Krebs and his collegues have published results in the New England Journal of Medicine suggesting that robot-assisted therapy can improve the rehabilitation of arm function after stroke.  This research has prompted recent medical guidelines to recommend robot-assisted therapy.

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Occupational Therapist Jodi Berg assists Ted Giuttari in using the InMotion 2.0 Shoulder/Arm Robot for physical therapy at the Jerry and Dolores Turco (JDT) Center in Lincoln Park. Giuttari suffered a stroke that left the right-side of his body incapacitated.

In addition, Berg feels that it will help patients become more proactive in their recovery, so they feel like they are making an effort in the process as well.

Roughly five patients are currently taking advantage of the device.

The JDT center plans on adding an accessory that will allow for hand therapy as well as the shoulder therapy.

Feliciano said there could be a possibility of expanding the program and purchasing more devices, but wants to wait until the JDT Center is maxed out on using the first device before considering purchasing another.

Feliciano hopes that the device will show that the JDT Center is “committed to being the best in providing excellent therapy and maximum recovery,” for its patients. The JDT Center plans on holding a formal presentation of the robotic device on May 26 from 10 a.m. to 6 p.m. and has invited various health professionals and health-care doctors and representatives throughout the tri-state area.

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A Customer Case Study

“As therapists we think, ‘How do I tap into the motor control theory – getting patients to do a high number of repetitions in an engaging activity? How many times can I ask them to reach for a cone while sitting on a mat?’” said Dan Parkinson, PT, Director of Clinical Services at Braintree Rehabilitation Hospital, provider of acute inpatient and outpatient rehabilitation in Braintree, Mass. and surrounding communities.

Solution: Robotic Therapy

Always looking for the latest proven technologies in rehabilitation, Braintree Rehab purchased the InMotion shoulder-elbow robot, wrist robot and hand robot to augment its arsenal of evidence-based treatment tools. They were drawn to the InMotion therapy robots for a few reasons – one of the most significant being the ability to provide active-assisted motion for the patient. The robot can ‘back off’ proportionate to the patient’s changing ability to move independently. Because the machine helps to stabilize the affected arm, movement is more fluid and controlled. “You don’t get frustrated that your arm is all over the place,” said Rich Vartanian, a physical therapist and stroke survivor who uses the InMotion robots during his own outpatient therapy. In addition, a therapist can see how much assistance the patient needed, helping to assess improvement.

 Working with the InMotion robot requires attention, eye-hand coordination, and coordination of the affected arm, but patients are often so engrossed in the game – for example, a game of on-screen ping-pong – they end up doing a few hundred repetitions of a particular movement – a result that is challenging to elicit during traditional therapy. “I’m not saying we’ve abandoned cones and bean bags, but the InMotion robots help us get to the high number of repetitions while keeping patients motivated,” said Parkinson.

Patients with various neurological conditions, from stroke to spinal cord to brain injuries, work with the robots. Beth Lus, OT, occupational therapy clinical advisor at Braintree Rehab, has even used it with patients with flaccidity. Lus also uses it with patients who have neglect or attention issues. “There have been patients who do not attend well with other therapy, but I’ve put them on the robot and they can focus on the task for 20 minutes,” Lus said.

Patient Outcomes

Vartanian has noticed functional gains around the house — unloading the dishwasher, folding clothes, and opening bottles. And Parkinson likes to tell of a 42-year-old woman who was 21 years post-stroke. Hypertonia had severely affected her left arm, but she had learned to compensate with the other side. She had worked with the robot for some time when one night she walked into her bedroom. Her husband, walking behind her, started shouting, “You turned on the light! You turned on the light!” Subconsciously, she had turned on the light with her affected arm rather than compensating by turning her body to use the other side.

Hospital Impact

Braintree believes that their investment in InMotion and other rehab technology has made a favorable impact on the hospital.  ”It is hard to attribute any specific initiative to inpatient volume growth, however Braintree believes evidence-based technology has helped to increase admissions of neurologic patients for both inpatient and outpatient programs”, says Parkinson.  ”Technology has also helped with our therapist recruitment and retention.  Our clinical staff is excited about contributing to the development of clinical applications for rehab technology.  Braintree is proud that we can offer patients such innovative treatment.”

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Over the past few years, MIT engineers have successfully tested robotic devices to help stroke patients learn to control their arms and legs. Now, they are building on that work to help children with brain injuries and disorders such as cerebral palsy.

A young stroke patient tests out an MIT-developed robotic therapy device at Blythedale Children's Hospital in Westchester County, N.Y. photo by / Peter Lang

 ”Robotic therapy can potentially help reduce impairment and facilitate neuro-development of youngsters with cerebral palsy,” says Hermano Igo Krebs, principal research scientist in mechanical engineering and one of the project’s leaders.

Krebs and others at MIT, including professor of mechanical engineering Neville Hogan, pioneered the use of robotic therapy in the late 1980s, and since then the field has taken off.

Above: Robotics: A New Hope in Cerebral Palsy. This video shows devices developed at MIT as well as non-MIT robots.View this post on MIT TechTV.

“We started with stroke because it’s the biggest elephant in the room, and then started to build it out to other areas, including cerebral palsy as well as multiple sclerosis, Parkinson’s disease and spinal cord injury,” says Krebs.

The team’s suite of robots for shoulder-and-elbow, wrist, hand and ankle has been in clinical trials for more than 15 years with more than 400 stroke patients. The Department of Veterans Affairs has just completed a large-scale, randomized, multi-site clinical study with these devices.

All the devices are based on the same principle: that it is possible to help rebuild brain connections using robotic devices that gently guide the limb as a patient tries to make a specific movement.

When the researchers first decided to apply their work to children with cerebral palsy, Krebs was optimistic that it would succeed, because children’s developing brains are more plastic than adults’, meaning they are more able to establish new connections.

The MIT team is focusing on improving cerebral palsy patients’ ability to reach for and grasp objects. Patients handshake with the robot via a handle, which is connected to a computer monitor that displays tasks similar to those of simple video games.

In a typical task, the youngster attempts to move the robot handle toward a moving or stationary target shown on the computer monitor. If the child starts moving in the wrong direction or does not move, the robotic arm gently nudges the child’s arm in the right direction.

Krebs began working in robotic therapy as a graduate student at MIT almost 20 years ago. In his early studies, he and his colleagues found that it’s important for stroke patients to make a conscious effort during physical therapy. When signals from the brain are paired with assisted movement from the robot, it helps the brain form new connections that help it relearn to move the limb on its own.

Even though a stroke kills many neurons, “the remaining neurons can very quickly establish new synapses or reinforce dormant synapses,” says Krebs.

For this type of therapy to be effective, many repetitions are required — at least 400 in an hour-long session.

Results from three published pilot studies involving 36 children suggest that cerebral palsy patients can also benefit from robotic therapy. The studies indicate that robot-mediated therapy helped the children reduce impairment and improve the smoothness and speed of their reaching motions.

The researchers applied their work to stroke patients first because it is such a widespread problem — about 800,000 people suffer strokes in the United States every year. About 10,000 babies develop cerebral palsy in the United States each year, but there is more potential for long-term benefit for children with cerebral palsy.

“In the long run, people that have a stroke, if they are 70 or 80 years old, might stay with us for an average of 5 or 6 years after the stroke,” says Krebs. “In the case of cerebral palsy, there is a whole life.”

Most of the clinical work testing the device with cerebral palsy patients has been done at Blythedale Children’s Hospital in Westchester County, N.Y., and Spaulding Rehabilitation Hospital in Boston. Other hospitals around the country and abroad are also testing various MIT-developed robotic therapy devices.

Krebs’ team has focused first on robotic devices to help cerebral palsy patients with upper body therapy, but they have also initiated a project to design a pediatric robot for the ankle.

Among Krebs’ and Hogan’s collaborators on the cerebral palsy work are Dr. Mindy Aisen ’76, former head of the Department of Veterans Affairs Office of Research and Development and presently the director and CEO of the Cerebral Palsy International Research Foundation (CPIRF); Dr. Joelle Mast, chief medical officer, and Barbara Ladenheim, director of research, of Blythedale Children’s Hospital; and Fletcher McDowell, former CEO of the Burke Rehabilitation Hospital and a member of the CPIRF board of directors.

MIT’s work on robotic therapy devices is funded by CPIRF and the Niarchos Foundation, the Department of Veterans Affairs, the New York State NYSCORE, and the National Center for Medical Rehabilitation Research of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Get more info on InMotion Robots for Cerebral Palsy rehabilitation.

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Source: By Todd Neale, Staff Writer, MedPage Today
Published: April 16, 2010

Robot-assisted rehabilitation resulted in some improvements in motor function and quality of life for patients with chronic disability following stroke, a randomized trial showed.

Significant gains in both basic motor function (P=0.02) and the time to complete everyday tasks (P=0.005) were observed in the robot-assisted group at 36 weeks compared with usual care, the researchers reported online in the New England Journal of Medicine.

This despite the fact that on the primary endpoint — determined at 12 weeks, immediately after rehabilitation ended — motor function was not significantly improved in the robot-assisted group, according to Albert Lo, MD, PhD, of the Providence Veterans Affairs Medical Center in Rhode Island, and colleagues.

The findings “provide evidence of potential long-term benefits of rehabilitation and challenge the widely held clinical belief that gains in motor function are not possible for long-term stroke survivors,” Lo and his colleagues wrote.

In an accompanying editorial, Steven Cramer, MD, of the University of California Irvine, wrote, “Studies such as that by Lo et al reinforce the theory that the adult brain has the capacity for clinically relevant plasticity even in the chronic phase after a stroke.”

The findings were originally reported at the American Stroke Association meeting in February and were discussed at the American Academy of Neurology meeting in Toronto this week.  

“Movement does matter,” Lo told attendees at the AAN meeting.

He added that similar benefits would probably be obtainable in the lower extremities with suitable modifications to the devices.

There are no effective rehabilitation therapies for patients with long-term impairments following stroke, according to the researchers, but robot-assisted therapy might hold promise.

To evaluate its efficacy, they recruited 127 patients from four VA medical centers who had moderate-to-severe upper limb disability from a stroke suffered at least six months before randomization.

The patients (mean age 64.6; 96% male) were randomized to robot-assisted therapy (49 patients), comparable human-assisted therapy (50 patients), or usual care consisting of medical management, as-needed clinical visits, and rehabilitation services in some cases (28 patients).

The two rehab programs involved a maximum of 36 one-hour sessions over 12 weeks and were comparable in the number of arm exercises and repetitions.

Most of the patients had had an ischemic stroke (85%).

The time from stroke to randomization was longest in patients assigned to usual care (6.2 years), followed by human-assisted therapy (4.8 years) and robot-assisted therapy (3.6 years).

The primary outcome was the change from baseline to 12 weeks on the Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke, a measure of basic motor function. There were no significant between-group differences on this measure at 12 weeks.

Compared with usual care, robot-assisted therapy was superior on one of the secondary endpoints, the Stroke Impact Scale, which measures quality of life and social participation (+7.64 points, 95% CI 2.03 to 13.24).

At 36 weeks, the robot-assisted group had modest, but significantly greater, improvement on the Fugl-Meyer assessment (+2.88 points, 95% CI 0.57 to 5.18) compared with usual care.

There was also more improvement on another secondary outcome, the Wolf Motor Function Test, which assesses the time it takes to perform everyday activities (-8.1 seconds, 95% CI -13.61 to -2.60).

There were no significant differences between the robot-assisted and human-assisted groups on any outcome at any time.

Treatment-related adverse events occurred in 24% and 18% of the robot-assisted and human-assisted therapy groups, respectively, but they were mild and included pain, stiffness, soreness, and fatigue.

Per-patient cost of the rehabilitation programs was $9,977 for robot-assisted therapy and $8,269 for human-assisted therapy.

After 36 weeks, the total cost of therapy and additional healthcare use was $15,562 in the robot-assisted group, $15,605 for the human-assisted group, and $14,343 for usual care.

In his editorial, Cramer noted that it might have been difficult to observe between-group differences because of the effects of certain patient characteristics, like depression.

In addition, he wrote, “finding a treatment difference between groups also might have been hampered by recruitment of highly motivated patients in all three study groups, since patients who had had a stroke sometimes many years earlier had to agree to leave home for 36 visits to a research laboratory.”

Nonetheless, “the potential for robotic therapy after stroke remains enormous,” Cramer wrote, noting that robots never get tired, can design training regimens in reproducible ways, reduce the need for human oversight, can measure performance during therapy, and can provide simultaneous cognitive training by interfacing with computers.

Lo and his colleagues acknowledged some limitations of the study, including the mostly male population, the lack of blinding in the group assignments, and the frequent use of some form of nonstudy rehabilitation by the patients at baseline.

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The study, which examined the effectiveness of a class of robotic devices developed at MIT, found that in chronic stroke survivors, robot-assisted therapy led to modest improvements in upper-body motor function and quality of life six months after active therapy was completed; these improvements were significant when compared with a group of stroke patients who received the traditional treatment. Moreover, the robotic therapy — which involves a more intense regimen of activity than traditional stroke therapy — did not increase total health-care costs per stroke patient, and could make intensive therapy available to more people, say the researchers who led the study.

The study results also challenge the notion that physical therapy only benefits stroke patients within the first six months after the stroke, says Albert Lo, a neurologist at the Providence VA Medical Center who led the study.

“There are nearly six million stroke patients in the U.S. with chronic deficits,” says Lo. “We’ve shown that with the right therapy, they can see improvements in movement, everyday function and quality of life.”

Mind and body

The study, conducted at four Veterans Affairs (VA) hospitals, found that patients who used the MIT robotic devices for 12 weeks experienced a small but significant gain in arm function. Another group of patients who received high-intensity therapy from a therapist, which matched the number and intensity of the robot movements, showed similar improvements.

Hermano Igo Krebs, a principal research scientist in MIT’s Department of Mechanical Engineering who developed the MIT-Manus robot, has been working on robotic therapy since his graduate student years at MIT almost 20 years ago. In his early studies, he and his colleague, Professor Neville Hogan, found that it’s important for stroke patients to make a conscious effort during physical therapy.

The MIT-Manus system, which Krebs started developing more than 20 years ago, is based on that principle. The patient grasps a robotic joystick that guides the patient’s arm, wrist or hand as he or she tries to make specific movements, helping the brain form new connections that will eventually help the patient relearn to move the limb on his or her own.

In the New England Journal of Medicine study, researchers at VA hospitals in Baltimore, Seattle, West Haven, Conn., and Gainesville, Fla., compared the MIT-Manus system to a high-intensity rehab program delivered by a human therapist, which was designed specifically for this study.

Each group included about 50 patients, who were also compared with a group of 28 stroke patients who received so-called “usual care” — general health care and three hours per week of traditional physical therapy for their stroke-damaged limb.

Patients using the MIT-Manus system grasp a joystick-like handle connected to a computer monitor that displays tasks similar to those in simple video games. In a typical task, the subject attempts to move the robot handle toward a moving or stationary target shown on the computer monitor. If the person starts moving in the wrong direction or does not move, the robotic arm gently nudges his or her arm in the right direction.

“The ability to be interactive is critical,” says Krebs. “We program the robot to only give assistance as needed.”

Patients in the study received therapy three times a week for 12 weeks, and during each hour-long session, they made hundreds of repetitive motions with their arms. At the end of 12 weeks, tests revealed a small but statistically significant improvement in quality of life, and a modest improvement in arm function. When the subjects were tested again at 36 weeks, both the robot therapy group and intensive human-assisted therapy group showed improvement in arm movement and strength, everyday function and quality of life compared to the usual-care group.

The high-intensity, interactive physical therapy offered to patients who did not receive robot-assisted therapy was developed specifically for comparison purposes for this study, and is not generally available. Furthermore, the physical demands on the therapist make it unlikely that it will ever be widely used.

“If you can get a therapist to work at that pace with a patient, certainly the benefits are roughly the same, and we showed this benefit when we designed this intensive comparison group, but it’s not practical,” says Krebs. “Robotics and automation technology are ideal for this kind of highly repetitive tasks. We’re using 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.”

This particular study was designed to test the effects of only conventional therapy versus only robotic therapy, but Bruce Dobkin, a neurologist at the UCLA Stroke Center, says the best approach may end up being a combination of those two strategies. “If robotic therapy is going to be helpful, you need to find a more integrated way to use the robotic device,” he says.

The value of robots

Another way to make robotic therapy more practical could be to lower the costs, says Dobkin, who was part of the data-safety monitoring committee that supervised the research. In the VA study, the robotic therapy cost an average of $9,977 per patient, and the intensive nonrobotic therapy cost $8,269 per patient. However, overall healthcare per-patient costs, including costs for those who received only usual care, were not very different over the total 36-week study period — $15,562 per patient for robot-assisted therapy, $15,605 for intensive nonrobotic therapy, and $14,343 for usual care.

Krebs believes that once the robotic devices can be mass-produced, which he expects will occur within the next 10 years, the costs will drop. “What you have to do is make more of them, and that will drive down costs to a point where people can have them in their homes,” he says.

Krebs is also encouraged by the fact that many of the patients in the study had either suffered multiple strokes or had experienced their strokes many years earlier, yet still showed improvement. “We put the bar very high,” he says. “If we worked with patients sooner after their first stroke, we may get even better results.” He is now working with doctors to plan such a study.

Krebs and his collaborators are also studying whether the MIT-Manus could help patients with cerebral palsy, multiple sclerosis and spinal cord injury.

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Heather’s left side has been paralyzed since she was an infant. About 18 months ago, she qualified for an experimental program at Blythedale Children’s Hospital in Valhalla using MIT-created robots to move her left arm in a circle hundreds of times to see if it would help return movement to her left side.

The results have been outstanding, said Donna Matthews of Tappan, Heather’s mother. Two days before her First Communion in May, Heather raised her left arm as high as her ear – the first time she had done so since she was 17 months old.

“I think she’s really come a long way in the last two years,” said Eleanor Lacovetta,who has been Heather’s occupational therapist for three years and was helping her with the cut-and-paste project yesterday at her Rockland Board of Cooperative Educational Services summer school class.

“Her fine motor skills have really improved.  Now, when she’s engaged in a cutting activity, she’s stabilizing the paper with her left hand and bringing it to the cutting edge and helping guide the paper to the scissors. She was never able to do that before,” Iacovetta said.

Donna Matthews said her younger daughter was a normally developing infant who walked, ran and talked right on schedule. She especially enjoyed getting up early to wave goodbye to her older sister as the then 10-year-old Amber went off to school. And then one Monday, she wasn’t making noise and demanding that her mom get her out of her crib.

“At 17 months … I put Heather to bed and she was healthy – no sickness, no cold, nothing, and she didn’t wake up in the morning,” Donna Matthews said. She watched her elder daughter leave, thinking her baby was just sleeping late after a long weekend of activity.

“I went into her room and … she’s on her back with her eyes sunk into the back of her head almost lifeless,” Donna Matthews said. “I phoned 911.”

Doctors eventually diagnosed Heather’s condition as viral encephalitis – brain swelling caused by a virus. She spent the next five weeks in the hospital with her mother at her side through seizures, tests and medications. Her left side remained paralyzed, her vision was impaired and, when she came home, she was developmentally a newborn, her mother said.

Donna Matthews, an operations manager for Marshall’s in East Rutherford, N.J., said she decided against putting Heather in a residential therapy program, opting for learning physical therapy procedures so she could work with her at home. For the next few years, she worked with Heather in the mornings and spent the afternoons at hospitals doing outpatient therapy.

When Heather was old enough, she was enrolled in a BOCES class for developmentally disabled children, where she met Beth Doremus, who has been her teacher since kindergarten at a class at Pearl River’s Franklin Avenue School.

“When she first started with me, her left hand was always clutched into a fist, there was no movement of anything on the left side,” Doremus said. Even Heather’s pictures were drawn entirely on the right side of the paper as if the left didn’t exist, she said.

Her therapy was making some inroads into left-side movement when Iacovetta learned that Blythedale was looking for children for its research project into robotics use on repetitive actions. She sent a note home in Heather’s backpack alerting Donna Matthews, and Heather qualified to participate.

Dr. Joelle Mast, chief medical officer at Blythedale and principal investigator for the study, said she had always been fascinated by how children recover from injuries. The pediatric neurologist took 20 years of research into using robot-guided repetitive motions to help adults recover from strokes and other brain injuries and looked to extend that research to children ages 5 to 18.

“It’s not to replace (human) therapy,” Mast said. “It’s to raise your functional ability to give the therapist so much more to work with.” Robots can be programmed to repeat a motion perfectly, she said.

Mast’s first project started about 18 months ago; Heather was one of more than a dozen children being helped by robots to increase different types of movement. The results have been very encouraging, Mast said.

About two weeks ago, Heather was tagged to work with robots again, this time on wrist movement. She commutes to Blythedale twice a week for a session.

Donna Matthews said she expects big things from the process. Heather’s self-confidence has improved, and she’s been using her left arm and side with more ease and control.

“At this point, I’m a firm believer that therapy is going to help her to regain everything she lost,” she said.

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