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Explaining Robotics in Gait Rehab

What role do technology and robotics play in gait rehabilitation? How can adopting the use of these devices improve the quality of care in clinical practice? In this episode of MossRehab Conversations: Therapy Edition, Trish Crane, PT, clinical manager at MossRehab Plymouth Meeting, and Andrew Packel, PT, locomotor coordinator, discuss technology to help patients improve their walking ability.

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Welcome to MossRehab Conversations: Therapy Edition, a new series where clinicians at this nationally-ranked physical rehab facility come together to discuss their expertise. In this episode, we joined Trish Crane, clinical manager at MossRehab Plymouth Meeting and faculty member in the Orthopedic PT Residency Program, as she speaks with Andrew Packel, a physical therapist at MossRehab's Main Campus in Elkins Park, where he has been in practice for 23 years. Packel splits his time between the inpatient Stroke Program and as locomotor coordinator. He is board certified in Neurology Physical Therapy practice. 

Andrew, thank you so much for joining me today. I'm very excited to talk to you about the incorporation of technology and robotics in gait rehab. For the past year, you served as MossRehab's Locomotor Coordinator, what can you tell me about this role in your background?

Physical Therapists in a lot of different settings and especially in inpatient rehabilitation, spend a lot of time helping people with their walking ability and often regaining the ability to walk. So we've recognized that it's helpful to have someone to direct the team's efforts in this area. Specifically, we have a lot of technology that can be used to help people regain the walking ability. And so I am helping everybody to coordinate and best use that technology. 

Tell me more about the Locomotor Program, what it is and how it was developed and how did this program evolve over time?

Really over the past five to 10, or even a little bit more years as we've been accumulating technology, we've been trying to put it into practice and the technology is increased in complexity and increased the number of options we have for training to help people with their walking ability. So we've recognized that we've needed to be a little bit more structured in our approach. Previously, maybe five, six years ago, we established a locomotor committee to help try to guide these efforts, but I think the Moss administration recognized that having a point person to really lead that role would be important moving forward.

You use the term technology to describe some of the devices that you utilize in treatment. Can you explain what is meant by the term technology as it applies to your role? 

We have a lot of different options now. There's a lot of robotic devices and basically when we use the term "robotic" we're thinking about there's both sensors that can help detect different parts of movements and then motors, that can help to assist and direct movement. So robotics are a big part. But then we also have different types of equipment that may not necessarily have those sensor components to those motor components. They may have one or the other, so they may not be considered robotic. 

What is the big distinguishing factor between robotics and technology?

Really, the term robotics would specifically include both sensors and motors to help some type of computerized algorithm to assist with movement. We have some technology devices, for example, dynamic body weight support systems that can measure somebody's weight and provide some assistance with that that probably wouldn't be considered robotic, but are still a use of technology. 

Are the robotic devices all worn externally?

There's primarily two types of different robotics that can help people with their walking ability. So one is called an exoskeleton type of device. And that would be worn on the body part that to be assisted. So in the case of walking, it covers some of these legs, typically the hips and knee joints, although we also have a robotic device that works the ankle joints. There's another type robotic walking device called an end effector device and that one, the feet just strap on to and so it's going to just move the feet in a prescribed pattern, but it's not really going to control the hips and knees. So it's two different approaches to help and walking ability. 

What benefits do you see when you're treating patients using these devices in Gait Rehab? 

We have a lot of different approaches that we can use. The traditional approaches we practice having people walk, you know, as they normally would walk over ground, but especially when people are more severely impaired, they may only be able to get a few steps in. We may have two or three therapists trying to help them walk. These devices by supporting and maybe assisting the patients as they need, it can offer them the appropriate assistance with a lot less use of people that provides a much more consistent amount of assistance. And it can go for a much longer time. So someone may be able to take hundreds and hundreds of steps in one bout instead of just a few steps before getting overly fatigued. 

Are there specific criteria that the patient needs to meet in order to be a candidate for the device, a specific functional level that they need to meet to use robotics or technology?

That can vary across the different devices we have. Some of the devices are really most appropriate for people who really need the most help. So someone who really has minimal walking ability, they might not be able to walk it all by themselves. And it might require heavy assistance from one person or more assistance from two people. We know those individuals can have a lot of benefits from devices but a lot of the devices are also able to challenge people at a higher level, too. So we're finding different uses. And some of the devices are certainly geared toward people who are already performing at a higher level. So we have a wide range of devices that can help a wide range of abilities. 

It must be such a huge benefit to have a device that can allow for repetition and practice for an individual that is functioning at a lower level. 

That's absolutely right. You know, we have some emerging things from the literature and the research on different devices. And we know that number of repetitions, which is also referred to as dosage or the amount of practice is an important component, we know that we must be getting the right kind of practice for our patients. So these devices can really help with both pieces that can give us large numbers, repetitions and a lot of practice for our patients. And we can also make sure that they're getting the right type of practice that that individual needs. 

I've heard you speak a couple times on this topic. One thing that really struck me when I heard you speak is the idea that the device is really not the treatment, it's a modality that you use in treatment. Can you explain this further and what the therapists role is compared to what is the role of the device?

Some people have said that they're concerned that you know, these devices are going to take the place of physical therapist and I just don't see that happening. Physical Therapists need to be still making a lot of decisions when they're using these devices. So there's not one particular way that any device gets used. There's parameters of the different devices. Some devices can be used with different types of orthotics or assistance. Often the therapist may be queuing or facilitating the person within the device. Some of the devices have different types of feedback, and we can select that kind of feedback. So the devices and the way that the device is set up in particular, we think of those as ingredients that are used in that treatment session, but they're not the treatment itself. So the therapist needs to be mindful about what they're offering to the patient. They're offering practice with a device with certain parameters. But there's a lot of other things being offered too that may be important ingredients leading to the success of that treatment. 

What are some of the barriers that you've encountered with regards to incorporating technology into treatment? 

We've been working through those barriers. Certainly any change in practice is something that people have to get used to. We have a lot of physical therapist at MossRehab, and we have many that have been practicing for a number of years. And so traditionally, they're used to doing things without this equipment. So it's a change in practice over established patterns to think you know, "When can I use a piece of equipment?" Or even starting to change that equation instead of the therapist asking themselves, should I be using a piece of equipment for this patient in certain instances? Every patient we're trying to ask is there some a quick It might be appropriate. And often the cases that there is, even for a higher level patient, if it's, you know, just a treadmill, that's an important piece of technology. So certainly, changing practice is one potential barrier. There's logistical barriers, some of the equipment takes more time to set up. And so we've got to either find a way to provide more time to get that patient in, or the therapist has to recognize that part of their treatment time is going to be devoted to setting up that equipment, which means they have to feel that the benefit of that equipment is worth that. So we're trying to help therapists recognize all these concerns, and be able to address each one of them. 

How is the use of technology and robotics and physical therapy treatment evolved at MossRehab?

We started with our first robotic device, which was the Lokomat this was probably in 2004 or so. So it's been 15 years that we've been expanding our collection of devices. And again, we're trying to get more savvy with our understanding of how we apply these devices, how we make decisions to apply these devices to different patients. So that's where we're at. At the same time, just as in every other area of technology. The devices are improving, they're getting better, they're getting more accessible. One of the things we're seeing now is instead of rigid devices, we're seeing some wearable exoskeletons typically made out of fabrics and soft devices that attached to the body rather than hard, rigid devices. So they have the potential to be more comfortable, maybe more accessible to be worn with clothing or underneath clothing a little more easy. And I think that's the way that this technology is going to continue to go. 

Tell me about some of the pieces of technology that are available for your use at MossRehab.

I mentioned the Lokomat. So again, this was the first commercially available robotic gait device and it was originally invented in 2001 and evolved over the years. So we still use that device here at MossRehab. That's an exoskeleton body weight supported treadmill device, we have the G-EO, an end effector robotic device that uses body weight support. And in that you're walking on foot plates somewhat similar to an elliptical if you can imagine that. They can help with walking and stair climbing. And then we have other types of devices. We have a SafeGait dynamic body weight support harness. We have the Ekso by Ekso Bionics an overground exoskeleton type of device. It's one of the newer devices we're starting to use here at MossRehab that that allows us to take someone down the hallway and an exoskeleton device and ReWalk robotics. In addition to using their rigid exoskeleton, they have also come with our first wearable device called the ReWalk ReStore, an ankle robotic wearable exoskeleton device that allows someone's ankle to be controlled by a robotic device to assist in lifting their foot up and pushing their foot down while they're walking. 

Would that be used for an individual that has a foot trapped or has some loss of motor control after a stroke? 

Those are the most typical uses, yeah, with somebody really with weakness that we really want to focus on their ankle. So often after foot drop or a stroke, where it might even be a spinal cord injury that has a major effect at the ankle. And that can help to lift the foot during swing, and importantly can also help with propulsion. So as somebody walking can help to assist sort of pushing them forward, which is an important function of the ankle that we don't have another way of addressing at this time.

Are there plans for new devices in the future at Moss?

Yeah, I think Moss is really committed to being a leader in technology and in the use of robotic devices. So I don't expect that we're going to slow down in our incorporation of devices. We have relationships with some of the manufacturers of devices. So we're getting devices sometimes. And we're testing them and giving feedback to the manufacturers, the developers, the devices, and those relationships will continue. We're anticipating in the next month, or so, receiving another type of end effector walking device that's similar to the G-EO but offers different features and a smaller footprint and maybe a little easier use. So I think we're going to continue to expand our use of robotics and just as the field continues to grow, we'll continue to look for new ways to use the new devices. The other thing is a lot of the robotics right now you need to come to see us at Moss and then there's a lot of talk about, is there a way to get these robotic devices out and let people take advantage of some of the technology and things in their home, let's say. Or if they're attending outpatient therapy, could they have a device that they're using the community as an extension of their therapy. I know that's an area that's being looked at in order to maximize the efficiency of our treatment. 

What is the most rewarding thing to you with regards to your role as the locomotor coordinator?

My career as a physical therapist is really about helping people and specifically, I'm interested in helping people to walk better. And so really my career I've been geared towards, "How can I help people walk better?" And that's geared towards individual patients I work with and I've assisted with research projects, and I kind of see that as a way that I can help the field move forward. And in this role as locomotor coordinator, I can help other therapists at Moss be able to help their patients better as well. So that's really meaningful to me. I want to see every patient who comes to Moss be able to have their locomotor training and their experience optimized and really to achieve the best walking ability they can. 

Andrew, thank you so much for joining me today and for sharing your expertise. It's really exciting to see some of the things that we can look forward into the future of physical therapy. So I really appreciate your time today.

My pleasure, Trish. Thank you for having me.

That was MossRehab Physical Therapist Andrew Packel, who works in the inpatient Stroke Program and as locomotor coordinator at our main campus in Elkins Park. To learn more about MossRehab's work in this field, go to mossrehab.com/robotics. Also on the web at mossrehab.com/conversations you can listen in as we talk with pioneers in physical medicine from around the globe. Thanks for joining us, I'm Bill Fantini.

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