Patent Publication Number: US-10780009-B2

Title: Apparatus for locomotion therapy

Description:
The present invention relates to an apparatus for locomotion therapy which enables to start locomotion training in an early stage of rehabilitation therapy. 
     In incompletely paraplegic patients the possibility has been shown to exist of improving walking ability up to normality by means of adequate locomotion training. To this end, an apparatus has been developed to provide an intensive walking training (activation of the central pattern generator in the spinal cord) of paraparetic and hemiparetic patients in early stages of rehabilitation when they are for example in a still unstable circulatory situation. Such an apparatus is for example described in EP 1 169 003 B1. In the apparatus described in this document, a table is provided which may be moved gradually between a horizontal position corresponding to a horizontal position of a patient to a vertical position corresponding to an upright position of the patient. Furthermore, in this apparatus a knee mechanism and a foot mechanism are provided, the knee mechanism being able to move the knees and therefore the legs of a person without the person himself having to exert any effort. 
     In this apparatus, the foot mechanism as well as the knee mechanism have an adjustable position on the table to be able to adjust the apparatus to various heights of patients. However, depending on the height of the patient such an adjustment may result in the patient being relatively high above the ground in a vertical position of the table, which for example may make it more difficult for a therapist to care for the person, which is in particular needed if the person is in an unstable circulatory condition or otherwise still seriously impaired. 
     Therefore, it is an object of the present invention to provide an apparatus for locomotion therapy of the general kind described in EP 1 169 003 B1 in which a position of a person in the vertical position of the apparatus may be kept low. 
     In this respect, an apparatus as defined in claim  1  is provided. The dependent claims define further embodiments, at least some of which define further improvements of the above-mentioned apparatus of EP 1 169 003 B1. 
     According to an embodiment, an apparatus for locomotion therapy is provided, comprising: 
     a base, 
     a first table portion, 
     a tilting mechanism coupling said base to said first table portion, 
     a foot mechanism mounted to said first table portion, 
     a leg movement mechanism for moving the legs, in particular the knees, of a patient, and 
     a second table portion coupled to said first table portion, a position of said second table portion being adjustable with respect to said first table portion to adapt the apparatus to different heights of patients. 
     In such an apparatus, using the tilting mechanism a table formed by the first table portion and the second table portion may be moved between a horizontal position and a vertical position. As the foot mechanism is mounted to the first table portion, and the adjustment to a height of the patient is performed by adjusting the position of the second table portion which is coupled to the first table portion, the position of the foot mechanism in particular in a vertical position is independent of an adjustment of the apparatus to the size of the person, which may keep a position of the patient low and make it easier for therapists to care for the patients. In other words, the second table portion in such embodiments is connected to the tilting mechanism only via the first table portion, but not directly. 
     In an embodiment, the tilting mechanism may tilt the first table portion about an axis coupling the first table portion with the tilting mechanism. Furthermore, in an embodiment, the apparatus additionally comprises a lifting mechanism to move said first table portion, possibly together with said tilting mechanism, in a vertical direction. 
     In addition to the adjustment of the second table portion with respect to the first table portion for height adjustment, the second table portion may be tiltable with respect to the first table portion to selectively adjust a hip extension or hip flexion. 
     In some embodiments, the foot mechanism may comprise a first footrest and a second footrest. In an embodiment, the first and second footrests may comprise load sensors to measure a load the patient exerts on the footrest. Alternatively or additionally, other load sensing mechanisms may be provided to measure the load. In other embodiments, additionally or alternatively to the load sensors the first and second footrests may comprise mechanical stimulating elements for selective mechanical stimulation of areas of the feet of the patient. This mechanical stimulation may be performed synchronously with a movement of the leg movement mechanism. 
     The foot mechanism may further comprise a first base and a second base, the first and second bases being mounted to the first table portion, for example slidably mounted to the first table portion to accommodate movements of the legs. The first footrest may be mounted to the first base portion via a first double joint, and the second footrest may be mounted to the second base portion via a second double joint. Via such double joints, which may comprise a rod, a plate or other elongated element between the two joints, one end of the rod being coupled with the first footrest at a tip portion thereof via a first joint of the double joint and a second end of the rod being coupled with the base portion via a second joint of the double joint, a natural movement of the foot may be improved. In some embodiments, the natural movement may be additionally improved by generating an additional stimulus on the foot through an impact when the footrest is decelerated or stopped at a stopper. This stopping may be performed using a resilient stopper like a spring to adjust the force acting on the foot. 
     It should be noted that the above-described foot mechanisms may also be used in other apparatuses for locomotion therapy than the one described above. 
     The apparatus may further comprise an electrical stimulation device which may be configured to electrically stimulate muscles, in particular leg muscles, of the person synchronously with a movement of the leg movement mechanism. 
     The leg movement mechanism may comprise a first mechanism for a left leg and a second mechanism for a right leg of the patient. A distance between the first mechanism and the second mechanism may be adjustable to accommodate the leg movement mechanism to a “track width” of the patient. Such an adjustment may also be used independently of the apparatus described above, i.e. may also be used in other apparatuses for locomotion therapy. 
     In some embodiments, a pelvic harness may be fixed to said first table portion and/or said second table portion, in particular said second table portion. Additionally, shoulder straps may be provided to fix a torso of the patient to the apparatus. 
     The adjustment of the leg movement mechanism may be performed while the first and second table portions are in a horizontal position, i.e. while the patient is lying on the table. By fixing the pelvic region of the patient via the pelvic harness and adjusting the leg mechanism accordingly, a correct centre of rotation may be provided for the leg movement, thus avoiding or reducing shearing forces which may occur when the mechanical centre of rotation and the orthopedically correct center of rotation deviate from each other. 
    
    
     
       Further features and embodiments will become apparent from the following detailed description with reference to the attached drawings, wherein: 
         FIG. 1  is a side view of an apparatus according to an embodiment; 
         FIG. 2  is a perspective view of the apparatus of  FIG. 1 ; 
         FIG. 3  is a perspective view of the apparatus of  FIG. 1  with a table in an intermediate position; 
         FIG. 4  is a side view of the apparatus of  FIG. 1  with the table in a near vertical position; 
         FIG. 5  is a side view of the apparatus of  FIG. 1  with the table in a vertical position; 
         FIG. 6  is a partial view of an apparatus according to an embodiment for illustrating an adjustment of a leg movement mechanism; 
         FIG. 7  is a partial view of an apparatus according to an embodiment illustrating an embodiment of a foot mechanism; 
         FIG. 8  is a diagram illustrating loading of an apparatus according to an embodiment; 
         FIG. 9A-9C  show examples for a foot stimulation; 
         FIG. 10  is a schematic diagram showing various muscles which may be stimulated in an embodiment; 
         FIG. 11  shows a block diagram of some features of some embodiments; 
         FIG. 12A-12C  show a particular embodiment of a foot mechanism in three different positions; 
         FIGS. 13A and 13B  show pelvic harnesses usable in some embodiments; 
         FIG. 14  is a side view of an apparatus according to an embodiment illustration an emergency lowering mechanism; 
         FIG. 15  is a perspective view of an apparatus according to an embodiment; and 
         FIG. 16  is a further perspective view of the apparatus of  FIG. 15 . 
     
    
    
     In the following, embodiments of the present invention will be described in detail with reference to the attached drawings. It should be noted that these embodiments are given only for the purpose of illustration and are not to be construed as limiting the scope of this application. 
     It should be noted that features of different embodiments may be combined with each other unless specifically noted otherwise. Furthermore, describing an embodiment with a plurality of features is not to be construed as indicating that all those features are necessary for practicing the present invention, as other embodiments may comprise less features and/or alternative features to the ones shown in the drawings or described herein. 
     Various components of the embodiments shown are not necessarily drawn to scale with each other, but are depicted in a manner to provide a clear understanding of the respective embodiment. 
     Turning now to the figures, in  FIG. 1-5  various views of an apparatus for locomotion therapy according to an embodiment are shown. In particular,  FIG. 1  shows a side view of the apparatus with a table comprising a first table portion  15  and a second table portion  17  being in a horizontal position. In other Figures, other positions of the apparatus are shown. It should be noted that training is possible in various positions, e.g. in the horizontal position shown in  FIG. 1  or in tilted or vertical positions described later. 
     The apparatus of  FIG. 1  further comprises a base frame, i.e. a base  11  having wheels  19  for rolling the apparatus on a floor  10 . However, in other embodiments, the apparatus may be stationary without having wheels. First table portion  15  is coupled with base frame  11  via a lifting mechanism  12  and a tilting mechanism  13 . Using lifting mechanism  12  which comprises rods and actuators, tilting mechanism  13  together with first and second table portions  15 ,  17  may be lifted in a vertical direction, in this case following an arc as indicated by an arrow  20 , i.e. also with a movement component in the horizontal direction. 
     Furthermore, as will be explained further below, for tilting the table formed by first table portion  15  and second table portion  17  between the horizontal position shown in  FIG. 1  and a vertical position, first table portion  15  may be rotated about an axis  22  by tilting mechanism  13 . It should be noted that the shown lifting and tilting mechanisms  12 ,  13  are merely an example, and in other embodiments other mechanisms, for example using more than one axis, may be used to lift and/or tilt first table portion  15  with respect to base  11 . 
     Furthermore, a foot mechanism is mounted to first table portion  15  and configured to receive feet of a patient using the apparatus. Also, a leg movement mechanism  14  which may comprise belts as shown to fix the legs of the person to the mechanism is provided for moving legs of a person using the apparatus, in particular to flex knees of the person to emulate a walking movement, to give an example. The belts may be adjustable to accommodate leg movement mechanism  14  to different leg diameters. Suitable leg movement mechanisms are described in the above-mentioned EP 1 169 003 B1 in detail and will not be described in greater detail here except for an additional adjustment possibility described later with respect to  FIG. 6 . 
       FIG. 2  shows a perspective view of the apparatus of  FIG. 1  in the same position, i.e. tilting mechanism  13  being slightly lifted via lifting mechanism  12  and first and second table portions  15 ,  17  being in a vertical position. As can be seen in  FIG. 2 , second table portion  17  is coupled to first table portion  15  via a drive mechanism  24 , for example a linear drive. Using drive mechanism  24 , the position of second table portion  17  may be adjusted as indicated by an arrow  21  with respect to first table portion  15  to adapt the apparatus to patients of different heights. For example, for taller patients, second table portion  17  which in operation for example accommodates back and head of a person may be moved away from first table portion  15 , and for smaller persons it may be moved towards first table portion  15 . As first table portion  15  is mounted to tilting mechanism  13  to tilt about axis  22 , such an adjustment to accommodate different heights of patients does not change the distance between foot mechanism  16  and axis  22  and therefore, as will be explained in more detail later, helps to keep the position of foot mechanism  16  and therefore of the patient low when tilting first table portion  15 . 
     The result of such a tilting motion is shown in  FIG. 3 . Here, lower table portion  15  has been tilted about axis  22  as indicated by an arrow  23  by tilting mechanism  13 , in particular by using a drive  300  of tilting mechanism  13 , to a position between a horizontal position and a vertical position, for example a position of about 45 degrees. 
     In  FIG. 4 , the first table portion  15  and therefore also the second table portion  17  connected thereto are shown in an almost vertical position. Also, as shown in  FIG. 4  using a mechanism  26 , for example a further linear drive, second table portion  17  may be tilted as indicated by an arrow  25  with respect to first table portion  15  about an axis  27 . In this way, an extension or flexion of a hip joint of a patient may be adjusted (hereinafter shortly referred to as “hip extension” and “hip flexion”, respectively). A hip extension may for example be increased by tilting second table portion  17  backwards, i.e. to the left side in  FIG. 4 , while a hip flexion may be increased by tilting second table portion  17  forward, i.e. to the right side in  FIG. 4 . In some embodiments, in this way even an “overhanging” patient position may be reached if desired. In other embodiments, mechanism  26  may be omitted, for example be replaced by a rigid element, such that the angular relationship between first and second table portions  15 ,  17  is fixed. 
     Also, as can be seen in  FIG. 4 , foot mechanism  16  is close to floor  10 , which is achieved by tilting first table portion  15  and performing any height adjustment by adjusting the position of second table portion  17  relative to first table portion  15 . Adjusting the vertical position of tilting mechanism  13  and therefore of axis  22  may additionally contribute to keep foot mechanism  16  and therefore the patient close to floor  10 . 
     Finally, in  FIG. 5  first table portion  15  is tilted to a completely vertical position. It should be noted that also in this position or in all intermediate positions, second table portion  17  may be adjusted with respect to first table portion  15  as indicated by arrow  21 . 
     It should be noted that the various drive mechanisms used for performing the adjustments and movements described with reference to  FIG. 1-5  may comprise electric motors, pneumatic elements or other actors. It is also conceivable that some of these elements are adjusted manually, for example by providing a crank lever and a corresponding gear mechanism. 
     In the following, with respect to  FIG. 6-16 , various optional additional features which may in some embodiments be implemented in the apparatus of  FIG. 1-5  will be described. It should be noted that these optional additional features may not only be implemented in the apparatus of  FIG. 1-5 , but also in other apparatuses for locomotion therapy which enable a movement or tilting of a person between a horizontal position and a vertical position, for example the apparatus of the above-mentioned EP 1 169 003 B1. It should further be noted that the various features described with reference to  FIG. 6-12  may be used independently from each other, but also combinations of some or all of these features may be used. Nevertheless, for ease of reference these optional features will be described with respect to the embodiments of  FIG. 1-5 . 
     In  FIG. 6 , an optional adjustment possibility for a leg movement mechanism is shown. In the embodiment of  FIG. 6 , the leg movement mechanism comprises a first mechanism  14 A for a left leg of the patient and a second mechanism  14 B for a right leg of the person. These mechanisms themselves may work as in the above-mentioned EP 1 169 003 B1, e.g. move to flex and extend a knee of a person and for example be driven by eccentric drive. As indicated by an arrow  30  in  FIG. 6 , a distance between first and second mechanisms  14 A and  14 B is adjustable to accommodate the apparatus to different “track widths” of patients. Such an adjustment may for example be provided by mounting leg mechanisms  14 A,  14 B slidably in tracks or bearings or using a drive mechanism using a gear rack. However, other adjustment mechanisms are also possible. 
     In  FIG. 7 , a specific implementation of a foot mechanism  16  is shown. In the embodiment of  FIG. 7 , foot mechanism  16  comprises a first footrest  35 A for a left foot of a person and a second footrest  35 B for a right foot of the person. In footrests  35 A,  35 B load sensors  36  may be provided to measure a load caused by the patient, i.e. a force which is exerted by the patient on footrest  35 A and/or  35 B. With cyclic exercises like a cyclic flexion and extension of the knee the force relative to the body weight may be plotted over the number of repetitions as shown as an example in  FIG. 8 . In such a way, a good control and documentation of the therapy is possible. 
     In other embodiments, instead of or in addition to load sensors  36  provided in footrests  35 A,  35 B other kind of load sensing mechanisms may be used for measuring the load. For example, a load may be measured indirectly by measuring a displacement of footrests  35 A,  35 B caused by a load e.g. by measuring an angle or using potentiometers and taking a restoring force of springs or other resilient elements biasing footrests  35 A,  35 B towards a predetermined standby position into account, or by sensing a force or a torque at another point in the foot mechanisms than directly at footrests  35 A,  35 B. 
     In addition to sensors  36  or as an alternative thereto, footrests  35 A,  35 B may also comprise mechanical stimulation elements  37 . Through such mechanical stimulation elements, pressure may be exerted locally and selectively to various areas of the soles of the feet of the person. Such a stimulation may in particular be performed synchronously with the movement of the leg movement mechanism, such that the mechanical stimulation of the soles of the feet may simulate the feeling of rolling the foot from heel to toe while walking, thus being in synchronicity with the walking movement emulated by the leg movement mechanism. It is to be noted that such a synchronous control of the leg movement mechanism and the mechanical stimulation of the soles of the feet is not restricted to cyclic movements or stimulations, but also other kinds of coordinated control also are considered as being a synchronous control within the scope of this application. For example, foot stimulations simulating a stumbling may be inserted at certain points of the movement of the leg movement mechanism, or the leg movement mechanism itself may be controlled to simulate a stumbling or other event. 
     In particular, possibilities for foot stimulations will now be explained with reference to  FIG. 9  in more detail.  FIG. 9A  shows a movement parameter like an amplitude or a position of a leg movement mechanism over time, a high amplitude for example corresponding to a flexed knee and a low amplitude corresponding to a more extended knee. A foot stimulation may for example be performed in portions with lower amplitude, for example between times t 1  and t 2  of each cycle of the leg movement mechanism. The remaining time, for example the higher amplitudes, may for example correspond to phases of the walking movement where the foot would be lifted from the ground. Consequently, in these times no foot stimulation is performed, i.e. no additional pressure is exerted on the foot. 
     Between t 1  and t 2 , stimulation may start at the heel and then move to the tip of the foot. Heel and tip of the foot may be divided in different portions which are stimulated at different times and/or with different intensities. An example for this is shown in  FIGS. 9B and 9C , where  FIG. 9B  shows various zones of a foot (in this case a right foot) and  FIG. 9C  shows corresponding stimulation curves for the zones. A zone and its associated stimulation curve (intensity of stimulation over time) bear the same reference numeral  100 - 109 . However, the partitioning of the foot into zones and the stimulation curves shown in  FIG. 9C  serve only as examples, and in other embodiments, other partitionings or stimulation curves, for example partitionings with less zones or more zones, are possible. 
     In some embodiments, also an electrical stimulation of muscles of the patient, in particular leg muscles, is used. Such an electrical stimulation is also known as functional electrical stimulation (FES). 
     For example, in  FIG. 10 , a front view and a back view of a person are schematically shown with muscles groups marked by  1 - 8 . These muscle groups may for example be stimulated synchronously with the leg movement mechanism  14  of the preceding embodiments. 
     For example, regarding the muscles groups shown in  FIG. 10 , during a phase of increasing amplitude of the leg movement as shown in  FIG. 9A  (positive slope), muscles groups  2 ,  4 ,  6  and  8  may be stimulated, and during a phase of falling amplitude (negative slope) of  FIG. 9A  muscles groups  1 ,  3 ,  5  and  7  may be stimulated via electrodes to which a corresponding voltage is applied. However, this stimulation scheme serves only as an example, and for example in other embodiments only some of the muscle groups depicted may be stimulated. 
     In  FIG. 11 , a block diagram of a part of an embodiment employing foot stimulation and electric stimulation is depicted. A control unit  50 , for example a correspondingly programmed microprocessor, controls a leg movement mechanism  51 , for example leg movement mechanism  14  of the embodiments of  FIG. 1-5 . Additionally, control unit  50  controls a foot stimulation  52 , for example the foot stimulation explained with reference to  FIGS. 7 and 9 , synchronously with leg movement mechanism  51 . Additionally or alternatively to foot stimulation  52 , control unit  50  may also control an electric stimulation  53  synchronously with leg movement mechanism  51 , for example as explained with reference to  FIG. 10 . It should be noted that in other embodiments, foot stimulation  52  and electric stimulation  53  may be omitted. Additionally, control unit  50  may receive signals from a load sensing mechanism  54  which may be implemented as described above with reference to  FIG. 7 . 
     Next, with reference to  FIG. 12A-12C  a specific embodiment of a foot mechanism  16  will be described. This foot mechanism may be employed in the embodiment of  FIG. 1-5 , but may also be employed in other apparatuses for locomotion therapy. Moreover, the foot mechanism of  FIG. 12A-12C  may be combined with the load sensors and/or the mechanical foot stimulation of  FIG. 7 , but may also be used without these features. 
       FIG. 12A-12C  show foot mechanism  16  in three different positions corresponding to three different phases of a cycle of the leg movement mechanism, for example. While in  FIG. 12A-12C  only a single mechanism for one foot is shown, two such mechanisms may be provided, one for the left foot and one for the right foot of the patient. 
     The foot mechanism  16  of  FIG. 12A-12C  comprises a mounting portion  68  to be mounted for example to first table portion  15  of the embodiment of  FIG. 1-5 . For the mechanism, a base portion  60  in form of a ridge is slidably mounted on mounting portion  68 . Fixed to base portion  60  is an intermediate portion  62 . A footrest  66  is coupled with intermediate portion  62  and therefore with base portion  60  via a double joint comprising, in the embodiment of  FIG. 12A-12C  a first joint  63  at intermediate portion  62 , and a second joint  65  at a tip portion (i.e. a portion where the tip of the foot rests) of footrest  66 . Joints  63 ,  65  are connected via an elongate member  64 , for example a rod or an elongate plate. When footrest  66  is essentially parallel to intermediate portion  62  as shown in  FIG. 12B , joint  63  is closer to a heel portion of footrest  66  than to the tip portion. Joints  63 ,  65  may for example comprise hinges. 
     Through the sliding movement of base portion  60  on mounting portion  68  and the double joint between footrest  66  and intermediate portion  62 , in some cases a disadvantageous positioning of a lower leg of the person may be prevented and damages to the knee may be prevented in some cases. 
     For example, in  FIG. 12A  a movement for a flexion or bending of the knee (which may be initiated by leg movement mechanism  14  of  FIG. 1-5 ) is shown. In this case, base portion  60  as indicated by an arrow  61  slides upward (towards a head of the patient), footrest  66  moves away from intermediate portion  62  and base portion  60  as indicated by an arrow  67 , and footrest  66  tilts as indicated by an arrow  72 . In contrast thereto, in  FIG. 12B  the situation for a knee extension, i.e. a straightening of the knee, is shown. Here, base portion  60  slides downward (away from the head of the patient) on mounting portion  68  as indicated by an arrow  69 , and footrest  66  is parallel and close to intermediate portion  62 . 
     In  FIG. 12C , the foot mechanism is shown in a position that corresponds to a dorsal extension of the ankle joint of a patient. Here, also base portion  60  moves slidingly on mounting portion  68  as indicated by an arrow  71 , and footrest  66  tilts as indicated by an arrow  70 , which corresponds to a lifting motion of the tip of the foot. 
     Other kinds of movements may also be enabled by the foot mechanism of  FIG. 12A-12C . 
     It should be noted that such a foot mechanism may be a passive foot mechanism, i.e. the movement may be caused for example by the leg movement mechanism, and the feet pull/push the foot mechanism accordingly, or active components like electric motors may be provided to actively control the movements of the foot mechanism, for example movements as explained with reference to  FIG. 12A-12C . In such a case, also the foot mechanism may be controlled by a control unit like control unit  50  of  FIG. 11  synchronously to the leg movement mechanism. 
     It should be noted that joints  63 ,  65  of the double joint may be configured to be arrestable to fix the foot mechanism in a desired position. Furthermore, one or more resilient stoppers, for example springs, may be provided to allow for a smooth deceleration with reduced force acting on the foot when footrest  66  reaches an end of a movement range, for example the position of  FIG. 12B . Such forces acting on the foot may provide an additional stimulus. 
     Various possibilities may be employed for fixing a patient to the apparatuses described so far with reference to  FIG. 1-12 . For example, a patient may be fastened to the apparatus using a harness as described in the above-mentioned EP 1 169 003 B1, where the patient is essentially suspended from above. A further possibility used in some embodiments is shown in  FIGS. 13A and 13B . Here, the patient is fixed to the apparatus, in particular to second table portion  17 , via a pelvic harness  81 . The pelvic harness  81  is directly fixed to the apparatus, for example second table portion  17 . To prevent a tilting of the torso, shoulder straps may be provided. For example, in  FIG. 13A  straight shoulder straps  82  are provided for fixing patients  80  whereas in  FIG. 13B  crossed-shoulder straps  83  are provided. 
     In addition to this fastening mechanism which generally fastens patient  80  to the apparatus, specific body parts of the patient may be additionally fastened to the apparatus. For example, the legs may be fastened to the leg movement mechanism, the feet may be fastened to the foot mechanism, and/or a head of the patient may be additionally fastened, which may be particularly helpful for training in the vertical position. For such fastenings, for example velcro strips or similar devices may be used. Also, paddings may be used to make the patient more comfortable and to prevent pressure sores. 
     Also the fastenings of  FIGS. 13A and 13B  may be used in conjunction with the previously described embodiments, but also independently therefrom. 
     In some embodiments, an emergency lowering mechanism may be provided which may be used to lower the first and second table portions  15 ,  17  and therefore the patient from a vertical or tilted position to a horizontal position as shown in  FIG. 1  even when actuators like drives used for tilting (or lifting) fail, for example due to a power failure. Such a mechanism is schematically shown in  FIG. 14 . The embodiment of  FIG. 14  corresponds to the embodiment already discussed with reference to  FIG. 1-5 , which some additional elements as explained below. In  FIG. 14 , lifting mechanism  12  is only partially shown for a clearer representation of the emergency lowering mechanism. 
     For performing an emergency lowering of the patient from the vertical position shown in  FIG. 14 , a lever  120  is operated by a person, for example a therapist supervising the training. To initiate the movement from the vertical position, a gas cylinder  122  or similar, preferably power-independent actuating element is provided. When the movement has been initiated in a direction indicated by an arrow  400  and the first and second table portions  15 ,  17  are in a tilted position such that a centre of gravity of the patient in the view of  FIG. 14  is on the left side of axis  22 , the weight of the patient additionally supports and drives the movement. To prevent the movement from becoming to fast, the actuators or drives used in normal operation of the apparatus for tilting, like drive  300  of  FIG. 3 , may damp the movement, or additional dampers may be provided. To enable such a movement, the actuators and drives like drive  300  may be configured such that they allow a movement when e.g. power fails. 
     Further optional features of some embodiments are shown in  FIGS. 15 and 16 .  FIG. 15  shows a perspective view of an apparatus according to an embodiment with first table portion  15  in a position tilted about 60 degrees to horizontal, and  FIG. 16  shows the embodiment in a vertical position. The embodiment of  FIGS. 15 and 16  is based on the embodiment of  FIGS. 1-5 , and only additional features will be discussed in the following. 
     In addition to features already described, the embodiment of  FIGS. 15 and 16  comprises armrests  130 . Arms of a person in some embodiments may be fixed to armrests  130  using belts, Velcro straps or similar devices. 
     Furthermore, the embodiment of  FIGS. 15 and 16  comprises a panel  131  for monitoring and/or operating the apparatus. Panel  131  may comprise a so-called touchscreen to allow user input and operating of the apparatus while also being usable to display information regarding the status of the apparatus and/or of the patient training. For example, the curves of  FIG. 8  may be displayed. In other embodiments, panel  131  may comprise a conventional display and other input elements like a keyboard. Panel  131  may also be located differently than shown. In still other embodiments, panel  131  may be omitted, and the apparatus may be controlled via a remote device like a computer or a handheld device which is linked to the apparatus in a wireless or wire-based manner. In still other embodiments, both a panel and a remote device may be used. 
     While various embodiments have been described in detail, it is emphasized again that these embodiments serve only for illustration purposes and are not to be construed as limiting the scope of the present application.