G.G. Fluet , A.S. Merians, Q. Qiu, S. Saleh, V. Ruano, A.R. Delmonico & S.V. Adamovich

Standardized vs. Customized Interventions

Studies examining robotically facilitated and virtually simulated rehabilitation have produced outcomes equivalent to optimized protocols of traditionally presented rehabilitation

These studies utilize standardized protocols applied to large groups.

Kwakkel 2007, Mehrholz 2008, Lo 2009, Laver 2012, Saposnik 2012

Fluet-Merians-Adamovich (Unpublished)

Standardized vs. Customized Interventions

Multiple authors cite the flexibility of robotic systems as one of their major strengths.

Adamovich 2009, Brewer 2009

HypothesisCould studies of robotic rehabilitation that utilize a highly standardized protocol be underestimating the potential effectiveness of this modality?

Customized InterventionsTask Parameter Adaptation

Parameters for successful completion of a task are modified as the intervention is performed in an attempt to maintain the highest training intensity possible

Merians 2011, Cameriao 2011 & 2012

Objectives

Present an intervention utilizing robots integrated with virtual environments designed to address the specific impairments demonstrated by an individual subject.

Discuss modifications of the intervention made based on the subjects responses to the intervention

Subject

Uses a power wheelchair for mobility but is able to walk up to 150 feet with contact guard using a cane.

Performs self care with 25-50% assistance

Performs PT / OT 2-3 hours biweekly x 4 years in his home

PM is an 85 year-old gentleman with left hemiparesis secondary to an intracerebral hemorrhage five years prior to his examination.

Case Timeline

Intervention

Three ninety minute sessions / week

4 weeks

Six simulated activities

Impairment chosen to address

Initial configuration

Modified configuration based on response

Reach TouchSynergistic extension of his trunk during shoulder flexion(Arm elevation AROM)

Stable TrunkWorkspace is increased dailySimulation recalibrated weekly

Cup ReachSynergistic extension of his trunk during shoulder flexion(coordination of trunk flexion and arm elevation)

Encouraged a forward trunk flexion, then reach strategy

Workspace is increased dailySimulation recalibrated weekly

Helped subject challenge himself during final week calibration

Virtual Piano TrainerInability to flex fingers individually

Poor response to first weekAdded CyberGrasp 100% of second week5 Minutes of CybeGrasp third weekNo CyberGrasp final week

Hammer Task Finger Extension (dynamic)Difficulty stabilizing hand while manipulating objects

Increased or decreased target size based on success or failure of preceding rep

-0.11 -0.1 -0.09 -0.08 -0.07 -0.06 -0.05 -0.04 -0.03 -0.02-0.03

-0.02

-0.01

0

-0.14

-0.12

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

-0.1 -0.08 -0.06 -0.04 -0.02 0 0.020

0.05

0.1

0.15

-0.14

-0.12

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

x

1.018 cm/sec 0.626 cm/secx

z

x

y

z

Space PongDifficulty controlling the aperture of his hand

100% Gain

30% Gain

Small response to first week of training

Scaled gain downWeaned back over balance of

intervention

Hammer Task Pronation (fixed)Difficulty performing activities requiring pronation of his hand

Poor initial responseScaled gain up

No consistent response

Clinical OutcomesImpairment Level

Clinical Outcomes Activity Level

Clinical Outcomes Activity Level

Synergistic trunk extension during arm elevation

OutcomesKinematics during untrained activity

start

object

1

2

3

target

OutcomesParticipation Level

24 Hour Activity Monitoring

DiscussionNo adverse responses

Robust improvements

Activity level

Participation level

Despite……..

chronic stroke

advanced age

multiple co- morbidities

extensive rehab history

Customized

Six activities chosen from a suite of 18

Modified

2 original configurations4 modified configurations

Discussion

Correlation between improvements in simulation performance and functional improvements Rohafza 2012

Resulting in improved performance in 5/6 simulations

ConclusionExpansion of the examination of robotically

facilitated / virtually simulated rehabilitation to include:

Customized interventions

Modified based on patient performance

Leverage a larger percentage of the advantages unique to these training modalities ………..

Thank you !!

University of Medicine and Dentistry of New Jersey

New Jersey Institute of TechnologyNJIT

NJIT-RAVR Lab

Rehab Team

CollaboratorsAlma S. Merians PT, PhDGerard G. Fluet DPT, PhD

Soha Saleh PhDQinyin Qiu PhDIan La Fond MS

Sergei Adamovich PhD

Andrea R. Delmonico OTR-LVivianna Ruano PT

Approval by the Institutional Review Boards of UMDNJ and NJIT Supported by NIH Grant RO1 HD58301