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In motion
1. InMotion Arm Robot:
improving quality of life
Recovering everyday function
After years of living with movement disabilities patients and their doctors
discover that there is hope. What was thought to have been permanent
can be restored. The coordinated shoulder, elbow and hand movements
required for accurate reaching and grasping are retrained.
Rethinking recovery
In-Motion Robot-assisted therapy engages the patient to "retrain the
brain". The patient is actively expressing and experiencing thousands of
interactive movement repetitions, leading to the achievement of meaning-
ful movement in everyday arm function even years post onset.
A new therapeutic strategy; evidence based technology which is proven to
be effective and safe. Currently used by leading clinicians and research-
ers worldwide.
Reach for recovery
2. NEW InMotion Products!
InMotion Adjustable Workstation
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The new InMotion Arm/Shouler robot workstation offers height adjust-
ments and ample knee space to accommodate children and
adults who use wheelchairs. The height manually adjusts from
22"-34" allowing both standing or sitting positioning.
The station also includes a comfort contoured ergonomi-
cally designed chair with shoulder and waist straps for
correct patient positioning.
With a table top area of 36" x 48",
it provides a large surface with
the additional benefit of upper
arm support.
The workstation is ADA compli-
ant with ease of access for most
patients.
The InMotion Hand Robot provides active (motor-
driven) grasp and release features.
The innovative Hand Robot now comes standard with
the InMotion Shoulder-Elbow Robot allowing en-
hanced functional movement by the patient.
3. <1NMOT1ON
ROBOTS FOR REHABILITATION
InMotion Robot Therapy
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Watertown, MA - May 13, 2010 - Patients with long-term stroke reported
reduced impairment, disability, and improved quality of life following InMotion
robot-assisted therapy, according to a Veterans Administration (VA) led study
published in the May 13,2010 issue of The New England Journal of Medicine.
"There are nearly 6 Million stroke patients in the U.s. with chronic deficits;' says
Dr. Albert Lo, a neurologist at the Providence VA Medical Center who led the
study. "We've shown that with the right therapy, they can see improvements in
movement, everyday function and quality of life:'
The study demonstrates that InMotion robots are safe and effective clinical
tools they can assist a Physical or Occupational therapist achieve the intense level of exercise necessary to achieve neuro-
plastic change and motor recovery following stroke, even years post-stroke. "Robotics and automation technology are ideal
for these kinds of highly repetitive tasks. We've used robotic technology to create a tool for the therapist to afford this kind
of high-intensity therapy while maintaining the therapist supervisory role, deciding what is right for a particular patient's
needs and tailoring therapy according to findings from the patient evaluation tools provided with the robots" says Hermano
Igo Krebs, principal research scientist in MIl's Department of Mechanical Engineering and inventor of InMotion robots.
"The study results also challenge the notion that physical therapy only benefits stroke patients within the first six
months after stroke" says Lo.
The VA-led randomized clinical trial, conducted at 4 hospitals, involved 127 patients with moderate to very severe arm
impairment six months or more after stroke. Patients were placed into three study groups: usual care, intensive comparison
therapy administered using conventional techniques, and intensive robot-assisted therapy.
At 36 weeks, patients in the two intensive groups demonstrated significantly more improvement in function, movement
and quality of life than patients receiving usual care. These patients received hour-long treatment sessions three times per
week and completed 1,024 exercise repetitions in each session.
Patients in the robot-assisted therapy group completed the exercises using four different types of InMotion upper-extremity
robots. The robots guide patients through exercise using video game-like software programs and the robot arm assists the
person with movement only when they are unable to initiate or complete the motion themselves.
Patients randomized to the intensive comparison therapy by a therapist also received very intensive arm exercise,
comparable to the 1,024 movements per 1-hour therapy, something that is typically not practical in everyday
care (typical exercise repetitions are closer to 40 movements per session).
Even more surprising, this better care did not cost the VA any more than usual care: "better care
for the same cost:'
Professor Neville Hogan and Hermano Igo Krebs, from the Newman Laboratory for Biomechanics and
Human RE!habilitation, invented the InMotion Robots and have been involved in over a decade and half
of research using this kind of interactive robotics.
4. ------------------------
InMotion Robots at Braintree, MA Rehab Hospital
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a physical therapist and stroke survivor Hypertonia had severely affected her
who uses the InMotion robots during his left arm, but she had learned to com-
own outpatient therapy. In addition, a pensate with the other side. She had
therapist can see how much assistance worked with the robot for some time
the patient needs, helping to assess when one night she walked into her
improvement. bedroom. Her husband, walking behind
her, started shouting, "You turned on the
Working with the InMotion robot re- light! You turned on the light!" Subcon-
quires attention, eye-hand coordination, sciously, she had turned on the light
and coordination of the affected arm, with her affected arm rather than com-
but patients are often so engrossed in pensating by turning her body to use the
"As therapists we think, 'How do I tap
the game - for example, a game of on- other side.
into the motor control theory - getting
screen ping-pong - they end up doing
patients to do a high number of repeti-
a few hundred repetitions of a particular
tions in an engaging activity? How many
movement - a result that is challenging
times can I ask them to reach for a cone " InMotion robots help us
to elicit during traditional therapy. "I'm
while sitting on a mat?'" said Dan Par- get to the high number of
not saying we've abandoned cones and
kinson, PT, Director of Clinical Services repetitions while keeping
bean bags, but the InMotion robots help
at Braintree Rehabilitation Hospital,
us get to the high number of repetitions patients motivated. "
provider of acute inpatient and outpa-
while keeping patients motivated," said
tient rehabilitation in Braintree, Mass.
Parkinson.
and surrounding communities.
Patients with various neurological condi-
Solution:
tions, from stroke to spinal cord to brain Braintree believes that their investment
Robotic Therapy
injuries, work with the robots. Beth Lus, in InMotion and other rehab technol-
OT, occupational therapy clinical advisor ogy has made a favorable impact on
Always looking for the latest proven
at Braintree Rehab, has even used it the hospital. "It is hard to attribute any
technologies in rehabilitation, Brain-
with patients with flaccidity. Lus also specific initiative to inpatient volume
tree Rehab purchased the InMotion
uses it with patients who have neglect growth, however Braintree believes
shoulder-elbow robot, wrist robot and
or attention issues. "There have been evidence-based technology has helped
hand robot to augment its arsenal of
patients who do not attend well with to increase admissions of neurologic
evidence-based treatment tools. They
other therapy, but I've put them on the patients for both inpatient and outpatient
were drawn to the InMotion therapy ro-
robot and they can focus on the task for programs", says Parkinson. 'Technol-
bots for a few reasons - one of the most
20 minutes," Lus said. ogy has also helped with our therapist
significant being the ability to provide
active-assisted motion for the patient. recruitment and retention. Our clinical
The robot can 'back off' proportionate staff is excited about contributing to the
to the patient's changing ability to move development of clinical applications for
Vartanian has noticed functional gains rehab technology. Braintree is proud
independently. Because the machine
around the house -- unloading the dish- that we can offer patients such innova-
helps to stabilize the affected arm,
washer, folding clothes, and opening tive treatment."
movement is more fluid and controlled.
bottles. And Parkinson likes to tell of a
"You don't get frustrated that your arm is
42-year-old woman who was 21 years
allover the place," said Rich Vartanian,
post-stroke.
Founded in 1975, Braintree rehabilitation Hospital has gained recognition as a world-class healthcare provider. Braintree
offers a wide variety of specialty programs at its acute Inpatient Rehabilitation Hosptial in Braintree, MA, satellite rehabilitation
hospital locate"d at Medtrowest Medical Center in Natik, MA and multiple community-based outpatient clinics. Braintree is a
leading provider of Nuerorehabilitation services such as Stroke, Brain Injury, Parkinson's Disease, Multiple Sclerosis and Spi-
nal Cord Injury. The Join Commission awarded the hospital Disease Specific Care Certification for its Stroke and Brain Injury
programs.
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5. THE ART & SCIENC~EHABlLITATION
Rancho Robotics for Rehabilitation
Are you a survivor of stroke, traumatic brain injury, cerebral palsy,
spinal cord injury, multiple sclerosis or neurological condition?
'!he young man a60ve fias gainea tfie a6iCity to 6egin ariving a powerwfieeCcfiair ana to use utensiCs to
feea fiimsefJ. J{e fias participatea in approxjmatefy si:(j;eenro6otic training sessions at 1(ancfio.
Rancho offers innovative programs including traditional therapies and advanced robotic training
which treat body and mind deficits for adults and children.
Comprehensive Wellness, Drivers Training and Life Skills Programs are also available.
Amy Salinas, MS, OTR/L, CBIS, PAM
Director, Rancho Robotics for Rehabilitation
7601 E. Imperial Highway Downey, Ca 90242
562.401.6275 562.401.6271
amysalinas@dhs.lacounty.gov
6. Rancho Robotics for Rehabilitation
On May 19, 2009 I was driving my car when I had a sudden headache. I had a stroke. I
underwent surgery to relieve the bleeding and treat three blood clots. I spent six weeks
recovering in an acute rehab hospital.
After traditional inpatient and outpatient rehabilitation, I participated in sixteen robotic
training sessions.
• HoUf my grantftfaugfiter on my rap to reaa to fier
• rrum figfit switclies on ana off
• HoUf onto tfie steerine wfieeCwfiife an:vine
• Hug peopfe witfi 60tfi arms
• jlssist witfi carryine o6jects
I have also gained noticeable arm improvements in:
• 1@nee of motion
• ~aucea tigfitness
• ~aucea pain
7. "Robot-Assisted Therapy for Long-Term Upper-Limb
Impairment after Stroke"
Albert La, M.D., et al.
The New England Journal of Medicine, May 13, 2010
FREQUENTLYASKED QUESTIONS
Why is this research so important?
"We've shown that with the right therapy, [stroke patients] can see improvements
in movement, everyday function and quality of life - this is giving stroke survivors
new hope." Dr. Albert Lo, Principal Investigator. The implications for stroke recovery
and study design were so powerful that this was the first article ever published in the
prestigious NEJM on the topic of rehabilitation.
Why were InMotion Robots selected for the study?
The unique assist-as-needed exercise delivered by InMotion robots is the optimal way to
drive recovery through neuro-plastic remapping of sensory-motor pathways. InMotion
interactive robotics actively engage neurologically injured patients in repetitive tasks that
reinforce normal movement patterns and improve everyday function, even years post
injury.
Is InMotion interactive robot-assisted therapy an established practice?
Yes, many leading rehabilitation hospitals and VA hospitals are using InMotion Robots
every day to improve arm function following stroke, brain injury and other neurological
diagnoses. The NEJM article, the 1A level of evidence cited in Stroke*, and over 15
years of prior research gives a large evidence base for the treatment effectiveness.
*"ComprehensiveOverview of Nursing and InterdisciplinaryRehabilitationCare of the Stroke
Patient:A Scientific Statementfrom the American heart Association, Miller, et.al, Stroke
2010;412402-2448
What improvements in functional abilities do patients or therapists report?
Some examples of new abilities using the affected arm following robot-assisted therapy:
Put on a shirt or jacket Hold a shopping bag
Push a door open Pick up a laundry basket
Turn on a light switch Do household chores
Pick up a cup of coffee Put a leash on a dog
What treatment methods were compared? Patients were randomly assigned to three
study groups: 1) usual VA care 2) intensive InMotion robot-assisted therapy and 3)
(robot) intensity- matched treatment delivered by a therapist. Patients in both the robot-
assisted and the intensity-matched treatment group received 1024 exercise repetitions
$ per session, a level of intensity that is only practical with robot assistance.
8. Yes The study enrolled sixty-five percents (65%) of interested Veterans. Only those with
mild impairments due to stroke, or those unable to travel for the duration of the study
were excluded.
This study involved a very severe population, and many had only trace shoulder
movement (Fugl-Meyer Assessment (FMA) Scores ranging 7 to 38 out of a possible 66
points). About 1/3 had multiple strokes. Average time post onset was 4.7 years. Finally,
most were too severe to be candidates for modified constraint-induced therapy
Yes, after the 36 week study period the robot-assisted group out-performed BOTH the
intensive therapy and usual care groups. The robot-assisted therapy group Fugl-Meyer
Assessment Score (FMA) gain was 5 points greater than the usual care group. And, a
significant number of the robot-assisted participants showed much higher FMA gains
ranging above 6 points.
"Usual VA Care"Was Not Typical Care
Robot-assisted care was superior despite the fact that "usual care" in the VA study
averaged 3.6 hours of upper limb therapy per week. By contrast, the large majority of
patients in third party payer settings receive little if any rehabilitation beyond the first year
post-stroke. The VA considered the advantages of robot-assisted and (robot) intensity-
matched care so great that they discontinued usual care midway through the study.
Is robotic therapy cost effective?
Yes, the TOTAL cost to the VA was roughly the same between the usual care and the
robot-assisted therapy groups. Despite the cost of the robotic equipment, the robot-
assisted group experienced significant reduction in cost and use of other medical
services compared to the usual care group.
Differentiate your stroke program
with the new standard of care
NMOTION
ROBOTS F()H REHABH.lTATtON
80 Coolidge Hill Rd Watertown, MA 02426
Tel: 617926-4800 Fax: 617 926-4808
www.interactive-motion.com
9. Clinical ResearcJh With In'Motion Robots
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IMT tec'lnology has undergone more than a decade of clinical InvCSligatl0ns
Involvln~ more than 600 patients.
There is compelling evidence from clinical evaluations involving IMT technology
lrlat interactive robotic therapy significantly enhances motor recovery
In a multi-center, randomized, controlled trial involvin~1 127 :;,troke patient~, W!tll mod,:::rav:
to severe upper-limb impairment, InMotion robot-assisted therapy patients demOrl'Slrclled
significant improvement in arm movement, function and qUcllity of liTe
LO A C , etal "Robot-Assisted Therapy for Long-Term Upper·Limb Impairment after Stroke", New Englano .'ourne! 01
Medicine, :;,621772, May 13, 2010.)
In a clinical study involving 56 stroke inpatients, the motor skills of the robot-treated
group improved significantly more than the control group An analysis of impairmenl
measures showed that (1) interactive robotic therapy significantly reduu.:d mOlO'
Impairment of the treated limbs, and (2) added to con'/entional therapy Imer~ICllve
[(Jbotic therapy provided about double the impairment reduction.
Volpe, 8 T, Krebs, HI, Hogan, N :::delsteln, OL, olels, C and Aisen, M , A novel apDroach '0 srJoyt;;' r,,'h:;;':.>,:,r.'!:e,"
;obot-aldecl sensorimotor stimulation, Neurology, 54 (2000) 1938--44 )
10. Patients from an early clinical 2Tudy were rec21led up to three years later, and It was
found that patients who rece:ved robotic therapy sustained their improvement over those
who did not. Moreover, sub.;equent follow-up studies re-examining these patients also
confirmed the finding.
(JOlpe, 8T , Krebs, H.I., Hogan, N., Edelsteinn, L., Diels, C.M. a"d Aisen, M.L .. RobOI tralnln£ enhanced mo,or (lulUY"'-
.n 0811pnts wltr, stroke maintained over 3 years, Neurology, 53 (1999) 1874-6)
i ·JOlp0.. 8 T . Krebs, H I., Hogan, N., "Is robot-aided sensorimotor training In stroke rol,aL)"lailon a reali:;"c (,,-,:,(,:-.-
Curmnt Oplnl' In Ji1Neurology, LJPPJi1colt lVil/iams & lVilkins, 14:745- 752, 2001)
A multi-center VA study of 127 patients with long-term upper-limb impairment from a
stroke that occurred at least 6 months before enrollment (average brr.e of 4.7 years 3:?/:lo
with multiple strokes) found that "The improvements .. provide evidence of potential
long-term b(~nefits of rehabilitation and challenge the widely held clinical belief that gains
In motor fur,ction are not possible for long term stroke survivors."
C . etal , 'Robot-Assisted
! i_o. p, Therapy for I_ong- Teml Upper-limb Imp81m1enl after Stroke". Nevil EnglancJ ,i,ju.-:-:':'. 1 •
M/Jc;,c,ne. 3621772, May 13,2010)
Patients who had suffered a single unilateral stroke one to five years earlier, and who
were demonstrated to be in a "stable phase," showed significant improvement after
receiving robotic therapy three times a week for six weeks.
These findings also suggest that such patients have a potential for further recovery
which conventional therapy has been unable to tap into.
IFasoil, S D, Krebs, H I, Stem, J, Frontera, W.R. and Hogan, N, Effects of RobotiC Thci'ap'~ ·n ''I(J,(';
impaulI,en, and Recovery in Chronic Stroke, Archives o/Physica! MedlclI1e and K'eiw!Ji/lla(/OI1, S-:i(~rn::,,:--.
S2 )
l.Fas,)i,. S [, KiCbs, H i., Stcln, 1., Frontera, V.R., Hughes. R-, and Hogan, N., "RobotiC Thcrapy (or Ch,onlc t.IOi(;;
impal""cnts aftcr Stroke Follow-Up Results." Archives 0/ Physical MediCine and Rehabrl,(a(lol1. 85 1106-11 I I. ~0()J 'j
tFer-aro. Ivl .. Palazzolo, 11., Krol, 1, Krebs, H.I., Hogan, N, Volpe, B.T., "Robot Aided Scnsorlmotor Arm Tril1n':1f..
improves Outcome in Pallents With Chronic Stroke," Neurology, 61: 1604- I 607, 2003.)
12 children ages 5-12 With cerebral palsy and upper limb hemiplegia rec81vecJ rot)(;li,~.
therapy (!Vlce a week for 8 weeks. The children showed significant Ir"nprovem(~nl In IC;i.,.!,
Quality of Upper Extremity Skills Test (Quest) and Fugl-Meyer f-sscssment Scores
A "questionnaire administered to the children's parents also showed slgnlflcan~
Improvement in "how much" and "how well" the children used the paretic cHili dUrliin
functional tasks at home
11. (rasa/I. SE.. rrClgala-Pinkham, Yo., Hughes, R , Hogan, N., Krebs. HI.. Stein, J, "Upper Limb RoboliC Therapy iOI
Children with Hemiplegia, "Arnencen Journal of REhabilitation, 87: 11929-936 (2008)
A pilot ~tudy of two patients with incomplete spinal cord injuries, level C4-6 that had
occurred greater than two years ago, was conducted at Burke Rehabilitation Hospital
Patients received treatment in the shoulder-elbow robot for 18 sessions over 6 weeks
with one arm followed by 18 sessions over 6 weeks with the other arm Patients showed
changes greater than 10% in Fugl-Meyer Scores and 20% in the Motor Power scales
The study also showed that while one arm was treated both arms showed comparable
Improvement.
("rebS,HI, Dlpletro,L, Levy-Tzedek,S, Fasoli,S, Rykman,A, Zipse,J, fawcen,J. Steln,J, PQlzncrH, L(.) ,- '/'_11i)f:: 6;
Hogan,N, ",Q,Paradigm Shift for Rehabilitation Robotics." IEEE-EMBS Magazine, 27461-70 (2003'1
A pilot study of two MS patients at the West Haven VA Medical Center has shown trat
treatment with the InMotion AnkleBot twice a week for twelve total sessions resulted In
significant improvement in torque production at the ankle and movement accuracy
Although the training did not include gait activities the researchers noted cerry o'/sr
Improvement in gait function when measured through six minute walk tests
(Krebs.HI, Dlp,etro,L, Levy-Tzedek,S, Fasoli,S, Rykman,A, Zipse,J, Fawcen,J, Steln.J. POI~n~r.j-l. La. f.... 'Oll)r; !:','
Hogan,N, "A Paradigm Shift for Rehabilitation Robotics," IEEE-EMBS Magazme. 27~61-70 (2008)
~NW10TjON ROBOTIC THERAPY?
1 the repetitive exercise which may evoke and enhance a neuro-plastic recovery prOC8<::S
I
whereby new neural pathways replace some of the neural pathways lost due ;0 br2'li
InJury;
:z (he continuously interactive nature of robotic therapy, which ensures patient partlclpatlor.
by assisting only as needed;
(he 3daplive nature of robotic therapy, which adjusts the degree of movement challenge
and rot)otic assistance to accommodate each patient's individual needs and present
abilities:
12. ,1 the number of movements provided by the robot. which far exceeds any dosage i;,;'i
mlgrH be admlrllstered by a human therapist:
:J the benefiCial coupling of movements Vvlth sensory information - from both the VISUcl;
display and the robot arm itself - which shows the goal, the desired path to follow i',,::,
current hand position, and measures of movement q:Jality; and
6 the fact that all movements are successful due to the robot assistance; the robot cJoesnt
let the brain experience grossly inappropriate responses to it's motor commands
Aisen, M L , Krebs, H I., McDowell, F.; Hogan, N.; Volpe, 8T, "The Effect of Robot Assisted
Therapy and Rehabilitative Training on Motor Recovery Following a Stroke"; Arch of Ncuiol
54 .143-446, (1997)
Krebs, H I.; 8rashers-Krug, T.; RaUCh, SL; Savage, C.R.; Hogan, N.; Rubin, R H, Fischma:,
A J , Alpert, NM; "Robot-Jl,ided Functional Imaging: Application to a Motor Learning SlU(~'i"
,!--{uman Brain Mapping; John Wiley & 'Sons, 6:59-72; (1998)
'<rebs, HI, Hogan, N , Alsen, M.L.; Volpe, 8T; "Robot-Aided Neuro-Rehabilitation", IEf.E-
'i'l ansael,ons on Rehabilitation Engineering, 6.175-87: (1998)
Krebs, HI, Hogan, N , Aisen, ML.; Volpe, B.T., "Quantization of Continuous Arm Movements Ii:
Humans With Brain Injury", Proc. Nat. Acad. of Science 964645-4649, (1999)
Hogan, N, Doeringer, J.A; Krebs, H.I; "Arm Movement Control is both Co,tlnuous and Olscreie'
Cognitive Studies; 8ulletin of the Japanese Cognitive Science Society, 6 3254-273, (1999)
Volpe, B T , Krebs, HI, Hogan, N, Edelstein, L , Diels, C.M, Aisen, M L, "Robot Training
E:ihanced Motor Outcome in Patients with Stroke maintained over 3 years", Neurology 5~
12;0 (1999)
Kiebs f I I , Volpe 8 T, Alsen, M L, Hogan, hJ , "RobOtiC I'.... pplicatlons ill Neuromoto,
F~erlab;lltatlon", Topics In Splflal Cord Injury Pehabllitation, 53, pp50-63, (1999)
Volpe, 8 T , Krebs, H I, Hogan, N, Edelstein, L, Diels, C.M., Aisen, M .. ",6.. Novel/.,pprO.3ctl ,0
Stroke Rehabilitation. Robot Aided Sensorymotor Stimulation", Neurology, 541938-194<. ;00(';
Krebs, HI, Volpe, 8T, Aisen, M.L., Hogan, N.; "Increasing Productivity and Quality of Care
Robot-Aided Neurorehabilitation", VA Journal of Rehab!1 Res and Oev, 3713639-652, (2000)
..
Krebs. HI. Volpe, 8 T, Palazzolo, J; Rohrer, 8; Ferraro, M ; Fasoll, S , Edeistelll, L . Hogan :":
"F<obc)~-,LlcJed
Neuro-Rehabilltation In Stroke Interim Results on the FolloVv-up of 76 Pallen,) c;::c
on MovE'Jnent PerfOriilanCe Indices". In Mourllr rv10khtari (ed), IntegratiOn of ASSlslrve T,~c,";i1,)::::~
13. 'II [tie Informalion Age: 10S Press, .AS~·istlveTechnology Researc-, ,Series, frn';;l(:;r,j2Jrrl. :2()(l I
I
Krebs, H 1, Hogan, N., Hening, W., Adc.movich, S, Poizner, H; "Procedural Motor Learning In
Parkinson's Disease"; Exp. Brain Res i 41 :425-437 (2001).
Krebs, HI: Volpe, B.T.; Ferraro, M.; Fasoli, S; Palazzolo, J.; Rohrer, B; Edelstein, L , Hogan, !~.
"Robot-Aided Neuro-Rehabilitation: From Evidence-3ased to Science-Based Rehabilitation":
Topics in Stroke Rehabilitation; 84:5L1 ·70, (2002)
r!r..Jgan N "~,keletal Muscle Impedance in the Contrc,1 of Motor Actions"; Journal of Mech2nlCS in
,'!leOICllle 21()(j Biology 2(3 & 4):359-37::: (2002)
i=-~ohrer 8 , Fasoli, S., Krebs, HI , Hug;les, R, Volpe, B. Frontera, W R , Stein, J . Hoger" f..J
"Movement Smoothness Changes dUring Stroke Recovery", J Neurosci, 22.18 8297 -o30~
(2002)
Malfait, N, Shiller, D.M ; Ostry, D.J ; "Transfer of Motor Learning Across Arm Configurations"
Journal of Neuroscience; 22(22):9656-9660, November 15, (2002).
I:::lsoli, S D , Krebs, HI, Stein, J, Frontera, W.R and Hogan, N , Effects of RobotiC Ther'apy 0"
Motor Impallment and Recovery In Chronic Stroke, Archives of Physical MedlcJrle ijnd RUle!).
34477-82 (2003)
Krebs, HI, Volpe, B.T., Aisen, ML., Hening, W ,Adamovich, S., Poizner, H , Subrah~n8nY2n. v,
Hogan, N , Robotic Applications in Neuromotor Rehabilitation, Roborica, 21 3-11 (200:3)
Hogan, N, Krebs, HI, Rohrer, B, Fasoli, S, Stein, J, Volpe, BT, Technology for Recovery oft.er
Stroke, In JBogousslavsky, MP Barnes, B. Dobkin (Eds.), Recovery after Stroke, Camb!lrjgr~
r::>ress(2003).
Krebs, HI, Palazzolo, JJ, Dipietro, L., Ferraro, M.,·Krol, J, Rannekleiv, K, Volpe B T , Hogan
N , Rehar)llltation Robotics: Performance-based Progressive Robot-Assisted Therapy.
-~u!onomous Robots, Kluwer Academics 157 -20 (2003)
f--:erraro, M ; Palazzolo, J.J , Krol, J; Krebs, HI, Hogan, N; Volpe, B.T , Robot Aided
Sensorimotor Arm Training Improves Outcome in Patients with Chronic Strok.e Neurol'J9.v
0'11604-1607 (2003).
i-Ienriques, 0, Soechting, J.; "Bias and sensitivity in the haptic perception of geometry", b'p
3ratn Res (2003) 15095-108
Krebs, HI; Celestino, J.; Williams, 0; Ferraro, M.; Volpe, B.T.; Hogan, N; "A Wrist Ey.l'2nSlon Ie
MIT·MANUS;" In Z Bien and D. Stefanov (Eds.): Advances in Human-Friendly RobotiC
technologies for Movement Assistance / Movement Restoration for People With Oisabil!liC's
Springer-Verlag (2004)
i:;;lsoli, SO, Krebs. HI, Stein, J, Frontera, WR, Hughes R, and Hogan, N, RobotiC Th2r2r-~.. lor
Chronic Motor Impairments after Stroke: Follow-Up Results, ArchPhysMedRehab 8511 06-1 ~ 1 .
12004 )
.~
~.,
Fasoli, SO, Krebs, H.I , Ferraro, M, Hogan, N, and VoJ~e, B.T , Does Shorter RehabilllO(IOn
14. Hogan, N , Krebs, H.I.; "Interactive Robots for Nel 'o-Rehabilitation," In Platz (ed), Speclai IS';jj(=
on Motor System Plasl:ily, Recovery, and Rehab,·,tallOn, Restorative Neurology & Ncurosc,
(2G0L1)
KrebS, H I. Volpe, B T, Lennlnhan, L, Fasoli, S, lynch, 0, Dominick, L , Hogan N .. "N(,:.=-s ()o:
r~.ehablillatlon Robotics end StrOke," In. F. Lofaso, il, Roby-Brami, J.F. Ravclud (Eds )
Tr=:chnoiog,cal Innovations and Hancf'cap, Frison R:jche, pp 177 -194 (200.1)
,!o;pe S T , Ferraro, M , Lynch, D, Christos, P, Kr~)I, J, Trudell, C, Krebs. HI, Hogan ~J .
'RubollCS and Oltier 00vlces In ti,e -,-reatment of F'atlents Recovering from Stroke," Cur
;:Jnneroscler Rep, 6 314-319 (2004')
Krebs. HI, Ferraro, M, Buerger, SP, Newbery, ~"1.J.,Makiyama, A., Sandmann, M , Lynch. D
'/olpe, B T , Hogan, N., "Rehabilitation Robotics: Pilot Trial of a Spatial Extension for MIT-fv1a:lus
Journal of NeuroEngineering and Rehabilitation, E;:omedcentral, 15 (2004)
Stein, J, Krebs, H.I., Frontera, W.R, Fasoli, S.E., Hughes, R, Hogan, N., "Companso~i of T,,(.
Techniques of Robot-Aided Upper Lirnb Exercise Training After Stroke." Arneocan Journal
PI:yS'CCJI Medicine Ref,abllJlation, 839720-728 (2004).
J.
ROhrer, 8, Fasoll, S, I<rebs, H,I, Volpe, B, Frontera, W.R, Stein, J, Hogan, N, "Submovements
Grow L2rger, Fewer, and More Blended During Str,pke Recovery," Motor Control, 8.472-<'183
(200.1) ,I
"
Fasoll, S E, Krebs, H.I., Hogan, N., "Robotic Technology and Stroke Rehabilitation. Transi8:w,<;
Research Into Practice," Topics in Stroke Rehabilitation, 114: 11-19, (2004)
Stein, J . Hughes, R, Fasoli, S., Krebs, HI., Hogan, N, "Clinical Applications of Robots In
Rehabilitation," Cot/cal Reviews in Physical and Rehabilitation Medicine, 17 (3). 217 -230 (:::'r.'C~,
Dipietro, L , Ferraro, M, Palazzolo, JJ, f<rebs, H.I, Volpe, 8T, Hogan, N , "Customized
I,teractlve Robotic Treatment for Stroke: ErvlG-Triggered Therapy," IEEE Transaction Neu/(I,
Sysrems and RehabilllatlOn EnQ,lneering, 13:3:325-334 (2005),
Finley, fV1 1., Fasoli, S E, Dipietro, L., Ohlhoff, J., I'vlacClellan, L, Meister, C, Whltall, J , M?C":'~1
R bever, C T, Krebs, H.I., Hogan, N., "Short Duration Upper Extremity Robotic Therapy I;~
Stroke Patients with Severe Upper Extremity Motor Impairment," VA Journal RehabJiilainJn
Research and Development, 42(5)683-692 (2005).
Daly ,J , Hogan, N , Perepezko, E" Krebs, H,I" Rogers, J" Goyal, K" Dohring, M , f:redrlckSGn
E ~Jethery, J , Ruff, R, "Re'sponse To Upper Limb Robotics and Functional Neuromuscular
Stimulation Following Stroke," VA Journal of Rehabilitation Research and Development Ij2(6!72~-
,35 (2005) ,
MacClellan, L R , Bradham, D.D" Whitall, J, Volpe, 8, Wilson, P 0, Ohlhoff, J ,Meister C
Hogan, N, Krebs, HI, Bever, C1" " Robotic Upper Extremity Neuro-Rehabilltatlon In ChrQi->IC
Strokei"patlents," VA Journal of Rehabilitation Research and Development 42(6) 717 -722 2005,
Krebs, HI, Hogan, N; Durfee, W,; Herr, H.; f-<ehabilitation Robotics, Orthotics, and Prosllietlcs
Cr,apter 48, In M.E. Selzer, S. Clarke, L.G. Cohen, PW Duncan, F H. Gag2 (Eds): TextLJOok 0:
16. W~~cO~l~~b-th~ ifobo_tm~Lap~!
~ April 20th, 2010 by David E. Williams Qfthe Health business blog
.~~s~tten, th~ Ne~ Englcrt1d Journal ofl'y~edici~e article (!ioDoc-Assisted TheralJv [or Long-Term
UODer-Llmb ImDazrm,ent after Stroke) clarms qUIte modest results for robot thera B tw h
I h h l' ~ l1-.~- 'fth '. . - , . py. e een me
:J21es,t oug ,~Ie p_owe~ LUlltS0 e J..;Jllpendmg
robot revolution. (The article is free and I
cncouIage you to read It.)
~es:arch~rs recruited Veterans A<:l,no~stratiO'n(VA) patients who'd suffered strokes an average of 5
yealS ec:rber. Volun1eers were randorruzed to 12 weeks of robot-assisted therapy, intensive
compa.1J.son therapy, or usual care (medical management and some rehabilitation servic~s available to
.. _---- ..
,,-' _---------'-,_ .. _--- .. -- ., _."._----_
.._-----_ ..,-- '--'-'.-.-'---,--_.
all patients), The primary outcome was change in motor function at 12 weeks as measured by the
Fugl-Meyer score. Patients were also evaluated after Q, 24 apd 36 weeks,
Results showed that robot-assisted therapy did not significantly improve motor function at 12 weeks
compared to usual care or intensive therapy, although there was significant improvement on the
Stroke Impact Scale (SIS). At 36 weeks robot-assisted therapy and intensive therapy perfo!TD.edabQ'J~
the saIne, and both were superior to usual care.
So what's the big deal? Actually a few tbings:
• Intensive therapy -whether performed by a robot or a hUJ:J:.Cin- dem.onstrated its superiority to
usual care. The intensive therapy delivered by therapists ii'l tills trial was so intensive: > 1000
movements in a session compared to 45 for typical stroke treatment -that it's really only
available under controlled conditions with a researcher standing over the therapist with a
stopwatch. If you want this l<..ind intensive' therapy for ycurself you'd beneT hire someO!2e
of
wit-h a whip (or bnng John Hen.:::Y,backfrom the dead' and~ake the harruner om ofbs t:.ar:.d) .
• A close read of Table 2 (Changes in Primary and Se..£.QQ.Q§ry Ol1tcomes at 12 Weeks) strO!2g!y
suggests better results for the robots thdn the authors are willing to claim explicitly. The le.5:
side of the table measures robot-assisted therapy 'Is. usual care. The right colUlT'..D.srneaS lre
'
robot-assisted therapy 'Is. intensive comparison therapy. The performance of the robot gTQl!~' is
much better on the right side of the table than the left. If we compare the robot numbers O!lthe
right with the usual care numbers on the le~ the cOIDJnrrisQuslook much betteT for the robots,
including a 5 point improvement on the Fugl-Meyer score (which is extremely impressive for
someone 5 years after a stroke). .
So why is the table set out this way? It appears that patients were only e!lIolled L'1 usual care fc:
the [lIst 16 months of recruitment, whereas the recruitment period for rob01-assisted and
~ntensive l;herapy cOIl,tinued for 24 months. I don't understand why the usual care recr'IJitrDe!2t
was stopped -perhaps the study was on a tight budget? In any case it's likely that the therapls'(c;
operating the robots fonowed a lea..ruing CUri''; du.ring the study and were betteT able to opeTatt
the TO bots in the second part of the study thaD.the fi...;rst,
willch is the portion of the study
analyzed on the left side of the table. The authors state that the robot manufacturer (ImtTaCti'/e
Motion Tecl-moloszies) had "no role in the st1;ldy,"willch could mean the therapists had to figt!.:t
om the robot for themselves and would not neve been as good at first.
The fact that tlois information is presented int21.esame table appears to be a tacit
a.cknowledgment that the researchers also beJieve in the GOmpa..risonI a..rnsuggesting .
. L'r.bor savings were large. One-hoW' sessions required or:0y.15 minutes of contact wit.l-J. t.l-J.e
theraDist fOTthe rot,ot versus 60 minutes fOT,the intensive comnanson theranv. Th?T hi'l.~
17. ~espite ~e ~$10.K cost ofusing,t1le robot. That means the robot group patients used only one-
~~ of tb,:.medlcal resour:ces of the ,usual care group ($5K versus $15K) while making
Sl.gmfica.:r:l.
rmprovements ill health status. That's incredibly g00d news and must have been a
big surpnse to the researchers. ".
"
An a~companying editorial (BrClin .Repc:ir c:fter Stroke) acknowledEes the accomplishments of this
study and emphasizes the broader rmpllcatlOns. ' ."
In the ?igge~ picture, the potential. for robotic therapy after snoke remains enormous.
RobOTIC deVlces can provide therapy in differ:ent functional modes, a point that was not
-ex~~db,yL-;- et ai Rob~ts work~'~-;onsistent"and p-;;ecisern?JIDer and over-lOng- ."
periods vYithout fatigue. They can modulate timing, content, and intensity of training in
reproducible ways, with a reduced need for human oversight. Robotic devices can also
measure the performance of patients during therapy. In addition, ro bot- based therapy can
interface with computers in brain-stimulation treatment or to provide simultaneous
cognitive training.
You C31"1 also check out a yideq, of the robot in action.
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