ArmeoPower Clinical Troubleshooting
Download the ArmeoPower Clinical Troubleshoot Document here:ArmeoPower Clinical Troubleshoot Document
How to Record Training Data with the LokomatPro, Software Version 6.5
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:
- Select the icon System Settings on the bottom of the main menu of the software.
- Select SYSTEM SETTINGS in the Lokomat options.
- Select CONFIGURATION on the bottom of the page.
- Check the box “Record all signals for each session”.
- 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:
- Open a Blank workbook in Excel
- Select Data > From Text/CSV
- Find and select desired Recording .txt file
- Click “Import”
- Select in a preview the delimiter Semicolon
- Press “Load”.
Now the data are ready to be viewed and analyzed.
Download the Overview of the Recorded Signals in Lokocontrol V6.5 here
Top 10 Exercises with the Andago®
Andago Quick Reference Guide
ArmeoSpring Quick Reference Guide: Patient Setup
How Should I Optimize the Fall Limit for Andago Training?
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.
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.|
- 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.
How to Should I Optimize Body Weight Support for Andago Training?
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.
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.
How is the Robotic Support Calculated for ArmeoPower?
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.
|Support level||Type of support (1D)||Type of support (2D/3D)|
|None||No robotic support||Initial movement:||No robotic support|
|During movement:||No robotic support|
|Start of support:||No robotic support|
|Low||Low guidance force (torque), builds up slowly||Initial movement:||No robotic support|
|During movement:||Slow robotic support|
|Start of support:||Intention detection|
|Medium||Medium guidance force (torque), builds up moderately||Initial movement:||Robotically supported|
|During movement:||Medium speed robotic support|
|Start of support:||Time offset|
|High||High guidance force (torque), builds up quickly||Initial movement:||Robotically supported|
|During movement:||Quick robotic support|
|Start of support:||Immediate support|
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).
How to Add and Remove Items from the Armeo Therapy Plan?
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.
What is A-ROM on Armeo and When Must I Do it?
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.
What is A-MOVE and When Must I Do it?
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.
How Long Does it Take to do an Armeo Session?
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.
How can I Prevent Jerky Arm Movements During ArmeoPower Therapy?
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 .
How can I Protect Patients’ Skin when they Train on the Lokomat?
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)
- 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.
Jeffrey et al., Considerations in Special Populations: Patients with vulnerable skin, National Pressure Ulcer Advisory Panel, 2015; www.npuap.org
At What Point and How Do you Increase Challenging the Patient with the Armeo?
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.
These recommendations are based on the feedback of experienced Armeo users.
Should a Clinician Conduct the Patient’s Arm Movement During ArmeoSpring Therapy?
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).
Which Parameters Shall I Adjust in Order to Reach my Therapy Goal?
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.
- 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.
How Do I Know Which Exercises to Select for my Patient on the ArmeoSpring?
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.
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.
These recommendations are based on the feedback of experienced Armeo users.
How can I Optimally Set the Patient Workspace for Armeo Therapy?
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
The training region define the boundaries of the exercises:
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.
Find below a file that contains “Common Issues, Their Explanation and Solutions” regarding the workspace
Common Issues, Their Explanation and Solutions
How Much Time Should I Schedule for an Erigo Session? What is the Content of an Erigo Session?
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
- 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)
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).
Which Movement Pattern Should I Select for my Patient?
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.
- 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.
- 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.
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.
What Are Some Indications that a Patient is Being Appropriately Challenged During Erigo Therapy?
One of the most important tasks of a therapist is to provide an appropriately intense training session in order to sufficiently challenge the patient. Erigo therapy has to be demanding enough to ensure a high therapy effect, but should not be too excessive and nor should it overstrain or frustrate the patient. We’ve collected advice from clinical experts who use the Erigo on a regular basis with the goal of providing recommendations on how to strike a balance between too much and not enough.
The easiest way to get feedback on the training intensity is by asking the patients themselves if they feel overstrained or insufficiently challenged (as long as they are able to communicate). However, don’t rely exclusively on the patient’s answer. Always consider other ways to assess how the patient feels.
Signs of Insufficient Challenge
- Decrease of compliance and the patient being bored often indicates insufficient training intensity.
- If the patient is able to perform Erigo sessions with a high degree of verticalization, a high loading and a high cadence for the whole therapy session, moving on to another device, such as Lokomat, or even starting with over-ground gait training might be more appropriate. For a bigger challenge also additional stimuli can be added (e.g. activities with the upper extremities etc.)
Signs of Excessive Challenge
- A decrease in blood oxygenation (SpO2) below 90%
- Rapidly increasing heart rate
- Shallow breathing, pale skin and (cold) sweat
- Increased muscle tone, which results in frequent interruption of the Erigo
- Moaning, crying or any other signs of discomfort
- The patient’s trunk being heavily twisted
We propose that the appropriate challenge for a patient lie between the two extremes listed above.
How Do I Define the Optimal Cadence and Tilt Angle for my Patient?
Cadence and tilt angle are the two main parameters you can use to challenge a patient during Erigo therapy. Both parameters should be set at the highest possible value while ensuring a safe and long training session. To support you on setting these parameters, read the following recommendations.
First Training Session and Adjustments over Training Progression
The goal of the first training session is to get the patient used to the therapy. Therefore, low values are appropriate for both parameters: a tilt angle of max. 45° and a cadence of max. 24 steps/min is recommended.
Cadence and tilt angle should be gradually increased during the following sessions. The higher the patient’s vigilance and cognition levels are, the higher cadence and tilt angle can be.
For training progression, the cadence and tilt angle should be set at the limit of the patient’s abilities. The higher the cadence and tilt angle, the greater the therapy impact. The intensity of afferent input, the level of challenge to the patient’s cardiovascular system, and the number of repetitions can be influenced through cadence and/or tilt angle.
However, bear in mind that the patient should be able to train for at least 20 minutes with the adjusted parameters.
These recommendations are based on the feedback of experienced Erigo users.
Possible Risk Factors that Need to be Considered
- Patients with a high level of spasticity should be trained with a low cadence to avoid triggering a spastic response. Additionally, we recommend as much loading as possible to regulate the muscle tone and as much verticalization as the patient can tolerate.
- Body position not aligned. The patient’s posture should always be aligned. If the patient’s body lies in an unnatural way, this could be a sign that the tilt angle is too high. This includes for example:
- Heavily twisted trunk
- Head falling to the side or to the front because of head instability
- Twisted ankles
- Skin irritations. Skin irritations are mostly caused by the leg straps in the patient’s groin area. In this case tilt angle and/or cadence should be reduced.
- Patient’s general condition. Paleness, sweat and increased muscle tone are signs that the cadence and/or tilt angle are too high.
How Do I Define the Leg Loading Value?
Beside the main challenging parameters cadence and tilt angle, patient can additionally be challenged with leg loading. Leg loading value can be adjusted between 0 and 40 kg. 0kg means, patient’s legs are moved without bearing any weight, 40 kg is the maximum weight which can be set by the Erigo on each leg. Leg loading value has to be defined correctly to guarantee a physiological movement.
Criteria for Defining the Leg Loading Value
Patient should be challenged in the Erigo as much as possible. Thus, leg loading should be as high as possible. On the other hand, pressure marks on patient’s legs should be avoided and movement pattern should look physiological. Thus, a balance between too much leg loading and too little leg loading / between a too high value and a too low value should be achieved.
A good criterion to identify the appropriate value and see the thin line between challenging and still physiological is patient’s knee extension. Leg loading should be adjusted in a way that it is possible for the patient to bring the legs into his personal maximum extension.
Adjustment of the Leg Loading During an Erigo Session
Patients usually get tired because of Erigo therapy, so we recommend re-adjusting the leg loading value in between the session. For example, you can start with a higher leg loading value and reduce it, when you can see at patient’s knee extension, that patient cannot stand the weight anymore.
Leg loading is connected with tilt angle, so we recommend to check leg loading every time when tilt angel is changed and vice versa.
How do I Define the Range of Motion for my Patient?
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.
How Should I Set the FES Parameters in the ErigoPro?
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).
* 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).
How do I Attach and Remove the FES Cables to and from the ErigoPro?
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
How Can I Improve Upper Extremity Positioning During Erigo Sessions?
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.
Practical Recommendations for Lokomat Therapy: What is the Optimal Frequency, Duration and Intensity for my Patient?
We have all heard that “intensity matters” and there is several evidence for this fact. However, it is not always easy to provide enough intensity on clinical settings (Spiess M et al 2017). According to a recent study, initial impairment at admission, age and intensity are associated with positive outcome (Boltzmann et al 2017).
Performing hundreds of gait cycles per day contributes to the improvement of gait and lead to a better walking ability. The Lokomat, is a robotic system for gait rehabilitation that proved to be effective for gait therapy and provide high intensity therapy by 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 or amount of unloading can be adjusted during the session. Additionally, goal oriented exercises and automatized training programs can be used to increase patient motivation and participation.
This 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 is the amount of Lokomat sessions per week that a patient receives. It will be influenced by different factors like age, fatigue level or skin fragility. However, a general recommendation can be done as follows:
- (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, examples of reference centers will be published soon)
Fatigue: patients with increased fatigue (like multiple sclerosis patients) 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 functions.
Age can also condition the frequency of the therapy. It is mainly related to their general physical condition. Ensure they have enough rest between sessions to let the muscles, tendons, skin etc recover properly.
Amount of Sessions
The amount 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 over-ground 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
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 1000m 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 train facilitate motor learning by providing more repetitions, to elicit physiological muscle activity by reproducing the nor-mal gait pattern and to train activity timing. Change speed in intervals of 0.1km/h. Speed training program can be used to challenge our 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 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 physio-logical gait pattern and 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.
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 this clinical recommendations.
Lokomat Training with Children with Cerebral Palsy Following Surgery. Practical Recommendations?
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. The effectiveness of different types of surgery have been proved by several authors (Rodda et al. 2006, Dreher et al. 2012, Bozinovski et al. 2014).
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 understood.
In this entry, we summarize the practical recommendations for Lokomat therapy after surgery as published by a group of physical therapists and physicians 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 (Hoiness et al. 2014). 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 is contraindicated after hip, knee and ankle arthrodesis.
Musculoskeletal Considerations after Surgery
Musculoskeletal deformities are a common secondary problem in children with cerebral palsy. General considerations apply for mild to moderate deformities. Strong 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).
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.
Practical Recommendations for Lokomat Therapy in Children with Cerebral Palsy: Patient-Specific Considerations?
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.
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
- 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.