EP1169003B1 - Device and method for a locomotion therapy - Google Patents

Abstract

The invention relates to an apparatus which actively moves the legs of a disabled person in a movement pattern that is similar to physiological walking. The inclination of the standing table can be adjusted between a horizontal and a vertical position as desired. The patient is fixed to the standing table by means of a belt gear. The aim of this kind of rehabilitating locomotion therapy is to activate the locomotion structures in the spinal cord in order to improve the muscular situation in a time optimal manner, to prevent the intensity of spasticity and to improve the circulatory conditions.

Description

8. The invention relates to a device and a method for starting locomotion training in patients with mobility problems in an early phase of rehabilitation, according to patent claims 1 and 8, respectively.

In the case of incompletely paraplegic patients, it has been proven that there is an opportunity to improve walking ability through normal locomotion training. The therapy required for this is currently carried out on a treadmill, whereby the patient is only able to walk through defined weight relief and in part through additional assistive guidance of the legs by physiotherapists (Wickelgren, I. Teaching the spinal cord to walk. Science, 1998, 279, 319-321). However, this type of locomotion therapy can only be started when the circulation is sufficiently stable, since the patient has to remain in an upright position for a long time. The required circulatory stability is usually not given in the first weeks after the onset of the spinal cord lesion.

In the rehabilitation of patients with restricted movement of the legs or after orthopedic surgery, various powered orthoses are already in use, which actively move the legs of lying patients.
U.S. Patent No. 5239987 (1993) describes such a system. In these devices, the legs are primarily guided by moving the lower leg relative to the thigh. However, there is no apparatus in which a knee extension with a weight load on the sole of the foot is achieved in the extended phase ("standing phase") of the movement cycle. Hip expansion is not present in the mechanisms mentioned.

U.S. Patent No. 4,986,261 (1991) describes an apparatus that also causes hip expansion. However, the knee joints are not moved as in physiological walking.
None of the systems described makes it possible to move the legs while at the same time adjusting the patient's inclination.

Another relevant document is GB-A-983 743, which corresponds to the first part of claim 1.

It is the object of the present invention to enable para- and hemiparetic patients to undergo intensive gait training (activation of the locomotion centers in the spinal cord) before they are physically able to participate in treadmill training, that is to say when the circulatory situation is still unstable. The aim is to create the possibility of continuously bringing the patient's body closer to the vertical position during training. The aim of the device according to the invention is to create a so-called 'active standing table' (tilting table) which enables the movement of the legs of paraplegic patients in a physiological manner similar to walking without the need to straighten it up.

According to the invention this object is achieved with an active standing table according to the wording of claim 1 and an associated method for operating the active standing table according to the wording of claim 8.

Fig. 1

Seitenansicht eines aktiven Stehtisches mit einem Patienten in vertikaler Lage

Fig. 2

Gesamtansicht eines ersten Ausführungsbeispieles eines aktiven Stehtisches in horizontaler Lage

Fig. 3

Mechanismus zur Einstellung des Hüftextensionswinkels

Fig. 4A

Kniemechanismus zu Fig. 2 in perspektivischer Darstellung

Fig. 4B

Kniemechanismus zu Fig. 2 in Seitenansicht

Fig. 5

Fussmechanismus zu Fig. 2 in perspektivischer Darstellung

Fig. 6

Kniemanschette zu Fig. 2 in perspektivischer Darstellung

Fig. 7

Gesamtansicht eines zweiten Ausführungsbeispieles eines aktiven Stehtisches in horizontaler Lage

Fig. 8A

Kniemechanismus zu Fig. 7 in perspektivischer Darstellung

Fig. 8B

Exzenterantrieb zu Fig. 7 in Aufsicht

Fig. 9

Fussmechanismus zu Fig. 7 in perspektivischer Darstellung

The invention is explained in more detail below with reference to the drawings. Show it:

Fig. 1

Side view of an active standing table with a patient in a vertical position

Fig. 2

General view of a first embodiment of an active standing table in a horizontal position

Fig. 3

Mechanism for adjusting the hip extension angle

Figure 4A

2 in perspective representation

Figure 4B

2 in side view

Fig. 5

2 in a perspective view

Fig. 6

Knee cuff to Fig. 2 in perspective

Fig. 7

General view of a second embodiment of an active standing table in a horizontal position

Figure 8A

7 in perspective representation

Figure 8B

Eccentric drive to Fig. 7 in supervision

Fig. 9

7 in perspective representation

Fig. 1 shows a side view of the active standing table with a patient in a vertical position. A base frame is used as the basis, as found on conventional bar tables. It consists of a chassis 1 with rollers 2 and 3 and a height-adjustable frame 6 (e.g. "tilting table Super", Gymna, Belgium). The height of the frame 6 can be adjusted manually or with a drive (not shown).

A hinge 7 is attached to the frame 6, with which a leg part 8, consisting of two spars and two cross struts (see FIG. 2), is articulatedly connected to the frame 6. The leg part 8 is in turn connected via a joint 9 to a head part 10 (frame similar to leg part 8), on which there is a lying surface 11 consisting of a wooden board with a foam cover. So that during therapy with the active standing table the angle of the standing table can be continuously increased from the horizontal to the vertical, the leg part 8 can be rotated around the joint 7 with a drive 4 and an angle of inclination β1 can be set to treat the patient to be able to carry out different angles of inclination in a known manner. In the figure, the angle of inclination β1 is 90 °, which corresponds to a vertical position of the patient. Due to the adjustability of the angle of inclination β1, patients with unstable blood circulation can be treated while lying down and then continuously brought into the vertical position appropriately during the therapy by slightly increasing the angle of inclination β1.

With a mechanism 21 for adjusting the hip extension, it is possible to fix an inclination between the leg part 8 and the head part 10, as a result of which a hip extension angle β2 is defined. In this way a hip extension of the legs can be realized during the therapy. When the standing table is in a horizontal position, β2 is always 180 °, since the head part 10 rests on the frame 6. If the angle β1 is now increased, then β2 also decreases until the mechanism 21 comes to a stop and the head part is also pulled upwards. In this figure, the angle β2 is 172 °, which gives the patient a hip extension angle of 8 °; preferred values are 12 °.

On the leg part 8 there is a knee mechanism 13 with two knee drives 24 and a foot mechanism 14. These two mechanisms can be moved parallel to the leg part on two rails 15 which are fastened on each side of the leg part 8 and thus allow the standing table to be adjusted to the anatomy of different patients.
In order to be able to carry out therapy, the lying surface 11 is tilted into the horizontal position and brought to the same height as the hospital bed on which the patient to be treated lies with the height adjustment of the base frame. The patient is then transferred to the lying surface 11 so that his upper body comes to rest on the lying surface and his hip joints lie on the lower edge of the lying surface. The patient is then tightened with a fixation strap 16 around his waist, which is fastened to eyes 22 with fixing straps 17 on the upper side of the lying surface 11 and to eyes 23 with fixing straps 18 on the lower side of the lying surface. This fixation prevents the upper body from moving up and down during therapy. It is designed in such a way that the trunk movements are minimized to prevent injuries to the still unstable spine. The fixation belt 16 corresponds to a belt that is used as standard for weight relief during treadmill training for paraplegics (eg treadmill belt "Walker", from Hamster's Fallschirmservice, Austria).
When the patient is fixed on the lying surface, the knee mechanism 13 is shifted on the rails 15 in such a way that the knee drives 24 come to lie directly under the back of the patient's knees. There the knee mechanism is fixed with locking screws 25. Thereafter, the foot mechanism 14 is also shifted so that an extension (extension) of the patient's legs press footplates 19a and 19b down as far as possible (see FIG. 5). The foot mechanism 14 is fixed in the correct position with locking screws 26. There are markings on the rails 15, which allow the position of the foot mechanism 13 and knee mechanism 14 to be read. With repeated therapies, the settings can be easily reproduced using the markings.

Next, knee cuffs 20 are attached to the patient's knees (see Fig. 6). These are attached to the knee drives 24, which pull the patient's knees down or down during therapy. push up. This causes a stretching or a bending of the legs. In the figure, the patient's right leg is shown bent, the left leg is stretched. It should be mentioned that at the beginning of the therapy, the two knee drives 24 are retracted. So the patient can be easily transferred to the standing table. Only at the beginning of the treatment is a knee drive extended and one leg bent.
During locomotion therapy, the knee drives 24 are moved up and down alternately, so that the patient's legs move with a movement sequence similar to that which occurs during normal walking. The sensory input (afferents) from the legs for the spinal locomotion centers in the spinal cord provides information similar to that of physiological walking, which stimulates the locomotion centers to activate.

Fig. 2 shows the overall view of a first embodiment of an active standing table in a horizontal position. The base frame, consisting of a chassis 1 with rollers 2a, 2b, 3a and 3b and the height-adjustable frame 6, can be seen again. Via the joint 7 is the leg part 8, a frame consisting of two bars 8A and 8A 'and two cross struts 8B and 8B ', connected to the frame 6. The leg part 8 is in turn connected via the joint 9 to the head part 10, on which the lying surface 11 is located. The mechanism 21 for adjusting the hip extension is located at the joint 9.
On the leg part 8 there are the knee mechanism 13 with the two knee drives 24a and 24b and a foot mechanism 14 which can be moved parallel to the leg part 8 on the rails 15a and 15b. On the leg part 13 and on the foot part 14 there are the locking screws 25 and 26, which for fixing on the rails 15a and. 15b serve.
Eyelets 22a, 22b, 23a and 23b are attached to the lying surface 11 for fixing the patient.

Fig. 3 shows the mechanism for adjusting the hip extension angle in side view. The joint 9 can be seen, each with a part of the leg part 8, the head part 10, the lying surface 11 and the rail 15. An angle 30 is attached to the leg part 8. At this angle 30 there is a limiting screw 31 in a thread.

If the standing table is in the horizontal position (angle of inclination β1 = 0), the head part 10 lies on the base frame of the tilting table and the angle β2 is 180 °. If the angle of inclination is now increased, the angle β2 decreases until the head part 10 rests on the screw head 43 of the limiting screw 31 and the head part is guided upwards. If the limiting screw 31 is now screwed further into the angle 30, the angle β2 becomes correspondingly larger, it is unscrewed, correspondingly smaller. A pointer 33 shows on a scale 32 which hip extension angle is set for the patient with the limiting screw. The hip extension angle corresponds to 180 ° - β2.

FIG. 4A shows the knee mechanism 13 of FIG. 2 in a perspective view. The square tubes 41a are located on each side of a cross member 40. These serve as a guide for the knee mechanism 13 on the rails on the leg part. The cross member 40 has two rectangular cutouts 40 ', in which the two knee drives 24a and 24b are located. The structure of these two drives is identical, which is why only one drive is numbered in the figure. Bearings 42, 43a, in which suspension shafts 44b and 45b can rotate freely, are attached to the cross member 40 on the lower side. These suspension shafts are each attached to a base plate 46b. The knee drives can be rotated by this mounting, so that they are moved by the patient's knee movement, around the axis of rotation of the hip joint, when bending or stretching. A motor 47b is fastened in the base plate 46b and two guide tubes 48b are embedded. There is also a guide 50b in the base plate 46b, in which a threaded rod 51b can be freely rotated. The structure of the drive by means of the threaded rod is described in detail in Fig. 4B. In the guide tubes 48b or 49b, a guide rod 52b and 53b can be moved up and down. If the linear drive is now moved up or down, a plate 54b and an attached knee pad 55b are also moved up and down. The patient's knees are brought into flexion when the knee pads are moved upwards, and are pulled into an extension when the knee pads are moved downward (see FIG. 6). The two guide rods 52b and 53b, which are guided in the guide tubes 48b and 49b, ensure lateral stability of the knee drive, so that the leg extends tends to the side of the patient. The guide tubes 48b and 49b and the threaded rod 51b are mounted in the plate 54b at the upper end and in a plate 62b at the lower end.
A protective cover 56a made of rubber protects the patient from injuries to the knee drives.

FIG. 4B shows the knee mechanism 13 from FIG. 2 in a side view. The principle of the drive is explained in more detail using this figure. The cross member 40 with the base plate 46 embedded in the cutout 40 'can be seen. The suspension shaft 44 can be seen on the base plate 46, which allows the knee drive to rotate about the axis indicated by the round arrow. The guide rod 52 can be displaced by the guide tube 48, and the threaded rod 51 can be displaced by the guide 50.
The motor 47, which is fixedly mounted in the base plate 46, drives a gearwheel 59 mounted on the guide 50 with a gearwheel 57, via a V-belt 58. There is a thread in gear 59. If the gear wheel is now driven by the motor 47, the threaded rod 51 in the base plate 46 is respectively upward. moved down, as indicated by the straight arrow.
On the base plate 46 there are a limit switch 60 and 60 'at the top and bottom. These serve to announce the reaching of the end positions to a control unit which controls the movement of the drives. When the drive has reached the lowest point, the plate with the knee sleeve presses on a contact button 61 and the limit switch 60 signals the control unit that the motor should run in the opposite direction. Then the drive moves up until the lower plate presses a contact button 61 'and the limit switch 60' gives the control unit another signal for switching.

Fig. 5 shows the foot mechanism 14 to Fig. 2 in a perspective view. On the lower side of a T-piece 63, a square tube 69a and 69b is firmly connected to it. These serve as a guide for the foot mechanism on the rails attached to the leg section. During therapy, the foot mechanism can be screwed in place with the fixing screws 26a and 26b. At the upper end of the T-piece 63 there is a footplate 19a and 19b on each side which can be rotated about a bearing at the attachment point on the T-piece. The The base plates are identical in structure, all parts appear symmetrically on both sides. The patient's feet can each be inserted into an elastic loop 65a and 65b on the footplates. They are then protected from slipping out by the heel holders 66a and 66b.
The foot plates 19a and 19b are each connected to a spring 67a. This is tensioned on a bolt 68a when the footplate is pressed down by the patient (arrow direction). This creates a pressure force on the sole of the patient's foot in the extended phase of the movement cycle, which simulates a weight force similar to that which occurs when walking. The strength of this weight can be adjusted by moving the bolt 68a in the different holes 68a '. When the angle of inclination of the standing table increases, so does the weight that acts on the legs. This effect can be compensated and controlled by pulling the patient more or less upwards with the fixation straps and the fixation belt.

Fig. 6 shows a knee cuff to Fig. 2 in perspective. At the upper end of the threaded rod 49 and the guide rods 54 and 55, a plate 70 is fixedly attached. On this a bracket 71 is attached, to which a knee pad 53 can be attached with two clip mechanisms 72 and 72 '. This knee pad 53 is a plastic-covered foam. The clip mechanism keeps the knee pad strong enough to extend the knee when the knee drive is pulled down. However, the connection is released if the patient's knee cannot be stretched for any reason due to incorrect manipulation. This serves as a load protection for the patient's legs and protects him from injuries. The clip mechanism releases the knee pads for loads or tensile forces of 150 - 200 N., preferably of 180 N. A knee cuff, consisting of two Velcro strips 73 and 73 ', is attached to the knee pad 53, which allows the patient's knee to be attached to the knee pad by attaching the tapes to the Velcro strip 74. The two ligaments are attached to the knee so that the patient's kneecap is between the ligaments so that no pressure is exerted on them when the leg is extended.

Fig. 7 shows the overall view of a second embodiment for an active standing table in a horizontal position. The basic structure is identical to the first embodiment. In contrast to this, in the present training machine, the patient's legs are not driven by linear drives, but by a cable 80 from an eccentric drive 81, which is described in more detail in FIG. 8. A knee part 82 and a foot part 83 can be moved on the rails 15a and 15b and can thus be adapted to the patient's leg length.

FIG. 8A shows the knee mechanism of FIG. 7 in perspective. It consists of the eccentric drive 81, ropes 80a and 80b (nylon ropes) and the knee part 82. A gear 91 is attached to a motor 90. This drives an eccentric 92, in which a pin 94 is inserted. If the eccentric disc 92 now rotates, the pin 94 moves on a circular path. This circular movement moves a carriage 95, in which the pin 94 is guided, back and forth, the carriage in turn being guided in guide rails 96 and 97. The movement of the carriage 95 causes a tensile force on one of the ropes 80a or. 80b. The ropes are guided over rollers 98a, 98b, 99a, 99b, 100a and then pull over a hook 101a, respectively. 101b on the knee cuffs the patient's knees into an extension.
Plastic-covered pads 102a and 102b made of foam protect the back of the patient's knees from injury in the extension and press when the ropes 80a and. 80b the knees back towards flexion. The pads are located on a plate 108 which has guide tubes 109a and
109b with locking screws 110a and 110b.
On the ropes 80a and 80b is a tensioning device 103a and. 103b attached, with which the ropes can be adjusted in length. This allows the train to hook 101 a, respectively. 101 b so that the patient's knees are extended into an extension by the movement of the eccentric disc 92.
As knee cuffs with which the patient's knees on the hook 101a or. 101b, Velcro strips can be used, similar to that described in FIG. 6.

Fig. 8B shows the eccentric drive to Fig. 7 in supervision. The motor 90 can be seen with the gear 91, on which the eccentric disk 92 is located. Various holes 93 are provided in this so that the pin 94 can be inserted into the eccentric disk 92 on different radii. The stroke length of the knee movement can be set to different sizes by the different positions of the pin 94 in the holes 93. Rollers 104 to 107 are mounted on the carriage 95 and support the plate in the guide rails 96 and 97. The two ropes 80a and 80b are also fastened to the slide 95.
In contrast to the first exemplary embodiment, a much simpler control unit is necessary here, since the motor can simply rotate and the extension or flexion of the leg is automatically obtained. The control unit only controls the speed of motor 90 and so determines the frequency of movement on the patient's leg. In the first embodiment, the control unit must always switch the drives from an upward movement to a downward movement and vice versa when the end positions are reached.

FIG. 9 shows the foot mechanism 83 of FIG. 7 in a perspective view. On the lower side of a plate 120, a square tube 121 a and 121 b is firmly connected to this. These serve as a guide for the foot mechanism on the rails attached to the leg section. During therapy, the foot mechanism can be screwed in place using the fixing screws 122a and 122b. A carrier 123 is fastened on the plate 120 and a second carrier 124 is attached to the upper end thereof. On both sides of the carrier 124 there is a footplate 125a, respectively. 125b, which can be rotated around a bearing at the attachment point on the carrier 124. A lever 126a is attached to each of the foot plates, which are connected to one another via a steel cable 127. This steel cable 127 runs over a roller 128 and serves as a reciprocation mechanism. When one footplate is pressed down, the other moves up. Under the foot plates 125a and 125b there is a spring 129a, respectively. 129b, which on a plate 130a or. 130b is tensioned. If one of the foot plates is pressed down from the patient's leg (extension), the other leg is automatically bent using the reciprocation mechanism. In addition, the spring 129 creates a weight force on the patient's sole (afferent Input).
With a cuff 131 a resp. 131 b, which via a connecting part 132 a or. 132b with the footplate 125a or 125b are connected, the patient's leg can be fixed. This way it is stabilized from the side so that it does not tip over to the side when it is bent. A heel bracket 133a resp. 133b protects the patient's foot from being damaged by the footplate 125a or. 125b to slide down.

With the active standing table according to the invention, it is possible to control the sequence of movements of all joint planes (hips, knees, feet) of the patient's lower extremities in a physiological pattern (kinematics and kinetics) that is similar to walking, if possible. The most important movement variables for successful locomotion therapy (triggering locomotion activity) are hip extension and the weight load on the sole of the foot during the extension phase of the leg. Both parameters can be individually adapted to the needs of the patient with the active standing table described here.
In addition, the active standing table can be adapted to the individual size differences of the patients.
With locomotion therapy on the active standing table, success can be achieved because training can begin very early, ie even if the patient is not yet allowed to be raised.

Claims (12)

1. Apparatus for locomotion therapy for the rehabilitation of paraparetic and hemiparetic patients, comprising a standing table adjustable in height and inclination, a fastening belt with holding devices on the standing table for the patient, a drive mechanism for the leg movement of the patient, consisting of a knee portion and a foot portion, characterized in that the standing table has a head portion (10) displaceable with respect to a leg portion (8), whereby an adjustable hip extension angle (β2) results for which an adjusting mechanism (21) is provided; and the knee portion (13) and foot portion (14) are displaceably arranged on rails (15) on the leg portion (8); the knee portion (13) has a knee mechanism; and the foot portion (14) has a foot mechanism which serves to establish the force on the sole of the foot during knee extension; and a control unit is provided for the course of the movement of the knee mechanism.
2. Apparatus according to claim 1, wherein two linear drives (24a, 24b) are provided for the knee drive in the knee mechanism, and extend or flex the patient's legs.
3. Apparatus according to claim 1, wherein an eccentric drive (81) is provided for the knee drive in the knee mechanism, and alternately extends one of the legs; and the legs are bent again by the cushions (102a, 102b) of the knee mechanism and a reciprocating mechanism (126a, 126b, 127, 128) situated on the foot portion.
4. Apparatus according to one of claims 1-3, wherein the foot mechanism can generate a weight force in the extended phase of the leg, two springs (67a, 67b; 129a, 129b) being arranged for the production of this weight force.
5. Apparatus according to one of claims 1-4, wherein the hip extension angle (β2) has a value of 0-20°, and preferably 12°.
6. Apparatus according to one of claims 1-5, wherein the knee portion (13) and the foot portion (14) are displaceable on two rails (15a, 15b) and the active standing table can so be matched to the patient's measurements, all positions having markings by means of which the ascertained settings are reproduced.
7. Apparatus according to one of claims 3-6, wherein a snap coupling (71, 72, 72') is installed on the knee portion (13) and unlatches under a tension of 150-200 N, preferably 180 N, and thus protects the knee from overloading.
8. Process for the operation of an apparatus according to one of claims 1- 7, wherein the knee portion (13) and the foot portion (14) are displaced on the standing table in order thereby to match the drive to the patient's leg length; and an extension of the hip joint is predetermined by means of the hip extension angle (β2) and, the angle of inclination (β1); and a movement of the patient's legs is effected with the knee mechanism situated on the knee portion (13) and with the foot mechanism situated on the foot portion (14), generating an afferent input or sensory information to the spinal cord like that arising in normal walking; and a weight force is produced on the sole of the foot during the knee extension; and the drives for the movements are controlled by a control which predetermines a pattern of movement similar to that of physiological walking.
9. Process according to claim 8, wherein the amount of movement is altered by the control unit or by the position of the pin (94) on the eccentric drive (92).
10. Process according to claim 8 or 9, wherein the speed of the leg movement is varied.
11. Process according to one of claims 8-10, wherein the weight force acting on the sole of the foot in the extended phase of the leg movement is set by displaceable springs (67a, 67b).
12. Process according to one of claims 8-11, wherein the positions of the knee portion and foot portion are read off, established, and reconstructed on markings.