massimiliano mangone mariangela vanadia vana… · un piano orizzontale robot per l’arto...
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Robotica e Spinometria
Massimiliano Mangone
Mariangela Vanadia
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RobotRobot
Il robot è una qualsiasi macchina (di forma più o meno
antropomorfa), in grado di svolgere più o meno
indipendentemente un lavoro al posto dell'uomo.indipendentemente un lavoro al posto dell'uomo.
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Terapia RoboticaTerapia Robotica
Ogni forma di terapia attuata grazie l’ausilio di un robot
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Terapia RoboticaTerapia Robotica
Interesse crescente
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The most common robot rehabilitation protocols employed to date
involve one or a combination of the following:
1) the robot initiates the movement and produces an assistive force to
push the subject's arm with a predefined trajectory and speed;
2) the subject initiates the movement but the robot then produces an2) the subject initiates the movement but the robot then produces an
assistive force;
3) the subject initiates and pushes the robot to an intended target
while the robot provide a resistive force;
4) the subject initiates and pushes the robot to an intended target; the
robot only corrects if the movement is off course or too slow.
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Haptics is the science of applying touch sensation and control
for interaction with virtual or physical applications
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END EFFECTOREND EFFECTOR ESOSKELETONESOSKELETON
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MIT MANUS
Robot a 2 DOF che consente movimenti dell’arto superiore su
un piano orizzontale
Robot per l’arto superioreRobot per l’arto superiore
un piano orizzontale
Krebs HI, Hogan N, Aisen ML, Volpe BT. 1998. Robot-aided neurorehabilitation. IEEE Trans. Rehabil. Eng. 6:75–87
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MIME (mirror image movement enhancer)
Robot a 6 DOF collegato ad uno splint a livello dell’avambraccio.
Molteplici orientamenti spaziali.
Robot per l’arto superioreRobot per l’arto superiore
-Modalità passiva
-Modalità attiva assistita con facilitazione
-Modalità attiva assistita con resistenza
-Modalità bimanuale (mirror)
Burgar et al. J Rehabil Res Dev 2000
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Assisted rehabilitation and measurement (ARM) guide
Assiste meccanicamente un movimento di reaching
Robot per l’arto superioreRobot per l’arto superiore
Reinkensmeyer DJ, et al. J. Rehabil. Res. Dev. 37:653–662
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Bi-Manu-Track
Robot a 2x1 DOF che consente due tipi di movimenti: prono/supinazione
dell’avambraccio e flesso/estensione di polso
Robot per l’arto superioreRobot per l’arto superiore
Hesse et al. Arch Phys Med Rehabi 2003
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NeReBot
Robot a 3 DOF che può essere anche
utilizzato a letto del paziente (fase acuta)
Robot per l’arto superioreRobot per l’arto superiore
Rosati et al. 2006
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Nudelholz mechanical arm trainer
Robot a 3 DOF che consente movimenti paramenti passivi di
flesso/estensione di gomito, addo/abduzione di spalla e
Robot per l’arto superioreRobot per l’arto superiore
flesso/estensione di polso. Destinato a pazienti più gravi
Hesse et al. 2006
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Leigh R. Hochberg et al, Nature 2012
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Robot Assisted Gait TherapyRobot Assisted Gait Therapy
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END EFFECTOREND EFFECTOR ESOSKELETONESOSKELETON
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LOKOMAT
Motor-driven gait orthosis secured to patient’s legs while the
patient is supported by a BWS system over a motorized
Robot per il camminoRobot per il cammino
patient is supported by a BWS system over a motorized
treadmill
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GAIT TRAINER
End-effector che funziona con I principio delle piattaforme
mobili ed è dotato di BSW
Robot per il camminoRobot per il cammino
mobili ed è dotato di BSW
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G-EO system
Evoluzione del GT, che consente anche movimenti diversi
rispetto al cammino (salire le scale)
Robot per il camminoRobot per il cammino
rispetto al cammino (salire le scale)
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1. Evidence increased that the injured motor system can reorganize in
the setting of motor practice.
However, the optimal training techniques for facilitating reorganization
remained unclear, in part because of difficulties quantifying dose, type,
MotivationMotivation for for RoboticRobotic TherapyTherapy
remained unclear, in part because of difficulties quantifying dose, type,
and consistency of rehabilitation therapy.
Robotic devices were seen as a possible way to precisely
control and measure therapy
Reinkensmeyer et al, 2004
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2. Patients began receiving less therapy following neurologic injuries such
as stroke, even though studies suggested that more therapy was better.
Robotic devices were seen as a possible way to automate
MotivationMotivation for for RoboticRobotic TherapyTherapy
labor-intensive training techniques, providing new tools for
therapists and improved access to therapy for patients
Reinkensmeyer et al, 2004
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3. Neurorehabilitation is based on two basic assumptions: that motor
learning principles apply to motor recovery and that patients can learn.
Robots provide the means to quantitatively test these two
MotivationMotivation for for RoboticRobotic TherapyTherapy
assumptions
Huang and Krakauer, 2009
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The «Slacking Hypothesis»
A robotic device could potentially decrease recovery if it
encourages slacking; i.e. a decrease in motor output, effort,
energy consumption, and/or attention during training
ASSISTANCEASSISTANCE--ASAS--NEEDEDNEEDED
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Primary outcomesPrimary outcomes
Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD006876. DOI: 10.1002/14651858.CD006876.pub3
Primary outcomesPrimary outcomes
The primary outcome was activities of daily living. We preferred the Barthel Index and
the Functional Independence Measure as primary outcome measures, if they were
available. However, we accepted other scales that measured activities of daily living.
Secondary outcomesSecondary outcomes
The secondary outcomes were impairments, such as motor function and muscle
strength, which were measured with the Fugl-Meyer score and the Motricity Index
Score
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Durata degli studi
• Da 2/3 settimane a 12 settimane (5-6 nella maggior parte)
Trattamenti valutati
• Robot-therapy vs placebo
• Robot-therapy + riabilitazione convenzionale vs riabilitazione
convenzionale
Frequenza del trattamento
Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD006876. DOI: 10.1002/14651858.CD006876.pub3
Frequenza del trattamento
• 5 volte/settimana nella maggior parte dei trials
Intensità del trattamento
• Da 20-30’ a 90’ a seduta
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Arm function
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Forza muscolare
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AuthorsAuthors’’ conclusionsconclusions
Patients who receive electromechanical and robot-assisted arm
Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD006876. DOI: 10.1002/14651858.CD006876.pub3
Patients who receive electromechanical and robot-assisted arm
training after stroke are more likely to improve their generic
activities of daily living. Paretic arm function may also improve, but
not arm muscle strength. However, the results must be interpreted
with caution because there were variations between the trials in the
duration and amount of training, type of treatment, and in the
patient characteristics.
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Authors’ conclusions
17 trials; 837 participants
Mehrholz et al. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006185.
Authors’ conclusions
Patients who receive electromechanical-assisted gait training in combination with
physiotherapy after stroke are more likely to achieve independent walking than patients
receiving gait training without these devices. However, further research should address
specific questions, for example what frequency or duration of electromechanical-assisted
gait training might be most effective and at what time after stroke. Follow-up studies are
also needed to find out how long the benefit lasts.
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4 trials; 222 participants
Mehrholz J, et al. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006676.
Authors’ conclusions
There is insufficient evidence from RCTs to conclude that any one locomotor training
strategy improves walking function more than another for people with SCI. Research in the
form of large RCTs is needed to address specific questions about the type of locomotor
training which might be most effective in improving walking function of people with SCI
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8 trials; 161 participants
Swinnen et al, 2012.
Authors’ conclusions
There is a limited number of published papers related to TT in persons with MS, concluding
that TT, BWSTT, and RATT improve the walking speed and endurance.
However, it is not clear what type of TT is most effective. RCTs with larger but more
homogeneous populations are needed
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Spinometria Formetric
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Introduzione
La radiografia rappresentata tuttoggi l' unico metodouniversalmente riconosciuto e standardizzato per la valutazione delle deformità della colonna
Tuttavia essa presenta dei limiti:Tuttavia essa presenta dei limiti:
• Bidimensionalità• Poca accuratezza nel quantificare i parametri• Non è dinamica• Invasività
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Storia
Tre metodi sono stati invece sviluppati fino a trovare effettivo impiego in ambito clinico:
• Integrated Shape Imaging System (ISIS)• Integrated Shape Imaging System (ISIS)•Quantec Imaging System •Rasterstereografia (Formetric)
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Sistema: Formetric 3D/4D
Specifiche di Sistema:
• Videocamera CCD• Videocamera CCD
• Proiettore a Bande
• Colonna
• Sistema PC
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Principi di Funzionamento: Triangolazione
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Principi di Funzionamento: Video Raster Stereografia
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Principi di Funzionamento: Video Raster Stereografia
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Dati Acquisiti: Morfologia Superficiale del Dorso
(Precisione= 0,01mm)
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Dati Acquisiti: Analisi delle Curvature
• convesso
• concavo
• forma di sella
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Dati ottenibili: Individuazione automatica punti di
repere
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Dati Ottenibili: Rappresentazione Tridimensionale della
Colonna Vertebrale
Per poter ora ricostruire la forma della spina dorsale sulla base dei dati relativi alla morfologia del dorso in 3D, è indispensabile calcolare:
•Deviazione laterale delle vertebre sul piano frontale•Rotazione delle vertebre sul piano trasversale•Profilo sagittale della colonna
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Dati Ottenibili: Rappresentazione Tridimensionale della
Colonna Vertebrale
Deviazione Laterale: è necessario localizzare i procesi spinosi
Nella rasterstereografia la linea dei processi spinosi viene pertanto determinata matematicamente mediante calcolo della cosiddetta linea di simmetria
(Hierholzer E. Objektive Analyse der Rückenform von Skoliosepatienten, Gustav Fischer Verlag, Stuttgart, New York, 1993)
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Dati Ottenibili: Rappresentazione Tridimensionale della
Colonna Vertebrale
Rotazione vertebrale :viene equiparata alla rotazione (ρ) della superficie dorsale in corrispondenza del processo spinoso, ossia della linea di simmetria.spinoso, ossia della linea di simmetria.La precisione della misura è di circa3°
Drerup B, Hierholzer E. Assessment of scoliotic deformity from back shape asymmetry using an improved mathematical model. Clin Biomech ; 11 : 376-383, 1996
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Dati Ottenibili: Rappresentazione Tridimensionale della
Colonna Vertebrale
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Analisi Dinamica: Motion
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• Vertebra non deformata
• I punti anatomici fissi si calcolano dall’analisi delle curvature
Limiti della Metodica: Ipotesi
curvature
• Rotazione nel piano più profondo della spinosa
• Utilizzo di tabelle antropometriche
• Basso spessore sottocutaneo nella regione del dorso
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Limiti della Metodica: Errori di Rilevazione
• 3° sul Movimento di Rotazione Vertebrale
• ± 2 mm sulla Determinazione della Posizione del centro vertebrale centro vertebrale
• ≤ 5mm sulla Determinazione della Posizione dei Punti di Repere
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Spinometria Vs RX
La metodica non si propone di sostituire l’esameradiologico, che fornendo informazioni morfologichenon può essere rimpiazzato dalla spinometria.non può essere rimpiazzato dalla spinometria.
Vuole fornire un esame che riveli molto piu’ dell’esameobiettivo con una riproducibilità comparabile con quellaofferta dai raggi X.
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Spinometria Vs RX
• Assenza di Radiazioni :
Su indicazione di esperti specialisti, le scoliosi e le cifosidiopatiche dei ragazzi vengono sottoposte a controlloradiologico almeno due volte l’anno.radiologico almeno due volte l’anno.
L’esposizione alle radiazioni che ne deriva può raggiungereuna dose superficie pari a 350 mGy/cm² per ciascunaradiografia della colonna completa.
(Reduction of radiation exposure in full spine images in youth Bernau A, Seeger W. Z Orthop IhreGrenzgeb. 1996 Jul-Aug;134(4):302-4. German.)
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Esposizione a radiazioni ionizzanti durante esecuzione di radiografiacompleta della colonna vertebrale
Dose Angolo di Cobb
97.0 cGy cmq
31.5 cGy cmq
TECNICA TRADIZIONALE
TECNICA DIGITALENon differenze
significative
Eur Spine J. 2006 Jun;15(6):752-6. Prospective randomized comparison of radiation exposure from full spine radiographs obtained in three different techniques.Kluba T, Schäfer J, Hahnfeldt T, Niemeyer T.
31.5 cGy cmq TECNICA DIGITALE
5.0 cGy cmq FLUOROSCOPIA
significative
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Spinometria Vs RX
• Riduzione dell’influenza del respiro e delle naturalioscillazioni del corpo sulla determinazione del modellodi colonnadi colonna
• Soluzione: AVERAGING
L’analisi 4D permette un’analisi dinamica con la possibilità di effettuare un’ operazione di media sui parametri calcolati
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Spinometria Vs RX
• La rappresentazione della curva della colonna, fornitadalla spinometria, ha resa tridimensionale
• L’informazione fornita dalla radiografia è la proiezione su• L’informazione fornita dalla radiografia è la proiezione suun piano di un sistema che in presenza di deformità puòassumere un carattere tridimensionale
• È difficile rilevare dall’esame radiografico con precisionela rotazione vertebrale
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Letteratura
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Letteratura
La digitalizzazione delle immagini è stata eseguita con ilmetodo Drerup, consentendo una rappresentazione deidati non per segmenti ma in forma di curve sinusoidali amodulazione di frequenza.modulazione di frequenza.
Si è poi proceduto alla sovrapposizione delle curvestereografiche e di quelle radiografiche digitalizzate.
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Letteratura
RX
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Letteratura
Formetric
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
Tratto di analisi: toracico/lombare
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Letteratura
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Metodi:Il progetto prevede il reclutamento di 40 soggetti con classi occlusali II e III chepresentino dislocazione riducibile del disco monolaterale e sintomatologiadolorosa, lasuddivisione randomizzata in 4 gruppi e la pianificazione di un’iter terapeuticofisioterapico e/o ortodontico per 3 di questi gruppi. Verrà, quindi, effettuato monitoraggioin itinere e valutazione al termine del trattamento.
Obiettivi:Verificare l’efficacia e le differenze nei risultati ottenutidai vari approcci riabilitativifisioterapico, ortodontico e combinato, sul miglioramento della sintomatologia e dellaqualità di vita, inoltre verificare utilizzando i paramentri estrapolatidagli esami Telecranioe Formetric eventuali relazioni tra possibili adattamenti posturali e ilcambiamento dellarelazione centrica occlusale
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Gran parte dei pazienti presenta accentuata rispetto al normale range la Flessione
antero-posteriore (VP-DM). E ben 19 pazienti dei 22 presenta un angolo cifotico
alterato rispetto al range di normalità(47-50), con 4 pazienti addiritturaal di sotto dei
30 gradi
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Il nostro studio ha rilevato nei pazienti che presentano dislocazione riducibile del
disco un significativo aumento dei valori medi delle frecce lombari e cervicali, della
deviazione laterale VPDM e dell’ aumento dell’ angolo cifotico ICT- ITL.
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La metodica offre la possibilità di avere:
• alta sensibilità
• follow up• follow up
• alta fruibilità