January 15, 2015
Clinical Integration of the Lokomat®: Hospital Hochzirl
Hospital Hochzirl neurology department team members.
Martin Niedermeier, Sport Scientist
Landeskrankenhaus Hochzirl, Austria
We have wide experience with rehabilitation robotics and a well-defined structure with a rehabilitation robotics department in our facilities for assisting SCI, TBI, Stroke and other patients since 2002. We deliver robotic therapy with several devices in parallel which contributes to improve our efficiency.
Here we describe our clinical setting and hope that it serves as an example to support other clinics that also work with the Lokomat.
We use the Lokomat for Stroke, Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI) patients, among others.
This includes acute patients in the early phase of rehabilitation (within the first weeks or months after the event) as well as chronic, severely affected patients.
Prescription: Inclusion Criteria
Criteria for receiving Lokomat treatment in hospital Hochzirl are:
- Free of contraindications
- Stable circulation situation
- Acute patient not being able to walk with rehabilitation potential regardless of the disease pattern
- Chronic patient for secondary benefits
The medical director takes responsibility and makes the final decision but responsible physical therapists make proposals about which patients should receive Lokomat treatment.
Duration and Frequency of Lokomat® Sessions
Lokomat treatment is organized at hourly intervals. Accordingly, Lokomat treatment time ranges between 45 and 50 minutes
Patients receive Lokomat treatment 2-5 times per week depending on the therapy goal and the capacity of the Robotics department.
If the patient’s rehabilitation is in between the phase of Erigo and Lokomat, the patient is getting one day Erigo and the other day Lokomat treatment.
The duration of Lokomat treatment depends on the therapy goals, the progress of the patients and the seriousness of the injury or event.
The goal for chronic patients is to gain secondary benefits. Therefore, they receive Lokomat treatment the whole time while they stay in the clinic. This time ranges between 3 and 15 months.
For acute patients, the goal is to get walking again. Therefore, they receive Lokomat treatment until they are able to continue with treadmill training with or without body weight support. Patients must often train between two weeks and three months on the Lokomat before starting treadmill training.
A responsible physical therapist individually assesses the patient’s therapy goals and orthopedic status (especially hip and knee joints, trunk and head stability) to see if Lokomat treatment is appropriate tool his rehabilitation. The physical therapist has to clarify the patient’s general condition with the medical director.
After this assessment, the physical therapist discusses with the clinician the proposed approach, especially if the patient is free from contraindications and how to convert the therapy goals into Lokomat treatment.
The Lokomat clinician has to find out if Lokomat treatment is appropriate for the patient. It depends on the patient’s past experiences, his preferences and aversions, his age and many other factors. Sometimes, it is necessary to simply try Lokomat treatment two or three times and look at the result and the reaction and decide afterwards to continue Lokomat treatment or not.
Reasons to Include the Lokomat® as Part of the Therapy Program
For most patients it is a very important therapy goal to walk again. Primarily, the Lokomat offers a functional walking pattern under facilitated conditions. With the help of the body weight support and the guidance force, patients are able to train the whole walking movement pattern in a state of rehabilitation, where otherwise it would be impossible.
The intensity of the training stimulus can be easily defined with body weight support, speed (number of repetitions), duration and guidance force. This guarantees individual and adequate input to the patient and positively affects the patient’s endurance . Despite all this, the Lokomat remains a tool whose use should be reduced as soon as the patient is able to walk independently.
Furthermore, we consider the possibility that the Lokomat might offer secondary benefits: dynamic verticalization helps to reduce all the physical problems connected with inactivity (e.g. calcification, contractures, etc.).
To have the feeling of being upright and walk is a new movement experience, especially for patients, who have been sitting in a wheelchair for a very long time.
This may have a psychological impact on the patient. Chronic patients often are in a state where it is very unlikely that they independently walk again. Thus, we are training chronic patients in the Lokomat so they might take advantage of the possible secondary benefits.
Unlike gait training without the assistance of robotics, the Lokomat allows the operating clinician to observe the patient’s motion sequence more easily and from another perspective, and to intervene whenever necessary. Gait training becomes less personnel intensive and less burdensome for the clinicians.
Other Therapies Provided in Addition to Lokomat®
At our facility, we provide patients with a combination of therapies adjusted to their needs including:
- Physical therapy (Bobath)
- Occupational Therapy (Bobath)
- Electrical stimulation
- General robotics (Erigo, Armeo, Amadeo, Hirob)
- Mc Millan (water therapy)
- Speech therapy
- Anti-spastic drug treatment
- Anti-spastic medical therapy.
A member of the team during a Lokomat session.
Organization: Responsible Therapy Team
In our clinic, Lokomat and Erigo sessions are carried out by one physical therapist and four sport scientists. Two members of the team are working together doing therapy with four patients simultaneously.
Before the patient starts, the clinicians discuss with the physical therapist in charge the therapy goals and the inclusion of robotic therapy.
Our experience with Lokomat specialists shows several advantages because they have an experienced eye to properly set all the parameters and routine makes them faster for the entire process.
As mentioned, two therapists are working on four de-vices simultaneously. After they have put the patient into the device (Erigo, Lokomat), they make individual adjustments and give instructions regarding the therapy goals. When everything is set and the patient is feeling secure, robotic training starts and the clinicians move on to the next patient. During the session, the clinicians give further instructions and corrections. In case of danger or when assistance required, one clinician takes care of the patient immediately.
There is the disadvantage that the clinician cannot observe each patient during the whole therapy session. But the patient is alone during a phase in the treatment when the presence of the clinician is not critical. Moreover, this system allows the clinicians to treat twice as many patients per day than if doing one-to-one therapy.
Billing and Financial Compensation of Lokomat® Therapy
There is no special refunding for our robotic treatment in general. Robotics, especially Lokomat, is part of the rehabilitation process in our hospital, which is paid for by health insurance.
Our medical director sees private patients, who themselves have to pay on their own. Private patients pay a doctor’s fee and pay the amount of treatment they get per minute. Charging is the same for Lokomat therapy as it is for other types of therapy.
Hospital Hochzirl, Department of Neurology, Austria is a hospital for post-acute follow-up assistance for neurorehabilitation. Established in 1995, the 74-bed hospital treats patients with various neurological injuries and diseases. Beside conventional physical therapy, occupational therapy, speech therapy, electrical stimulation and water therapy, we have provide robotically assisted training since 2002. Specifically, Lokomat, Erigo, Armeo, Amadeo and Hirob are used for rehabilitation of the patients. Our robotic team consists of one physical therapist and four sport scientists.