Realtà virtuale: l esperienza dell IRCCS Medea

Emilia Biffi Realtà virtuale: l esperienza dell IRCCS Medea Emilia Biffi, C. Maghini, E. Beretta, E. Diella, D. Panzeri, F. Brunati, M. Delle Fave, S. Strazzer, A.C. Turconi, G. Reni Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Italy

Emilia Biffi 2 INTRODUCTION Traditional physiotherapy Virtual Reality for rehabilitation Interactive environments but safe interaction Visual, auditory, proprioceptive and tactile stimuli Repetitive and personalized treatments Motivation and active participation

Emilia Biffi GRAIL 3 Gait Real-time Analysis Interactive Lab Dedicated solution for gait analysis and training As well as.. Simultaneous control Cognitive dual task

Emilia Biffi 4 GRAIL TECHNICAL FEATURES Dual-belt treadmill Integrated force plates 10 optoelectronic cameras and 3 videocameras 180 cylindrical screen Dolby surround Dynamic weight bearing system Pitch and sway of the motion frame

Emilia Biffi 5 IMMERSIVE EXPERIENCE THE USER Feels treadmill movements Sees 3D scenaries projected on the screen Hears sounds related to images Interacts with the system by moving his body

Emilia Biffi KEY FEATURES 6 Data acquisition: automatic labelling Self-paced walking: realistic gait training Real-time processing: feedback during the training Off-line analysis tool

Emilia Biffi 7 STATE OF THE ART Movement assessment Adult subjects: healthy, poststroke, amputees Comparability overground and GRAIL gait analysis Response to the VR environment Stability maintenance and perturbation compensation Overground and treadmill walking comparable (no influences of speed mode). (Gates et al 2012; Sloot et al, 2014) Useful to evaluate gait stability and adaptation. (Hak et al 2012; 2013) Children: healthy and cerebral palsy Comparability overground and GRAIL gait analysis Response to the VR environment Treadmill speed mode and VR do not cause clinically relevant changes in the (Sloot et al 2015; Van der Krogt et al 2014) kinematic and kinetic parameters. Overground vs treadmill: no differences in kinematics except for a wider step width; considerable differences in kinetics (from ankle to hip strategy). (Van der Krogt et al 2015)

Emilia Biffi 8 STATE OF THE ART Gait rehabilitation Adult subjects: post-stroke, amputees and elders Response to the VR based real time feedback Balance rehabilitation by delivering perturbations during gait Improvements in gait rehabilitation and performance (Darker and Wilken, 2011; Hak et al, 2013; Isaacson et al, 2013) Children: congenital and acquired neuromotor disorders Feasibility and effectiveness of a rehabilitative treatment on GRAIL Aim of our investigation

Emilia Biffi CLINICAL PROTOCOLS 9 Gait and balance rehabilitation of children suffering from acquired brain injury Gait and balance rehabilitation and neurofunctional changes in children affected by diplegic cerebral palsy Treatment: 10 sessions over GRAIL in 2 weeks 10 sessions physiokinesitherapy in 2 weeks Walking and balance training Treatment: 18 sessions over GRAIL in 4 weeks 20 sessions physiokinesitherapy in 4 weeks Walking and balance training Pre and post assessment: Gait evaluation over GRAIL in SP and FV Functional evaluation: GMFM, 6minWT, FAQ, OG gait analysis Pre and post assessment : Gait evaluation over GRAIL Functional evaluation: GMFM, 6minWT + metabolic expense, OG gait analysis Neuroimaging evaluation: structural MRI, DTI, resting state fmri

RESULTS Gait and balance rehabilitation of children suffering from acquired brain injury Emilia Biffi 10 STUDY group (SG): 8 children / adolescents with ABI Mean distance from the event: 7±6 months Mean age 12±3 years old 3 males, 5 females Motor damage: 5 left, 3 right CONTROL group (CG) (10 minute recordings during walking): 10 young healthy adults Mean age 26±1.7 years old 1 male, 9 females Aged matched group (van der Krogt et al, 2014; Sloot et al, 2015; van der Krogt et al, 2015) 11 typically developing children Mean age 10.6±2.2 years old 7 males, 4 females

RESULTS Stride length 1,80 1,60 More impaired side Less impaired side 1,40 Length [m] 1,20 1,00 0,80 0,60 * * * * * * Van der Krogt et al, 2014 0,40 0,20 0,00 SG T0 SG T1 CG Wilcoxon test and Mann-Whitney test p<0.05 Emilia Biffi 11

Degrees 16 14 12 10 8 6 4 2 0 RESULTS Peak ankle plantar-flexion during stance * * * * SG T0 SG T1 CG More impaired side Less impaired side Sloot et al, 2015 Wilcoxon test and Mann-Whitney test p<0.05 Emilia Biffi 12

RESULTS Hip rotation at initial contact 10,00 8,00 6,00 4,00 * More impaired side Less impaired side Degrees 2,00 0,00-2,00-4,00-6,00-8,00 Sloot et al, 2015-10,00 SG T0 SG T1 CG Wilcoxon test and Mann-Whitney test p<0.05 Emilia Biffi 13

4 3,5 3 RESULTS Max ankle flexion power More impaired side Less impaired side power [W/Kg] 2,5 2 1,5 * * * * * * 1 0,5 0 SG T0 SG T1 CG Van der Krogt et al, 2015 Wilcoxon test and Mann-Whitney test p<0.05 Emilia Biffi 14

Emilia Biffi 15 RESULTS Gait and balance rehabilitation of children affected by diplegic cerebral palsy STUDY group (SG): 3 children / adolescents with diplegic CP Mean age 11.7±4.2 years old 2 males, 1 females CONTROL group (CG): 10 young healthy adults Mean age 26±1.7 years old 1 male, 9 females Aged matched groups(van der Krogt et al, 2014; Sloot et al, 2015; van der Krogt et al, 2015) 11 typically developing children Mean age 10.6±2.2 years old 7 males, 4 females & 9 children with spastic CP Mean age 11.6±2.1 years old 4 males, 5 females

RESULTS Stance % 80 75 * T0 T1 70 stance % 65 60 55 50 SG Van der Krogt et al, 2014 Van der Krogt et al, 2014 CG Mann-Whitney test p<0.05 Emilia Biffi 16

RESULTS Mean pelvic rotation 5 0 * Van der Krogt et al, 2014 Van der Krogt et al, 2014 Degrees ( ) -5-10 T0 T1-15 -20 SG Mann-Whitney test p<0.05 CG Emilia Biffi 17

4 RESULTS Max ankle flexion power 3,5 3 power [W/kg] 2,5 2 1,5 * T0 T1 1 0,5 0 SG Van der Krogt et al, 2015 Van der Krogt et al, 2015 CG Mann-Whitney test p<0.05 Emilia Biffi 18

CONCLUSIONS Emilia Biffi 19 GRAIL is engaging for children and adolescents. GRAIL supports and motivates gait and balance rehabilitation of children suffering from acquired and congenital motor damage. Patients show changes in spatiotemporal, kinematic and kinetic parameters at the ankle, hip and pelvic level. ABI: changes at the most impaired side CP: changes due to functional improvements and adaptation? SG from the literature (9 CP children) not comparable to our SG at T0. CG (10 adults) comparable to the CG from the literature (11 children) except for the kinetic. Future directions: Increase the study groups size Aged-matched CG

THANKS FOR YOUR ATTENTION Emilia Biffi 20