustments are still the same, you only have a different software interface.

Please note that this video shows the safe walk adjustments with the Lokocontrol Software V6.2 with the FreeD module.

If you are using a different software on your Lokomat, the adjustments are still the same, you only have a different software interface.

Do you use the LokomatPro with both adult and pediatric patients?

Would you like a clear, step-by-step procedure to quickly and effectively change from adult to pediatric orthosis?

Watch the video or download the handout below!

Handout: How do I Change to Pediatric Orthosis on the LokomatPro?

Patients with a narrow pelvis, in particular children, may experience difficulties when training with the Lokomat because the cuffs might collide during walking. To avoid this and ensure a safe and correct walking pattern throughout the entire training session, follow these recommendations:

• Frontal plane settings (indicated by letters):
  Check whether the cuffs are placed correctly during setup. Leave enough space between the cuffs, especially around the thighs and knee joints, to avoid collision once the pelvis is fixed (picture 1).
  Make sure that the legs are correctly aligned. If the cuffs still collide with each other, move them laterally (towards the letter “A”).

Picture 1

• Cuff size: Make sure that the selected cuff size is not too large.

• Specific hip pads: Thicker hip pads are provided together with the pediatric orthosis. They increase the space between both orthoses during setup, thereby avoiding the collision of the cuffs during walking (picture 2).

Picture 2