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  1. 1. perspective in the IEEE Transactions on Neural Sysrems and way the robot reacts to mechanical penurbation from a patien: A Paradigm Shift for Rehabilitation Engineering, September 2007 (IEEE lNSRE). Therefore, rather than attempting to replicate the content of these or clinician and ensures a gentle compliant behavior. Toe machine was designed to have a low i~trinsic end-ooim im- Rehabilitation Robotics publications, in this article, we restrict ourselves to a sununary of the growing activities with our robots. Most researchers employ~ ing rehabilitation robotics have focused on stroke, as this is the pedance (i.e,. be back-drivable) to allow weak patie~ts to ex~ press movements without constraint and offer minimal resistance at speeds up 2 m/s (the approximate upper limit of unimpaired single largest cause of permanent disabiliry. We briefly review human performa.1ce, hence the target of therapy, and the maxi- the pohlished clinical literature in this emerging field and our mwn speed observed in some pathologies, e,g., the shock-like initial clinical results in stroke. However, we also report our movements of myoclonus). initial effOI1S that go beyond stroke, broadening the potential Following the successful clinical trials with WT-MANUS, Therapeutic Robots Enhance Clinician population that might benefit from this class of technology hy a one-degree-or-freedom (DoF) module [Figure 2(b)J was Productivity in Facilitating Patient Recovery discussing case studies of applications to other neurological conceived to extend the benefits of planar robotic therapy to diseases. We will also highlight the underexploited potential of spatial arm·movements, including movements against gravity.BY HERMANO I. KREBS, LAURA DIPIETRO, this technology as an evaluation tool. Therapists suggestions that functional reaching movementsSHELLY LEVY-lZEOEK, SUSAN E. FASOU, often occur in a range of motion close to shoulder scaption areAVRIELLE RYKMAN-BERlAND, JOHANNA ZlPSE, RobolicGym incorporated in the design {I]].JENNIFER A. FAWCETT, JOEL STEIN,HOWARD POIZNER, ALBERT C. LO, Figure 2(a) shows the pioneer of its class, the M1T-MANUSBRUCE T. VOLPE, AND NEVILLE HOGAN for planar shoulder-and.-elbow therapy, whose development started in late 1989 (IOJ. MIT-MANUS. from the Massachu- sens Institute of Technologys (MlI) mono "Mens et Manus" he demand for rehabilitation services is growing apace chronic disease of the central nervous system, and cur- (mind and hand), was desigoed for clinical oeurological appli- with the graying of the populatioo. According to the rently there is no cure for it. None of the current immu- cations. Unlike most indusoial robots, MIT-MANUS was World Health Organization (WHO), senior citizens at nomodulatory therapies convincingly alters long-tenn configured for safe, stable. and highly compliant operation in least 65 years of age will increase in number by 88% in progressive disability. Patients with nontraumatic spinal close physical COlltact with humans. This was achieved using the coming years. By 2050, the United States contingent of cord injUI) (SCI) may well equal this incidence. impedaoce control. a key feamre of the robot control system.seniors is expected to double from approximately 40 to 80 mil- SCI: It is the leading cause of disability in YOWlg adults in Here, we opted for a fixed-based design robot (actuators arelion (Figme I). With this increase comes increased incidence the Uoited States. The incidence of SO has beeo estimated fixed with respect to a stationary coordinate system) versus anof age-related disorders. The following is an example. to be between 30 and 60 new cases per million of the U.S. exoskeleton design. {Fixed-based or end-cffector designs like Cerebral vascular accident (S/7oke): For every decade population per year, with an estimated prevalence of MlT-MANUS are simpler, afford sigoificantly faster "don" after age 55. the relative incidence of stroke doubles (1]. 250,000 (700-900 per million of population). Almost and "doff" (setup time much smaller) than exoskeleton At present,. more than 700,000 Americans suffer strokes 80% are males younger than 40 years (4J, [5J. designs but typically occupy a larger volume. We employ a each year, more than half survive. In the United States Parkinsons disease (PDJ: It is a neurodegenerative disor- rule of thumb to guide us in the selection of configuration alone. close to 5 million stroke victims are alive today der characterized by bradykinesia., resting tremor. rigidity, based on the target range of motion. For limb segment [lJ. Even higher incidence is observed in other devel- and postural reflex impairment. It is one of the most com- movements requiring joint angles to change by 45° or less, end- oped countries with older populations (e.g., Japan). moo neurological disorders, with estimates ranging from effector designs appear to offer better compromises. Conversely, There can be some respite from stroke if phannacologi- 500,000 to 1.5 million affected in the United States, and exoskeletal designs appear to offer better choices for larger cal agents are successfully developed to preserve vessel this number will increase over the next 50 years as the ranges of motion.) Its computer control system modulates the patency, to protect neurons, and to stimulate neosynapto- average life expectancy increases (6), {7]. TIle time of genesis. However, if that should happen, an increase in onset is typically between 40 and 70 years of age, with stroke survival rates may well increase the number of peaks in the sixth decade of life. Most conunonly, the stroke victims in need of rehabilitation services. clinical status of the patient with PD progresses from a The need for rehabilitation services is even more pressing if relatively modest limitation at the time of diagnosis to anwe consider neurological diagnoses ocher than stroke. The fol- ever-increasing disability over a period of 10--20 years.lowing are some examples. There is both a need and an opportunity to deploy technolo- Cerebral palsy (CP); This is a term used to describe a gies such as robotics to assist recovery. This, in essence, consti- group of chronic conditions affecting body movement tutes a paradigm shift moving the field of rehabilitation robotics and muscle coordi.o.ation. which affects 2.8 in 1,000 chil- beyond assistive technology that helps an individual cope with dren born in the United States each year [2}. It is caused the environment to a new class of physically interactive, user· by the damage to one or more areas of the brain, usually friendly robots that facilitate recovery. 1bera.peutic robots occwring during fetal development; before, during, or further the clinicians goal of facilitating recovery not only by shortly after hirth; or during infancy (3). In addition, delivering measured therapy but also by affording new ways to studies have shown that at least 5,()(X) infants and tod~ evaluate patients progress. Here, we will focus on this para· Fig. 2. A gym of robots. (0) The shoulder-and-elbow MIT~ d1ers and 1,200-1,500 preschoolers are diagoosed with digm shift: robots that support and enhance the productivity of MANUS delivering therapy to a child with CP (Spaulding CP each year as developmental and motor delays be- clinicians in their efforts to facilitate an individuals recovery. RehabAttatfon Hospital). (b) The antigravity module (Balti- come more apparent. A recent IEEE puhlication described the rematkahle groW1hof more VAMC). (c) A person with PO and deep brain stimula- Multiple sclerosis (MS): It is the third leading cause of activities in the rehabilitation roOOtics in the past few years and tlon COBS) practicing with the wrist robot (University of disability in young adults in the United States, with a ourdevices deployed in clinical trials (see (9J fordetails). In addi- California Son Diego). (d) The .Integrated system affording prevalence of approximately one in every 1,000, with tion, the lead anthor recently edited two special issues presenting whol~rm training (transport of the arm and manipulation two thirds of these cases occurring in females for an a broad spectrum of leading research efforts in rehabilitation of objects, VA CooP Study Randomized Clinical Triol CSP estimated total of 350,000 in the United States. MS is a robotics: from the clinical perspective in the Veterans Adminis~ 558). (e) The hond module (without cover). (f) A person with trarions Journal of Rehabilitation Research and Development MS during therapy with the anklebot 0Nest Hoven VA Medi- (JRRD), September/Octoher 2006, and from the eogineering cal Center).
  2. 2. To extend the Dearment envelope beyond the shoulder and maximum reconfigurability llIld have taken me same modular wi!! be able to segregate science from fiction. A very common Robot Therapy: Stroke elbow, we designed and built a wrist module for robotic therapy approach employed for the upper extremiry. The first lower- Volpe et a1. reported the results of robotic training with 96 assumption is that movement therapy works by helping [12]. It features three active DoF, namely, flexion or extension, extremity robot module deployed to the clinic has been patients relearn motor control (part of the lext in this section consecutive inpatients admitted to Burke Rehabilitation Hos~ abduction or adduction, and forearm pronation or supination, dubbed the anklebot [9J, (18). The ankle joint is of panicular as extracted from [181). Although intuitively sensible, this pital who met inclusion criteria and consented to participate and can be operated as a stand-alone unit (Figure 2(c)J or importance because of the prevalence of drop foot, which is a notion may need to be refined. First, normal mo:or learning [19J. Inclusion criteria were diagnosis of a single unilateral mounted to the end of a shoulder-and~elbow robot (Figure simple name for a complex problem. The foot needs to clear stroke within four weeks of admission to the study; the ability does not have to contend with the neuromuscular abnormal- 2(d»). The most common fonn of unimpaired upper-extremiey the ground during the swing phase of gait, and it needs to have ities that are common sequelae of neurological injury, includp to understand and follow simple directions: and upper limb movement appears to be a combination of translating the hand a controlled landing during heel strike. Lack of proper control ing spasticity. abnormal tone, disrupted or unbalanced sensory weakness in the hemiparetic arm (i.e., a strength grade of 3/5 (with the shoulder and elbow) to a location in space and orient- during these two phases increases the likelihood of Dips and pathways, and muscular weakness. These deficits appear to or less in muscle groups of the proximal arm) as assessed with ing the hand (with the wrist) to facilitate object manipulation. falls. At present, drop foot is typically addressed in the clinic involve the peripheral nervous system and might suggest that the standardized Medical Research Council banery. Patients We are employing the wrist robot in both configurations to via an ankle-foot orthosis (AFO) that restricts the ankles muscles should be the focus of therapy. Nevenheless, central were randomly assigned to either an experimental or control determine what works best and for what rype of patient «(l3); range of motion. However, this approach has limitations and nervous system plasticity appears to underlie recovery. Thus, group. The sensorimotor training for the experimental group VA Coop Study, Randomized Clinical Trial, CSP 558). offers linle hope of reducing the impairment. To address the recovery may resemble motor learning in some respects, but it consisted of a set of video games in which patients were The next module required for whole-arm therapy is a hand impairment reduction, we recently introduced to the clinic (at is likely to be a more complex process. required to move the robot end-effector according lO the games robot [Figure 2(e)]. Moving a patients hand is not a simple the Center on Task-Oriented Exercise and Robotics in Neuro- Second, nonnal motor learning is far from fUlly understood. goals. If the patient could not perform the task., the robot task because the human hand has 15 joints with a total of logical Disease at the Baltimore Veterans Administration Topics of ongoing vigorous debate include questions such as: assisted and guided the patients hand. Although the patient 22 DoF. Thus, it was prudent to determine how many DoF are Medical Center and at the West Haven VA Medical Center) a What variables or parameters of action does the brain com· groups were comparable on all initial clinical evaluation necessary for a patient to perform the majority of everyday novel ankle robot that allows normal range of motion in all mand and control? How are these encoded and represented in measures, the robot-trained group demonstrated significantly functional tasks. Here, our clinical experience with more than 3 OaF of the foot relative to the shank while walking over- the brain? How are these encodings or representations acquired &teater motor improvement (higher mean interval change 300 stroke patients was invaluable as it allowed us to identify ground or on a treadmill. Only 2 of these 3 OaF are actuated: and retained? What training schedule optimizes acquisition? Is ± SEM) than the control group on the trained limb segment what was most likely to work in the clinic (and what probably plantar or dorsiflexion and inversion or eversion. As with all a period of consolidation between training sessions (e.g .• sleep) (shoulder and elbow). In fact, patients in the robot-trained group would not). Although individual digit opposition (e.g., thumb our devices. we purposely underactuated the ankle robot with required for long-term retention? All these questions have improved twice as much as patients in the control group for the to pinkie) may be important for the unimpaired human hand, it fewer DoF than are anatomically present. Not only does this practical relevance for therapy. For example, if the brain repre- trained limb segments. is clearly beyond the realistic expectations of most of our simplify the mechanical design, it allows the device to be sents action as a sequence of muscle activations, focusing In addition to the inpatient studies (see Table 1), we patients whose impairment level falls between severe and installed quickly without problems of misalignment with the sensorimotor therapy on muscles would seem profitable. How- recruited 117 community.<fwelling volunteers in the chronic moderate; a device to manipulate 22 DoF is unnecessary (or at patients joint axes. ever. a large and growing body of evidence indicates that under stage of stroke recovery at the Burke Medical Research insti- least premature). The hand therapy module is a novel design many circumstances the brain does not directly control mus- tute, Spaulding Rehabilitation Hospital, and Baltimore VA that converts rotary into linear movement and may be used to Robotic Theropy: A Paradigm Shin cles; instead, it controls the upper limb primarily to meet kine- Medical Center. Prior to engaging in robotic therapy, these train grasp and release, with its impedance determined by the The infancy of therapeutic robotics is easily demonstrated: a matic specifications (such as a simple motion of the hand in a patients were assessed on three separate occasions to determine torque between the TOtorand a free-floating stator [14). MEDUNE search prior to 1990 will return no articles on visually relevant coordinate frame) that adjust muscle forces to baseline function and to establish a within-subject contrOl. The Of note, it remains an empirical question whether we should therapeutic robotics. Of course, the application of robotics to compensate for movement-by-movement variation of mechan- primary outcome measures were the Fugl-Meyer and the deliver therapy to the whole arm or train individual limb seg. rehabilitation has a longer history, but as mentioned earlier, icalloads, which suggests that focusing on motions rather than Motor Power score. Our baseline analyses revealed no statisti- ments. A potential approach to increase the effectiveness the strong and sustained growth of activity in recent years is muscles may be more profitable. Of course, these are only twO cally significant differences among any of the pretreatment beyond Our past studies is to develop new whole·arm function. due to a significant shift away from assistive technology for of a large number of possible therapy variations. In our re- clinical evaluations, indicating the stabiliry of chronic motor ally based therapy approaches that integrate robotic therapy people with disabilities toward robotic therapies, which use search on robotic stroke rehabilitation, we have attempted to impairments in this subject group. However, after robotic train- with clinical practice and enhance the carry over of robot- the technology to support and enhance clinicians productivity ing, we found significant reductions in motor impairment of assess some of these possibilities. trained movementS into functional tasks. Two potential and effectiveness as they try to facilitate the individuals In the following sections, we will describe the robust results the hemiparetic upper limb [20), [21]. approaches to deliver such a functional training are 1) to train recovery. The magnirode of this change goes far beyond the in stroke and present case srodies of the effect of robotic ther- In fact. results from many other research groups have shown functional tasks with the robot or, alternatively, 2) to train by usual ebb-and-flow of activiry in technology~related fields. apy on other populations, in panicular, CP, MS. and SCI. As the same kind of impact. Figure 3 shows the result of a mera- aiming for impairment reduction at the capacity level, with dif- Tracking the approximate number of articles submined to the these studies are ongoing, we include data from representative analysis on upper-extrernjty robotic training trials published up to ferent robotic modules breaking these functional tasks into International Conference on Rehabilitation Robotics from samples of convenience (twO subjects per condition). Final October 2006 with the first. generation of thenpeutic robots. A components, and leave the carry over of the observed impair- 1997 to 2007 demonstrates a sharp increase in articles on ther- results including all the cohort of enroHed patients will be pub- computerized literature search was conducted in MEDLilJE, ment gains from robotic training into functional gains to the apeutic robotics, which rose from 33% to almost 80% of the lished in the near future in clinical journals by some of the CINAHL, EMBASE, Cochrane Controlled Trial Register, therapist. These alternatives are not mutually exclusive, but we submined articles. This is not a minor shift: robotics promises coauthors, Fasoli (CPl, Lo (MS), and Volpe (SCI), at the com- DARE, SciS=h, Doconline, and PEDro, and it returned 173 must understand the potential and benefit of both approaches to transform the way physical medicine is practiced. pletion of these ongoing studies. All protocols reported in this hits. Only those articles that compared robot training against a to maximize recovery and to begin building a scientific basis Although the sharp increase in activities is encouraging, we article were approved by the Committee on the Use of Human control group were included. Studies that compared different for the best rehabilitation practice. For example, it appears that must highlight the importance of the multidisciplinary effort Experimental Subjects of MET and by the institutional review forms of robotic ilierapy and stUdies on chronic stroke that com- the first approach might lead to benerresults with mild strokes, needed to segregate science from fiction and push the bounda. board of the respective testing site, and the informed consent pared discharge values with admission values were excluded. fIn whereas the second approach appears to lead to bener results ries of the state of the art (please note the large number of was obtained from all participants. addition, a significant number of hits were eliminated because of for patients with severe to moderate strokes [15}, [l6}, [17]. coauthors). Sustainable growth of activities in the area of reha- poor design. It emphasizes again the need forThe modularity of our suite of therapeutic robots, which is a bilitation robotics will only be achieved if we engage in serious a truly multidisciplinary effort. Of note,cornerstone of our design philosophy, is uniquely suited to chis clinical Dials to understand what works and what does not. Dr. Bruce Dobkin (University of California,investigation. It allows us to employ them in a standalone That said, engineers must recognize the need to bring the Los Angeles), who is the editor·in-chief ofmode to deliver therapy for particular impainnents or to inte- Between~G·r~~¢~~pOris·ons: Fi~~: Robot Trained technology out of the lab and into the clinic. Successful transla- Evaluation Minus Initial Evaluation (0 = 55) Neurorehabilitation and Neural Repair, iden-grate the modules to deliver whole-arm functional robotic ther- tional will occur only if we engage clinicians (physicians and tified this weakness and established the basicapy {Figure 2(d»). To the best of our knowledge, no other therapists) and patients (and their families). Otherwise, much Impairment measures (±SEM) principles to design successful clinical trialsresearch group can presently pursue this objective because of this flurry of excitement and growth will be transitory in Fvgl·Meyer shoulder/elbow 6.7 ± 1.0 4,5::!: 0.7 that can be accessed at that journal.) Thethere are no otherreconfigurabJe rehabilitation robots. nature (regrenably, not an unprecedented pattern in robotics). Motor power 4.1 ±0.4 2.2 ± 0.3 results demonstrated small but statistically The devices described earlier were intended to treat the There are a multitude of variables that may influence out~ Motor stotus shoulder/elbow 8.6 ± 0.8 3.8 ± 0.5 significant improvements because of theupper extremity, and as we completed the enabling tee hnology come, and we must determine the interaction or independence Moror status wrist/hand 4.1.± 1.1 2.6 ± 0.8 robot~assisted therapy even when comparedfor reconfigurable whole-arm therapy, we initiated th~ devel. among these variables and their actual impact on outcomes. If head to head with conventional therapy inopment of lower-extremity devices. Again. we are aiming for we can achieve significant inroads in this investigation, we stroke (22]. Another meta-analysis study.
  3. 3. +=which included studies on chronic movements in a temperanlle-conrrolled environment. This Robot Therapy: SCI Fugl-Meyer (Mean and 95% el)5loke that compared discharge val- protocol included twice-a-week training sessions for a total of Emergency medical and surgical services have decreased mortal-ues with admission values, indicates 12 sessions of approximately 45 minutes duration per session. ity rates after traumatic scr, which results in almost 1O,<XX:l newa similar positive impact of the Outcomes were measured a[ baseline and at discharge and survivors of traumatic SeI per year in the United States. Newtechnology [23]. included the timed 25-ft walk (T25FW), the 6-min walk treaonents are desperately needed for the subacute stage. Cur- Although stroke is the single larg- (6rvfW), isometric strength for ankle flexion or extension and rently, methylprednisolone is used as an effective treaonent,est cause of permanent disability in inversion or eversion, muscular fatigue as tested with sustained which has been delivered in high doses within eight hours ofthe United States, our interests go I L- injury (as a bolus and then continued for the first 24 h) {33] with Kahn 2000 N= 10 -0.58 [-1.88-Q.71} ~ hold, and accuracy. Here, accuracy was defined as the scorebeyond stroke: we believe that ro- patients achieved in the driving simulator training game. other potential candidates [32J. Improved gains in function and.botics may prove to be applicable to Patients were asked to move their ankle unassisted in plantar- importantly, gains in independence have been made primarilymost neurological disorders and willfundamentaJly change the process I, dorsiflexion or inversion or eversion and pass the vehicle through incoming randomly positioned gates. For every success- via assistive devices. Nevenheless, it is possible that therapeutic robotics may have a place in reducing impairment On the basisof rehabilitation. To achieve this, we Hesse 2005 N = 39 3.74 (2.68-4.80J ful maneuver through a gate, the patient scored + 10 points. For of preclinical information that plasticity occurring in the spinalmust understand whether delivering every collision with the walls, patient lost -10 points. Maxi- cord is possible, we anempted to influence the functional abil-movement therapy via robotic assis- Daly 2005 N= 12 0.11 [-1.02-1.24) -!<> _ mum score was 800. In addition, kinematic data were collected ities of patients with chronic traumatic SCI by using robotictants will have a genuine impact on Kahn 2006 N= 19 0.46 (-o.51-1.31} by the Ankleoot (see Figure 4). protocols that have been effective in patients with stroke. Weother afflictions, and we must under~ Of particular interest in this pilot study is the impressive screened 39 persons with SCI who were admined to Burkestand the distinctive features of each Lum o 2006 N= 15 0.48 [~.S7-1.S3] change in torque production at the ankle and the improvement Rehabilitation Hospital during the period of 2002 to 2006. Ofdisease. Here, we present our initial in movement accuracy (tested in the S,une temperature- those, nine fell within the incomplete C4-C6 lesion category.results with samples of convenience controlled environment) for these persons with MS after the 12 We trained these SUbjects with the shoulder-and-elbow robotin CP, MS, and SO. training sessions. The training protocol does not include a for 18 sessions over six weeks with one ann, followed by gait-specific task. Nevertheless. we observed a cany over to another 18 sessions of training with lhe other arm. We eval-Robot Therapy: CP characteristics of gait with a general improvement in the dis- uated these subjects using the Fugl-Meyer and Motor PowerWe engaged children 4-12 years tance covered in a 6WN and the time for a 25FW, even though scales, and we present here a case study of a representativeold having hemiplegic CP in 16 walking had not actually been trained. sample of convenience of two ofthese subjects (Table 4).robotic sessions of task-specific For these patients, we recordedtraining with the MIT·MANUS. changes greater than 10% in the Fugl-Hemiplegic CP is the most com- Meyer Assessment and 20% in the Motormon syndrome in children born at Power scales. Note especially that whileterm and is second in frequency Fig. 3. Meto-ona!ysis of robot-ossisted therapy trials on motor recovery following stroke. Pre- Post- Anklebot Anklebot we trained one ann at a time, both limbs Average of Two Subjectsonly to spastic diplegia among pre- simUltaneously improved by comparableterm infants [24J. Children with hemiplegia typically have T2SFW(s). 9.6 11.50% amounts. impaired sensory mechanisms [25), decreased motor control 6MW(min) 256 11.30%and muscle weakness {26], and spasticity. Typical therapy for Changes Ankle p1ontar1l~xion (N x m) 3.74 645% Robof·Based Evaluafionchildren with hemiplegia is often based on motor learning, in Admission to Modified Fugl·Meyer Ankle dorsiflexion (N x m) 0.4 3475% The results discussed earlier were limitedwhich varied experiences that promote task-speCific training are Discharge Ashworth Assessment" Upper Quest Movement accuracy (dorsi-plantorflex) 560 39.30% to standard clinical scales and did notused. Motor learning strategies that incorporate practice, repeti- (ChildID) Scale (/35) .Extremity (/66) (/100) take full advantage of the robots capa-tion, and context are commonly used in the current therapy -2.75 bilities [0 quantify patient performance. PII~02 4.5 7.1practices. Emolled children received [1.0 sessions of robotic PII_03 -2.5 6.0 7.7therapy per week at Spaulding Rehabilitation Hospital, with anemphasis on repetitive reaching exercises for the paretic Here. we are showing the results with two of the 12shoulder and elbow. These 16 one-hour therapy sessions, and Trace of Ankle Plantar or DorsifleXion(MS SUbject 302) Trace 01 Ankle Plantar or Dorsiflexion (MS Subject 302) children enrolled in this pilot study.clinical evaluations that measured changes in motor impair- 10 10ments, were administered over a 12-14-week period. Clinical 8 8assessments included the Modified Ashwonh Scale, FugJ- usual care for the chronic phases of MS. Studies employing inpa- 6 6Meyer Assessment (with specific scoring established for this tient rehabilitation have shown that rehabilitation in this settingpediatric population), and the Quality of Upper Extremity Skills can help to restore function in relapsing-remitting patientS with c c oTest (QUES1). nonremitting deficits [30]. However, the p:>tential role and effi- 0 0 o .~ The initial results for the first two children are shownhere (Table 2). Findings suggest that 16 h of robotic therapy cacy of outpatient rehabilitation have not been fully explored. There are no current interventions directed at correcting ankle ~ 1! ~with the MIT -MANUS can have a positive impact on reduc· impairment The current solution is to fit an AFO, which helps to ii -2 a -2ing tone and motor impairment in the paretic arm to the ensure that the foot clears the ground and also fixes the ankle and E -4 o -4orderof7-9%. thus induces compensatory movements at the knee and hip to accommodate this loss of articulation. j -0 ~ -6Robot Therapy: MS To address this problem, we are employing the AnkJebot in a 0- -8 a: -8Specific gait abnormalities have been observed in ambulatory pilot study at the West Haven VA Medical Center. Here, we -10 -10MS patients [27]-[29], including those with even minimal report a case study of a sample of convenience of twO subjects 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 o 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5impairment as measured by the Expanded Disability Status who had progressive disease and were ambulatory with cane Time(s) Tlme(s)Scale (EDSS < 2, [27]). These gait abnormalities have gener- assistance (Table 3). Both subjects had prominent drop foot and (a) (b)ally included reduced velocity. reduced stride length, increased were engaged in a protocol similar to a driving simUlator. Seateddouble suppolt time, and gait asymmetry. Rehabilitation for the subjects practiced a block of 320 plantar-dorsiflexion move-purpose of improving or sustaining motor function is not a pan of ments, followed by another block of 320 inversion-eversion
  4. 4. AcknOWledgmentsRehabilitation robotics can not only introduce new efficienciesinto cenain routine therapy activities but also provide a rich results from PO patients with implanted stimulators, tested with and without stimulation, and compare them to results •••• This work is supported by the National Institute of Child Health and Human DevelopmentlNational Rehabilitation Research (N1CHDINCMRR) Center for Medical grant I ROI-stream of objective data to assist in patient diagnosis, custom- from PD patients without stimulators. tested on and off medi- HD045343; the VA Veterans Affairs grants B3688R andization of therapy , adaptation of the way the robot is controlled cation. The subjects perlormed point-to-point reaching move~ B3607R; and the NYSCORE. S. Levy- Tzcdek is a Howard .g 0.025during therapy [33], assurance of patient compliance withtreatment regimens. and maintenance of patient records.Robotics can also ease the transition to fully electronic medical ments with lheir wrist. We scored the movements based on their accuracy and compared the scores from the four condi- tions: stimulation on, stimulation off, on medication, and off .. ~ Hughes Medical Instirute predocloral fellow. A.c. La and J.A. Fawcett are supported by grants from the Depanment of Veterans Affairs Rehabilitation Research and Developmentrecords. Here, we will present two examples. The first example medication. ~ 0.02 Service (B4145K and B54031). S.E. Fasoli was supported bydemonsrrates how we can characterize interlimb joint coordi- Tlle results from 12 subjects diagnosed with PD are the Charles H. Hood Foundation. H. Poizner was supportednation in stroke patients. The ability to reach appropriately for reported here. Five subjects had implanted stimulators (mean !3 by the National Institutes of Health (NIH) grants 2 R56an object or 10 move objects requires proper interjoint coordi- age 74.2 ± 4.9 y) and seven subjects did nOt (mean age 69.7 ± NS036449-~AI and 7 ROI NS036449 and National Sciencenation. The second example demonstrates that even a simple 7.6 y). The subjects with stimulators were tested both on and foundation (NSF) grant SBE-0542013. H.I. Krebs andmetric (the deviation from a straight line) can detect differen- off stimulation while continuing to follow their normal medi~ N. Hogan are coinventors in the MIT-held patent for the On ON Stimulation Stimulationces between the effectiveness of surgical (implantation of deep cation regimen. The subjects with no stimulators were tested robotic device used to treat patients in this work. They hold Medication Medication On Offbrain stimulators) and medical (pharmacological) therapies in both on and off medication. The United Parkinsons Disease equity positions in Interactive Motion Technologies. thePD. Thus, such robot-based evaluations can potentially add a Raring Scale (UPDRS) was used to provide a measure of the Fig. 6. Mean values or lateral deviotion across experimental company that manufactures this type of technology undernew and additional tool to the process of deciding when to con- clinical severity of each subject at the time of testing. TIle clinical groups and conditions. Whisker bars ~epresent standard license to MIT.sider the option of surgical implantation. state of all subjects improved on the UPDRS when given their errors. A significant difference exists bei"Ween the mean at therapy, be it surgical or medical. We note that the severity of the subjects tested off stimulation and the other three group Hermano J, Krebs has been a principalRobol-Bosed Evaluation: subjects in the DBS group was similar to that of subjects in the means (P < 0.05: •• p < 0.01). research scientist and lecturer at MITsStroke and InferJoinl CoordlnaMon medication group, both on and offthcrapy (upDRS DBS-ON = Mechanical Engineering DepartmentThe evaluation games employing the shoulder-and-elbow 28.1: DBS..QFF = 38.6; Medication-ON = 27.1; Medication- one center target and eight peripheral ones [Figure 2(c»). After since 1997. He also holds affiliate posi-MIT ~MANUS included drawing circles, stars (point-to-point OFF = 36.4; total possible score = 108; higher scores reflect an initial practice set. subjects performed a set of 80 reaching tions as an adjunct research professor ofmovements). squares. diamonds, and navigating through win- more impaired performance). Subjects were presented with movements to a randomly selected peripheral target within a neuroscience at Weill Medical College ofdows [34J. Some games reqUired predominantly shoulder time window of 1.6 s and then moved back to the center posi- Cornell University and adjunct professormotion, whereas others required predominantly elbow motion. tion. We found that the subjects with stimulators turned off had of neurology at the University of Mary~Additional games required the coordination of both shoulder the highest mean deviation from the straight line connecting land School of Medicine. He is one of the founders of Inter~and elbow. For example, the axis ratio of the ellipse fined to a Chonges from FUg,7r~;e:y!tr Motor Power the center and the peripheral target (Figure 6). Vlhen stimula· active Motion Technologies. a Cambridge-based start-upsubjects attempt to draw a circle provides a metric of the abil- AdmisS~on to DIscharge AssesSment"U66) u70) tion was turned on. these subjects deviated significantly less company robot technology for rehabilita-ity of subjects to coordinate interlimb joint movement. We (P < 0.05). The performance of subjects ithout stimulators tion. He received his electrician degree in 1976 from Escolafound that SUbjects were able to draw better circles over the Umb; 6.66 13:8 Tecnica Federal de Sao Paulo, Brazil, and the B.S. and M.S. was not significantly affected by medication. Subjects withcourse of 18 sessions of the robotic therapy program. Figure 5 Umb2 9.33 15.5 degrees in naval engineering (option electrical) from the stimulators turned off deviated significantly more than subjectsshows the changes in the axis ratio for 16 subacute inpatients Here. we ore showing the results with· two of the nine without stimulators. whether on or off medication (P < 0.01). University of Sao Paulo, Brazil. in 1980 and 1987, respec~attempting to draw circles (see [35) for OlOTedetails of this tively. He received another M.S. degree in ocean engineer- subjects enrolled in this pilot.metric and results with 117 chronic stroke volunteers). This ing from Yokohama National University, Japan, in 1989, Conclusionsresult demonstrates that the In this anic1e, we presented an overview of the remarkable and the Ph.D. degree from MIT in 1997. His overarchingsensorimotor point-to-point growth in the activities in the area of therapeutic robotics and goal is to pioneer life-improving and cost~saving rehabilita~training appears to facil- of ex;periences with our devices. We presented mounting evi- tion technologies beneficial to patients, clinicians. and theitate coordination and dence that robotics can be used as a general tool to harness health care system.generalize to tasks not brain plasticity and promote recovery, and this improvement,ex;plicitly trained. at least for stroke, is on average sustainable in the long ron for ••••....... _~.;:.. Laura Dipietro received the Laurea degree both subacute and chronic cases (see (37) for subacute and [20] . (summa cum laude) in electrical engineer~Robot-Based for chronic stroke). We emphasized that the same kind of . ).. : ing (biomedical curriculum) from the Uni-EvaluaMon: technology may have a broader impact beyond stroke therapy, .j i~ versity of Florence. Florence, Italy, in 1998PO and Deep with the preliminary evidence of its value for CP, MS, and SCI .. -ie:~·-" and the Ph.D. de~e in biomedica~ roboticsBroin Stimulation .SO! 0.6 being quite promising, even though these diseases impair very r .~, from Scuola Supenore S. Anna. Pisa. Italy.Deep brain stimulation(DBS) is the most com- •• c: 0.5 different parts of the central nervous system. Nonetheless • , , in 2003. She is currently a postdoctoral associate at the Newman Laboratory. MIT.mon surgical procedure ." 0.4 ~ significant challenges face us in the nex;t five to ten years. Erst, we must determine, among the multitude of variables that may Cambridge. Her current research interests include robot.for patients with PD. influence outcome, the level of interaction or independence assisted neurorehabilitation. motor control and learning, andAlthough DBS has been between these variables and their actual impact on outcomes. biomedical signal processing.shown to have a positive Second. movement therapy in general might only do so much,effect on PO symptoms, and we need to investigate the potential impact of the combina- Shelly Levy· Tzedek is currently a Ph.D.the specific nature of its tion of different modalities of therapy (e.g .• robotics, pharma- candidate at the Newman Laboratory foreffects on motor control is cological, electrical stimulation). Only then we will be Biomechanics and Human Rehabilitationnot yet understood. We successful in the quest to optimize therapy to meet particular at MIT. She is a Howard Hughes Medicalpreviously introduced the patient needs. We must pursue this challe:lge in a truly multi· Institute predoctoral fellow. She receiveduse of a wrist robot to Fig. 5. Axis rotlos tOt odmission ond discharge for eoch subject. Subjects were sorted according disciplinary fashion armed with tools that nOt only facilitate her B.S. degree summa cum laude in bio-study the effects of stimu~ to the value of oxis rotio at admission (subject labels have been omitted for clarlty). Bigger posi· and augment therapy delivery but also augment present clinical engineering from the University of Cali~lation on motor perform- tive changes from admission to diSCharge correspond to subJecll with lower axis ratios at admis· I evaluation scales with robot-based evaluation tools. fornia in Berkeley in 2002, where she wasance and learning [36J. sian. Note that an axis ratio equal to one indicates a perfect circle .• indicates stotlsticaltyHere. we present some signitlcant change from admission to discharge (P < 0.05).
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