inmotion robot-assisted therapy

inmotion robot-assisted therapy Evidence-Based Neurorehabilitation INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery

INMOTION Copyright 2013 Interactive Motion Technologies. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except as may be expressly permitted by the applicable copyright statutes or in writing by the Publisher. No license, express or implied, to any intellectual property is granted by this document. Release 2.0 Date June 2013 2

Evidence-based neurorehabilitation technology COntents Clinical Guidelines... 4 Clinical Partners... 6 InMotion Robotic Therapy... 7 Suitability of InMotion Robotic Therapy... 8 The Evolution of Upper Extremity Neurorehabilitation... 9 Case Study: Braintree Rehabilitation Hospital... 10 Published Research Using InMotion Robots... 11 Lower Extremities...13 Economic Analysis VA Robotics... 21 InMotion Robotic Therapy Protocols... 22 InMotion Eval Robotic Evaluation... 24 Case Study...26 Clinical Application... 27 InMotion WRIST...27 2D vs 3D Therapy...28 InMotion ANKLE Interactive Therapy System... 29 InMotion ARM Interactive Therapy System... 30 InMotion WRIST Interactive Therapy System... 32 New Hope For Neurologically Impaired Children... 34 3

INMOTION Clinical GUidelines upper extremity robot-assisted therapy The Use of Robotics for NeuroRehabilitation AHA Stroke Care Guidelines Recommend Robot Assisted Therapy for Care in the Inpatient, Outpatient Setting and Chronic Care Settings American Heart Association Scientific Statement Published in Stroke Miller et al. (2010); 41:2402-2448 Care in the Inpatient Setting h h Robot-Assisted UPPER EXTREMITY therapy, however, can improve motor function 174 175 176 during the inpatient period after stroke FIM score improvement 30% greater than control group Class IIa Level of Evidence A Improvement from robot therapy was maintained on a 3 year follow up evaluation The InMotion ARM Robot Drives Functional Gains in the Inpatient Setting Care in the Outpatient Setting Class I Level of Evidence A h h Robot-assisted therapy has been shown to improve UPPER EXTREMITY motor function in outpatient and chronic care settings 143 The Inmotion ARM Robot Drives Functional Gains in the Outpatient Setting Care in the Chronic Care Setting Size of Treatment Effect Class I Level of Evidence A INMOTION Estimate of Certainty (Precision) of treatment effect 4

Evidence-based neurorehabilitation technology Clinical Guidelines The Use of Robotics for NeuroRehabilitation VA/DOD Clinical Practice Guidelines 2010 for The Management of Stroke Rehabilitation Upper Extremity Department of Veterans Affairs and Department of Defense Recommendation: Robot-assisted movement therapy as an adjunct to conventional therapy in patients with deficits in arm function to improve motor skill at the joints trained. The Cochrane Collaboration The Cochrane Collaboration provides an international benchmark for the independent assessment and assimilation of scientific evidence World Health Organization Objective: Assess the effectiveness of robot-assisted arm training to improve ADL s, arm function, arm muscle strength Studies analyzed: 19 randomized controlled clinical trials Results: Patients who receive electromechanical and robot-assisted arm training after stroke are more likely to improve generic ADL s and paretic arm function (From page 4) 174. Robot training enhanced motor outcome in patients with stroke maintained over 3 years. Neurology. Volpe BT, Krebs HI, Hogan N, Edelsteinn L, Diels CM, Aisen ML. 1999;53:1874 1876. 175. Does shorter rehabilitation limit potential recovery poststroke? Neurorehabilitation Neural Repair. Fasoli SE, Krebs HI, Ferraro M, Hogan N, Volpe BT. 2004;18:88 94. 176. The effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke. Arch Neurology Aisen ML, Krebs HI, Hogan N, McDowell F, Volpe BT.1997;54:443. 143 Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. Neurorehabil Neural Repair Volpe BT, Lynch D, Rykman-Berland A, Ferraro M, Galgano M, Hogan N, Krebs HI. Neurorehabil Neural Repair. 2008;22:305 310. INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 5

INMOTION CLinical Partners A partial list of some of our clinical partners: Frazier Rehabilitation Institute Louisville, Kentucky Baptist Medical System Memphis, Tennessee Texas State University San Marcos, Texa Rancho Los Amigos Los Angeles, California VA Healthcare System Baltimore, Maryland Feinstein Institute North Shore Long Island Health System New York, New York Cleveland Clinic Cleveland, Ohio Braintree Rehabilitation Hospital Braintree, Massachusetts Riley Children s Hospital Indianapolis, Indiana Burke Rehabilitation Center White Plains, New York VA Healthcare System Providence, Rhode Island New York Presbyterian Hospital New York, New York Blythedale Children s Hospital Valhalla, New York Turco Medical Rehabilitation Center Lincoln Park, New Jersey Miami Baptist Hospital Miami, Florida Kernan Hospital University of Maryland Baltimore, Maryland Sister Kenny Institute Minneapolis, Minnesota Cardinal Hill Hospital Louisville, Kentucky Rehab Institute of Michigan Detroit, Michigan Clinque Les Trois Soleis France Queen Elizabeth Hospital Hong Kong Rede de Reabilitação Lucy Montoro Hospital Brazil Australian NeuroRehabilitation Institute Australia McGill University Canada Fondazione Salvatore Maugeri Italy Guttman Institute Spain Cardinal Santos Medical Center Philippines St Mauritius Therapy Clinic Germany Chonbuk National University Hospital South Korea Chungnam National University Hospital South Korea MyungJi Choon Hye Hospital South Korea East London University UK Northumbria Healthcare NHS Trust with Newcastle University UK University of Rome Sapienza Italy Bambino Gesu Hospital Italy Schön Klinik Hospital- Bad Aibling Germany Bad Aibling Hospital Germany Oulu Hospital Finland Chang Gung University Taiwan 6

Evidence-based neurorehabilitation technology InMotion Robotic Therapy Conventional Focuses on compensation Uses labor intensive manual methods, one therapist per patient InMotion Interactive robotic therapy Focuses on reducing impairment translating motor skill to improve function One therapist may treat multiple patients Treatment protocols not reproducible, vary in duration, intensity and frequency Low intensity average 13 movements (inpatient ) 45 movements (outpatient) Assumes gains in motor function not possible for long term stroke survivors Little demonstrated benefit over natural recovery Substantial residual motor impairment approx. 65-75% of stroke survivors. Reduced quality of life and loss of functional independence Assumes brain cannot recover from neurologic injury Patients have a difficult time adhering to therapy Time consuming traditional evaluation, difficult to distinguish true recovery from compensation Conventional care cost (expensive) Evidence based treatment protocols reproducible, quantifiable, high intensity task specific therapy (over 1000 movements per typical session) The positive results of InMotion Interactive Robotic Therapy have been shown to be: 1. Effective at reducing impairment and improving function [i] 2. Long lasting [ii] 3. Can occur even when started years after the persons initial injury [iii] 4. Cost effective [iv] Injured brain can recover through plasticity based remapping of pathways Inmotion is a truly interactive robotic rehabilitation system harnessing good plasticity to augment recovery Motivates patients for active participation Provides objective feedback during therapy InMotion Eval quantifies upper extremity motor control and movement recovery allowing clinicians to distinguish true recovery from compensation. Correlated [v] with traditional evaluation measures Better outcomes at lower cost i Extensive bibliography, for more information please contact IMT or visit our website to view the clinical research with InMotion robots i Robot Training Enhanced Motor Outcome in Patients with stroke maintained over 3 years, Neurology, 53(1999) 1874-6 iii Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after stroke The New England Journal of Medicine May 13, 2010. iv An Economic Analysis of Robot-Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke. Stroke 2011, 42:2630-2632. v Kinematic Robot-Based Evaluation Scales and Clinical Counterparts to Measure Upper Limb Motor Performance in Patients With Chronic Stroke Neurorehabilitation and Neural Repair 24(1) 62-69, 2010 INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 7

INMOTION Suitability of InMotion Robotic Therapy InMotion Robots are suitable for a broad range of patients, even those with very limited movement. It is the ideal clinical tool for the episode of care across setings. INMOTION InMotion Robotic Therapy Constraint Induced Movement Therapy Virtual Reality EMG Triggered Neuromuscular Stimulation Moderate 0 66 40 FUGL MEYER Impairment range Cerebral Palsy Stroke Traumatic Brain Injury 8

Evidence-based neurorehabilitation technology The epicenter of interactive robotics in neurorehabilitation Interactive Motion Technologies (IMT) is the global pioneer and leader in providing effective robotic tools for neurorehabilitation professionals. Developed at the Newman Laboratory for Biomechanics and Human Rehabilitation at the Massachusetts Institute of Technology (MIT), InMotion Robots are the most thoroughly researched technology available in the rehabilitation industry. InMotion robotic therapy augments each patient s remarkable capability to learn, reacquire and improve motor skills using the brain s own inherent neuroplasticity. InMotion robots patented {i] Assist as Needed technology and evidence-based treatment protocols ensures patients are continously engaged and able to perform over 1000 movements per interactive therapy session. By applying the latest research in neuroscience, neurorehabilitation and biomedical engineering, IMT is redefining recovery for neurorehabilitation professionals, patients and their families. Our mission is to improve function and quality of life to the broadest possible range of neurologic patients. Between 1994 and 1998 the MIT-Manus was tested with over 250 Stroke Patients InMotion Robots become available for clinical use MIT-MANUS project initiated Clinical Guidelines 1989 1994 MIT-MANUS Clinical debut Burke Rehabilitation Hospital where it has been in daily operation since 1994. 1998 2010 From 1998-2010, InMotion Robots were tested with over 800 stroke patients in the worlds leading medical research institutions 2012 National Health Service UK InMotion Robots were selected by the National Health Service (NHS) and its National Institute for Health and Clinical Excellence (NICE) to examine the efficacy and effectiveness of robotic therapy in the UK medical system According to NHS this is the Largest ever stroke rehabilitation study in the British Healthcare System backdriveable robotic hardware impedance control assist-as-needed modular rehabilitation system 3 CORE DESIGN PRINCIPLES Today the American Heart Association, American Stroke Association and the Department of Veterans Affairs all include robot-assisted therapy in their stroke rehabilitation guidelines for moderate to severe patients with upper extremity disability. [i] US Pat 5,466,213 Interactive Robotic Therapist 9

INMOTION inmotion robots Dan Parkinson PT, MBA Director of Rehabilitation, Braintree Rehabilitation Hospital, Braintree, MA 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. INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 10

Evidence-based neurorehabilitation technology Published research using inmotion robots Interactive Motion Technologies InMotion Robots have been used in all the publications listed below and are the most thouroughly researched technology available for neurorehabilitation. Stroke Significant Impairment Reduction and Improvement in Function In a multi-center, randomized controlled trial involving 127 chronic stroke patients with moderate to severe upper-limb impairment, InMotion assist-as-needed therapy demonstrated significant improvement in arm movement, function and quality of life. (Lo. A.C., et.al Robot-Assisted Therapy for Long-Term Upper Limb Impairment after Stroke, New England Journal of Medicine, 362:1772, May 13, 2010) In a controlled clinical study involving 56 stroke inpatients, the motor skills of the robot-treated group improved significantly more than the control group. Analysis showed that interactive robotic therapy significantly reduced motor impairment of the treated limbs, doubling the impairment reduction. 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, Neurologist Principal Investigator Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke The New England Journal of Medicine May 13, 2010 (Volpe, B.T., Krebs, H.I., Hogan, N., Edelstein, O.L., Diels, C and Aisen, M., A Novel Approach to Stroke Rehabilitation Robot-Assisted Sensorimotor Stimulation, Neurology, 54 (2000) 1938-44) Clinical research designed to measure the intensity of therapy needed to augment neuroplasticity shows at least 400 repetitions are required. InMotion Robots are designed to deliver over 1000 repetitions in a typical therapy session. 11

INMOTION Published research using inmotion robots Stroke Long Lasting Improvements Patients from an early clinical study were recalled up to three years later, and those patients who received interactive robotic therapy sustained their improvement over those who did not. Moreover, subsequent follow-up studies re-examining these patients also confirmed the findings. (Volpe, B.T., Krebs, H.I., Hogan, N., Edelstein, L., Diels, C.M. and Aisen, M.L. Robot Training Enhanced Motor Outcome in Patients with Stroke Maintained over 3 years, Neurology, 53 (1999) 1874-6) (Volpe, B.T., Krebs, H.I., Hogan, N.; Is Robot-Aided Sensorimotor Training in Stroke Rehabilitation a Realistic Opinion? Current Opinion in Neurology, Lippincott Williams &Wilkins, 14:745-752, 2001) Thanks to the InMotion Arm Robot, I am now able to use my left arm to hold my granddaughter on my lap to read to her. I m more balanced and have greater endurance when I walk. After the first robotic session, I was able to lift my left foot up to my buttock. David Karchem, stroke patient and volunteer, Rancho Los Amigos Rehabilitation Hospital Improvement can Occur Even Several Years Post Onset of Injury A multi-center VA study of 127 patients with longterm severe to moderate upper-limb impairment from a stroke that occurred at least 6 months before enrollment (average time of 4.7 years, 33% with multiple strokes) found that the improvements 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, A.C., et al, Robot-Assisted Therapy for Long- Term Upper-Limb Impairment after Stroke, New England Journal of Medicine, 362 1772, 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 potential for further recovery which conventional therapy has been unable to tap into. (Fasoli, S.D., Krebs, H.I., Stein, J., Frontera, W.R. and Hogan, N., Effects of Robotic Therapy on Motor Impartment and Recovery in Chronic Stroke, Archives of Physical Medicine and Rehabilitation; 84(2003)477-82) (Fasoli, S. D., Krebs, H.I., Stein, J., Frontera, W.R. and Hogan, N., Robotic Therapy for Chronic Motor Impairments are Stroke: Follow-up Results, Achieves of Physical Medicine and Rehabilitation; 85 1106-111, 2004) (Ferraro, M., Palazzolo, J. J. Krol, J. Krebs, H. I., Hogan, N., Volpe, B. T., Robot Aided Sensorimotor Arm Training Improves Outcome in Patients with Chronic Stroke, Neurology, 61: 1604-1607,2003.) 12

Evidence-based neurorehabilitation technology Published research using inmotion robots Lower-Extremities At its current state, robotic rehabilitation for lower extremity is still in its infancy, Dobkin, B.H. and Duncan, P.W., Should Body-Weight Supported Treadmill Training and Robotic-Assistive Steppers for Locomotor Training Trot Back to the Starting Gate, Neurorehabilitation and Neural Repair, 26 (308-317) May 2012. IMT in close collaboration with the Newman laboratory for biomechanics and human rehabilitation at MIT has developed the ANKLEBOT. The technology uses patented Assit-as-Needed technology and the initial results are quite encouraging. Lee Hyunglae, Ho Patrick Multivariable Static Ankle Mechanical Impedance with Relaxed Muscles, Journal of biomechanics (44) 2011 Roy, A, et al., Measurement of passive ankle stiffness in subjects with chronic hemiparesis using a novel ankle robot, Journal Neurophysiology 105:2132-2149, (2011) Forrester, LW, et al, Ankle Training With a Robotic Device Improves Hemiparetic Gait After a Stroke, Neurorehabilitation and Neural Repair, Vol 25, No 4, May (2011) Roy, A., et al., Robot-Aided Neurorehabilitation: A Robot for Ankle Rehabilitation, IEEE Transaction Robotics 25:3:569-582 (2009) CEREBRAL PALSY Improvement in Coordination and Function 12 children aged 5-12 with Cerebral Palsy and upper-limb hemiplegia received robotic therapy twice a week for 8 weeks. The children showed significant improvement in total Quality of Upper Extremity Skills Test (QUEST) and Fugl-Meyer Assessment Scores. A questionnaire administered to the children s parents also showed significant improvement in how the children used the paretic arm during functional tasks at home. (Fasoli, S. E., Fragala-Pinkham, M., Hughes, R., Hogan, N., Krebs, H.I., Stein, J., Upper Limb Robotic Therapy for Children with Hemiplegia, American Journal of Rehabilitation, 87:11:929-936 (2008) A childs brain is much more plastic than an adults brain, so if adults can make gains perhaps children with CP can make even larger gains. In our initial studies we saw gains that were completely unexpected! Chief medical officer Dr. Joelle Mast Blythedale Children s hospital Please see Dr: Joelle Mast in this video: http://video.mit.edu/watch/robotics-a-new-hope-in-cerebral-palsy-3789/ 13

INMOTION Published research using inmotion robots CEREBRAL PALSY Robotics Helps Tappan Girl Move Again By Randi Weiner To her mother, her special-education teacher and her therapists, watching 8-year-old Heather Matthew use both hands to cut out magazine pictures and glue them onto paper is like watching a miracle unfold. 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 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 Education 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 this before, Lacovetta said. Dan Fink President and CEO, Riley s Children s Hospital INDIANA http://www.youtube.com/watch?v=yi7hcmqkddw Frascarelli, F, et al., The impact of robotic rehabilitation in children with acquired or congenital movement disorders, European Journal of Physical Rehabilitation Medicine, (2009) 45: 135-41 Fasoli, S.E., et al., Robotic therapy and botulinum toxin type A: A novel intervention approach for cerebral palsy, American Journal of Rehabilitation, 87:8:1-4 (2008) Krebs, HI, et al., Robot-assisted task-specific training in cerebral palsy, Developmental Medicine and Child Neurology, 51 (Suppl. 4) Mast, J., et al., Robot Assisted Therapy in Pediatrics: A Pilot Study. Developmental Medicine and Child Neurology Supplement, September (2009) Krebs, H.I., et al., Robot-Assisted Task Specific Training, Development Medicine & Children Neurology. October, 51(4): 140-145. Fasoli, S.E., et al., Upper Limb Robotic Therapy for Children with Hemiplegia, American Journal of Rehabilitation, 87:11 9292-936 (2008) 14

Evidence-based neurorehabilitation technology Published research using inmotion robots Published research using inmotion robots Stroke Electromechanical and Robot-Assisted ARM training for improving general activities of daily leaving, arm function, and arm muscle strength after stroke. The cochrane Collaboration, The Cochrane Library, 2012 issue 6 Norouzi-Gheidari, N, et al., Effects of Robot-Assisted Therapy on Stroke Rehabilitation in Upper Limbs: Systematic Review and Meta-Analysis of the Literature, VA Journal of Rehabilitation Research and Development, 49 (4) 479-496 (2012) Dipietro L, Krebs H.I, Volpe B.T, Stein J, Bever, S.TMernoff, Fasoli S.E, Hogan N Learning, not Adaptation, Characterizes Stroke Motor Recovery: Evidence from Kinematic Changes Induced by Robot-Assisted Therapy in Trained and Untrained Task in the Same Workspace IEEE Trans Neural Syst Rehabil Eng. 2012 Jan;20(1):48-57. Epub 2011 Dec 16 Conroy SS, Whitall J, Dipietro L, Jones-Lush LM, Zhan M, Finley MA, Wittenberg GF, Krebs HI, Bever CT. Effect of gravity on robot-assisted motor training after chronic stroke: a randomized trial. Arch Phys Med Rehabil. 2011 Nov;92(11):1754-61. Epub 2011 Aug 17. Conroy, SS, et al., Effect of Gravity on Robot-Assisted Motor Training After Chronic Stroke: A Randomized Trial, Archives Physical Medicine Rehabilitation Vol 92, November (2011) Wagner, T, et al., An Economic Analysis of Robot-Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke, Stroke, Journal of the American Heart Association, Vol. 42 No. 9 September (2011) Dept. of Veterans Affairs and Dept. of Defense, Management of Stroke Rehabilitation Working Group. VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation, Guideline Summary. Washington, D.C.: Government Printing Office, October (2010) Vers. 2.0, p. 37 URL: http://www.healthquality.va.gov. Lo, A.C., et al., Robot Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke, New England Journal of Medicine, 362(19):1772-83. Miller, E.L., et al., on behalf of the American Heart Association Council on Cardiovascular Nursing and the Stroke Council, Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient: A Scientific Statement From the American Heart Association, Stroke, 41:2402-2448, (2010) Edwards, D.J., et al., Raised Corticomotor Excitability of M1 Forearm Area Following Anodal tdcs is Sustained During Robotic Wrist Therapy in Chronic Stroke, Restorative Neurology Neuroscience, 27:199-2007 (2009) Dipietro, L., et al., Submovement Changes Characterize Generalization of Motor Recovery after Stroke, Motor Cortex 45(3):318-24 (2009) Krebs, HI, et al., Transport of the Arm and Manipulation of Objects in Chronic Stroke: A Pilot Study, NeuroRehabilitation, 23:81-87 (2008). Hesse, S., et al., A mechanical arm trainer for the treatment of the severely affected arm after stroke: A single-blinded randomized trial, American Journal of Rehabilitation, 87:10:779-788 (2008) Krebs, H.I., et al., Transport of the Arm and Manipulation of Objects in Chronic Stroke: A Pilot Study, NeuroRehabilitation, 23:81-87 (2008) 15

INMOTION Published research using inmotion robots Stroke (cont.) Kwakkel, G., et al., Effects of Robot-assisted therapy on upper limb recovery after stroke: A Systematic Review, Neurorehabilitation and Neural Repair 22:2:111-121 (2008) Volpe, B.T., et al., Intensive Sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke, Neurorehabilitation and Neural Repair 22:3:305-310 (2008) Krebs, H.I., et al., Robotic Rehabilitation in Sub-Acute Stroke: A Comparison of Robotic Therapy in Multiple Sites Medimond (2007) Dipietro, L., et al., Changing motor synergies in chronic stroke, Journal of Neurology, 98:757-768 (2007) Masis, L., et al., Design and Characterization of Hand Module for Whole-Arm Rehabilitation Following Stroke, IEEE/ASME Transactions on Mechatronics, 12(4) 399-407 (2007) Palazzolo, J.J., et al., Stochastic Estimation of Arm Mechanical Impedance during Robotic Stroke Rehabilitation, IEEE Transaction Neural System and Rehabilitation Engineering; 15(1) 94-103 (2007) MacClellan, L.R., et al., Robotic Upper Extremity Neuro-Rehabilitation in Chronic Stroke Patients, VA Journal of Rehabilitation Research and Development 42(6)717-722 (2005) Daly, J., et al., Response to Upper Limb Robotics and Functional Neuromuscular Stimulation Following Stroke, VA Journal of Rehabilitation Research and Development, 42(6)723-735 (2005) Finley, M.A., et al., Short Duration Upper Extremity Robotic Therapy in Stroke patients with Severe Upper Extremity Motor Impairment, VA Journal of Rehabilitation Research and Development, 42(5):683-692 (2005) Dipietro, L., et al., Customized Interactive Robotic Treatment for Stroke: EMG-Triggered Therapy, IEEE Transaction Neural System and Rehabilitation Engineering, 13:3:325-334 (2005) Rohrer, B., et al., Submovements Grow Larger, Fewer, and More Blended during Stroke Recovery, Motor Control, 8:472-483 (2004) Stein, J., et al., Comparison of Two Techniques of Robot-Aided Upper Limb Exercise Training after Stroke, American Journal Physical Medicine Rehabilitation, 83:9:720-728 (2004) Volpe, B.T., et al., Robotics and Other Devices in the Treatment of Patients Recovering from Stroke, Cur Artheroscler Rep, 6:314-319 (2004) Krebs, H.I., et al., Notes on Rehabilitation Robotics and Stroke, In F. Lofaso, A. Roby-Brami, J.F. Ravaud (Eds). Technological Innovations and Handicap, Frison Roche, pp.177-194 (2004) Fasoli, S.D., et al., Does Shorter-Rehabilitation Limit Potential Recovery Poststroke? Neurorehabilitation & Neural Repair. 18 2:88-94 (2004) Fasoli, S.D., et al., Robotic Therapy for Chronic Motor Impairments after Stroke: Follow-up Results, Archives of Physical Medicine Rehabilitation: 85:1106-1111 (2004) Ferraro, M., et al., Robot Aided Sensorimotor Arm Training Improves Outcome in Patients with Chronic Stroke, Neurology. 61:1604-1607 (2003) Hogan, N., et al., Technology for Recovery after Stroke, In J. Bogousslavsky, M.P. Barnes, B. Dobkin (eds.), Recovery after Stroke, Cambridge Press (2003) 16

Evidence-based neurorehabilitation technology Published research using inmotion robots Stroke (cont.) Fasoli, S.D., et al., Effects of Robotic Therapy on Motor Impairment and Recovery in Chronic Stroke, Archives of Physical Medicine and Rehab, 84:477-82 (2003) Rohrer, B., et al., Movement Smoothness Changes during Stroke Recovery, Journal of Neuroscience, 22:18:8297-8304 (2002) Krebs, H.I., et al., Robot-Aided Neuro-Rehabilitation in Stroke: Interim Results on the Follow-up of 76 Patients and on Movement Performance Indices, In Mounir Mokhatari (ed), Integration of Assistive Technology in the Information Age. IOS Press, Assistive Technology Research Series, Amsterdam (2000) Volpe, B.T., et al., Robot Training Enhanced Motor Outcome in Patients with Stroke maintained over 3 years, Neurology 534874-1876 (1999) Aisen, M.L., et al., The Effect of Robot Assisted Therapy and Rehabilitation Training on Motor Recovery Following a Stroke, Archive of Neurology, 54:443-336 (1997) Upper-extremity Finley, M.A., et al., The Effect of Repeated Measurements using an Upper Extremity Robot on Healthy Adults, Journal of Biomechanics 25:2:103-110 (2009) Lonini, L., et al., An Internal Model for Acquisition and Retention of Motor Learning during Arm Reaching, Neural Computation 21:7:2009-2007 (2009) Krebs, H.I., et al., A Paradigm Shift for Rehabilitation Robotics, IEEE-EMBS Magazine 27:4:61-70 (2008) Krebs, H.I., et al., Robot-Aided Neurorehabilitation: A Robot for Wrist Rehabilitation, IEEE Transaction Neural Systems and Rehabilitation Engineering, 15(3) 327-335 (2007) Krebs, H.I., et al., Therapeutic Robotics: A Technology Push, Proceedings of IEEEI, Special Issue on Medical Robotics, 94(9) 1727-1738 (2006) Hogan, N., et al., Motions or Muscles? Some Behavioral Factors Underlying Robotic Assistance of Motor Recovery, VA Journal of Rehabilitation Research and Development, 43(5) 605-618 (2006) Krebs, H.I., Those Magnificent Men and Their Flying Machines, Guest Editorial. VA Journal of Rehabilitation Research and Development, 43(5) IX-XI (2006). Krebs, H.I., et al., Robotic Rehabilitation Therapy, Wiley Encyclopedia Biomedical Engineering, John Wiley & Sons, Inc (2006) Fasoli, S.E., et al., Functionally-Based Rehabilitation Robotics: A Next Step? International Journal of Assistive Robotics and Mechatronics, John Wiley & Sons, Inc (2006) Krebs, H.I., et al., Rehabilitation Robotics, Orthotics, and Prosthetics Chapter 48, In M.E. Selzer, S. Clarke, L.G. Cohen, P.W. Ducan, F.H. Gage (Eds), Textbook of Neural Repair and Rehabilitation, Cambridge University Press (2006) Stein, J., et al., Clinical Applications of Robots in Rehabilitation, Critical Reviews in Physical and Rehabilitation Medicine, 17 (3) 217-230 (2005) Krebs, H.I., et al., Rehabilitation Robotics: Pilot Trial of a Spatial Extension for MIT-MANUS, Journal of NeruoEngineering and Rehabilitation, Biomedcentral, 1:5 (2004) Hogan, N., et al., Interactive Robots for Neuro-Rehabilitation, In Platz (Ed). Special issue on Motor System Plasticity, Recovery and Rehabilitation, Restorative Neurology & Neuroscience (2004) 17

INMOTION Published research using inmotion robots Upper-extremity (cont.) Krebs, H.I., et al., A Wrist Extension to MIT-MANUS, In Z. Bien and D. Stefanov (Eds.), Advances in Human-Friendly Robotic Technologies for Movement Assistance / Movement Restoration for People with Disabilities. Springer-Verlag (2004) Henriques, D., et al., Bias and sensitivity in the haptic perception of geometry, Exp Brain Res (2003) 150:95-108 Krebs, H.I., et al., Rehabilitation Robotics: Performance-based Progressive Robot-Assisted Therapy, Autonomous Robots, Kluwer Academics 15:7-20 (2003) Krebs, H.I., et al., Robotic Applications in Neuromotor Rehabilitation, Robotica. 21:3-11 (2003) Malfait, N., et al., Transfer of Motor Learning Across Arm Configurations, Journal of Neuroscience, 22(22): 9656-9660, November 15, (2002) Hogan, N., Skeletal Muscle Impedance in the Control of Motor Actions, Journal of Mechanics in Medicine and Biology 2(3&4) 359-373 (2002) Krebs, H.I., et al., Robot-Aided Neuro-Rehabilitation: From Evidence-Based to Science-Based Rehabilitation, Topics in Stroke Rehabilitation. 8:454-70 (2002) Krebs, H.I., et al., Increasing Productivity and Quality of Care Robot-Aided Neurorehabilitation, VA Journal of Rehabilitation Research and Development, 37:6:639-652, (2000) Krebs, H.I., et al., Robotic Applications in Neuromotor Rehabilitation. Robot Aided Sensorymotor Stimulation, Neurology, 54:1938-1944, (2000) Hogan, N., et al., Arm Movement Control is both Continuous and Discrete, Cognitive Studies. Bulletin of the Japanese Cognitive Science Society, 6:3.254-273 Krebs, H.I., et al., Quantization of Continuous and Arm Movements in Humans with Brain Injury, Proceedings of National Academy Of Sciences of the United States of America 96:4645-4649, (1999) Krebs, H.I., et al., Robot-Aided Neuro-Rehabilitation, IEEE-Transactions on Rehabilitation Engineering, 6:1:75-87; (1998) Krebs, H.I., et al., Robot-Aided Functional Imaging: Application to a Motor Learning Study Human Brain Mapping; John Wiley & Sons, 6:59-72 (1998) Lower-Extremities Roy, A., et al., Robot-Aided Neurorehabilitation: A Robot for Ankle Rehabilitation, IEEE Transaction Robotics 25:3:569-582 (2009) Forrester, LW, et al, Ankle Training With a Robotic Device Improves Hemiparetic Gait After a Stroke, Neurorehabilitation and Neural Repair, Vol 25, No 4, May (2011) Anindo, R, et al., Measurement of passive ankle stiffness in subjects with chronic hemiparesis using a novel ankle robot, Journal Neurophysiology 105:2132-2149, (2011) 18

Evidence-based neurorehabilitation technology Published research using inmotion robots Cerebral Palsy Frascarelli, F, et al., The impact of robotic rehabilitation in children with acquired or congenital movement disorders, European Journal of Physical Rehabilitation Medicine, (2009) 45: 135-41 Fasoli, S.E., et al., Robotic therapy and botulinum toxin type A: A novel intervention approach for cerebral palsy, American Journal of Rehabilitation, 87:8:1-4 (2008) Krebs, HI, et al., Robot-assisted task-specific training in cerebral palsy, Developmental Medicine and Child Neurology, 51 (Suppl. 4) Children Mast, J., et al., Robot Assisted Therapy in Pediatrics: A Pilot Study. Developmental Medicine and Child Neurology Supplement, September (2009) Krebs, H.I., et al., Robot-Assisted Task Specific Training, Development Medicine & Children Neurology. October, 51(4): 140-145. Fasoli, S.E., et al., Upper Limb Robotic Therapy for Children with Hemiplegia, American Journal of Rehabilitation, 87:11 9292-936 (2008) SPINAL CORD INJURY Improvement in Strength and Function A pilot study of two patients with incomplete spinal injuries, level C4-6, that had occurred greater than two years ago, was conducted at Burke Rehabilitation Hospital. Patients received treatment on the InMotion ARM 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. Krebs, H.I., Dipietro, L., Levy-Tzedek, S., Fasoli, S., Rykman, A., Zipse, J., Fawcett, J., Stein, J., Poizner, H., Lo, A., Volpe, B.T., Hogan, N., A Paradigm Shift for Rehabilitation Robots, IEEE-EMBS Magazine, 27:4:61-70 (2008) Multiple Sclerosis (MS) A pilot study of two MS patients at the West Haven VA Medical Center has shown that 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 carry over improvement in gait function when measured through six-minute walk tests. (Krebs, H.I., Dipietro, L., Levy-Tzedek, S., Fasoli, S., Rykman, A., Zipse, J., Fawcett, J., Poizner, H., Lo, A., Volpe, B.T., Hogan, N., A Paradigm Shift for Rehabilitation Robots, IEEE-EMBS Magazine, 27:4:61-70 (2008) Parkinsons Krebs, H.I., et al., Procedural Motor Learning in Parkinson s Disease, Experimental Brain Research. 141:425-437 (2001) Levy-Tzedeck, et al., Parkinson s Disease: A Motor Control Study Using a Wrist Robot, Advance Robotics, 21(10) 1201-1213 (2007) 19

INMOTION Published research using inmotion robots Book Chapters Dietz, Volker; Nef, Tobias; Rymer, William Zev (Eds.)2012, Neurorehabilitation Technology Chapter 8 Forging Mens et Manus: The MIT Experience in Upper Extremity Robotic Therapy Stein, J., et al., Technological Aids for Motor Recovery, Chapter 19 in Stroke Recovery and Rehabilitation, Demos Press 2008 Krebs, H.I., Hogan, N., Robotic Rehabilitation Therapy, Editor, Metin Akay, Wyley Encyclopedia of Biomedical Engineering, 2006 Krebs, H.I., et al., Rehabilitation Robotics, Orthotics, and Prosthetics: In Selzer, M.E., Clarke, S., Cohen, L.G., Duncan, P.W., Gage, F.H., (eds), Textbook of Neural Repair and Rehabilitation, Chapter 48, Cambridge University Press, 2006 Krebs, H.I., et al., Notes on Rehabilitation Robotics and Stroke, In: F. Lofaso, A., Roby-Brami, J.F., Ravaud (eds), Technological Innovations and Handicap, Frison Roche, 177-194, 2004 Hogan, N., Krebs, H.I., Interactive Robots for Neuro-Rehabilitation, In: Platz (ed), Special Issue on Motor System Plasticity, Recovery, and Rehabilitation, Restorative Neurology and Neuroscience, 2004 Krebs, H.I., et al., A Wrist Extension to MIT-Manus, In: Z. Bien and D. Stefanov (eds), Advances in Human-friendly Robotic Technologies for Movement Assistance / Movement Restoration for People with Disabilities, Springer-Verlag, 2004 Hogan, N., et al., Technology for Recovery after Stroke, In: Bogousslavsky, J., Barnes, M.P., Dobkin, B., (eds), Recovery after Stroke, Chapter 30, Cambridge University Press, 2003 Volpe, B.T., et al., Robot aided sensori-motor training in stroke rehabilitation, In: Barnett, H.J.M., Bogousslavsky, J., Meldrum H. (Eds), Advances in Neurology. Ischemic Stroke Lippincott, Williams & Wilkins 2003 Hogan, N., and Breedveld, P.C. The Physical Basis of Analogies in Physical System Models, In: Bishop, R.H., (ed). The Mechatronics Handbook, CRC Press, Chapter 15 Krebs, H.I., et al., Robot-Aided Neuro-Rehabilitation in Stroke: Interim Results on the Follow-up of 76 Patients and on Movement Performance Indices, In: Mounir Mokhtari (ed), Integration of Assistive Technology in the Information Age, IOS Press, Assistive Technology Research Series, Amsterdam, 2001 Reinkensmeyer, D.J., et al., Rehabilitators, Robots and Guides: New Tools for Neurological Rehabilitation, In: Winters, J.M., Crago, P.E. (eds) Biomechanics and Neural Control of Movement, Springer-Verlag, 2000 20

Evidence-based neurorehabilitation technology ECOnOMIC analysis VA Robotics Advances in robotics and an increased understanding of the latent neurologic potential for stroke recovery led to our initiation of this multicenter, randomized, controlled trial, called the Veterans Affairs (VA) Robotic-Assisted Upper-Limb Neurorehabilitation in Stroke Patients study, to determine whether a rehabilitation protocol using the MIT Manus robotic system (Interactive Motion Technologies), as compared with a program based on conventional rehabilitative techniques or usual care, could improve functioning and quality of life of stroke survivors with long-term upper-limb deficits. Cost of Robotic Intervention Personnel Time Capital cost of robot system (3 modules) Financing costs Annual maintenance contract 5 year-life span for robotic system Facility overhead Average per patient additional cost of therapy Robot Therapy $5,152 ICT $7,382 Usual Care $0 As published in: Stroke Journal of the american Heart Association American Stroke AssociationSM A Division of American Heart Assocciation Total cost over 36 weeks Therapy + all other healthcare utilization Robot $17,831 (other healthcare $12,679) ICT $19,746 (other healthcare $12,364) Usual Care $19,098 (other healthcare $19,098) Conclusion: The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group Important results for ACO/ bundled payment models proposed under healthcare reform An Economic Analysis of Robot-Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke Todd H. Wagner, Albert C. Lo, Peter Peduzzi, Dawn M. Bravata, Grant D. Huang, Hermano I. Krebs, Robert J. Ringer, Daniel G Federman, Lorie G. Richards, Jodie K. Haselkorn, George F. Wittenberg, Bruce T. Volpe, Christopher T Bever, Pamela W. Duncan, Andrew Siroka and Peter D. Guarino Stroke published online July 14, 2011 Stroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 @2011 American Heart Association. All rights reserved. Print ISSN:0039-2499. Online INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 21

INMOTION InMotion Robotic Therapy Protocols Evidence-based Therapy protocols Consistent with principles of motor learning Simple clinical integration Easy to use Click and go protocols Intuitive user interface Ensures over 1000 repetitions are completed in a therapy session In session performance feedback Inpatient setting 5x/week, 1 hour per day in adjunct to Conventional Physical Therapy and Occupational Therapy Maximizes functional recovery* CLinical Outcomes From a Randomized Controlled Clinical Trial Group FIM Motor FIM Cognition Motor Power COntrol 19.5 5.5 1.7 InMotion Robot 25 6 4.1 A 31 point change in FIM score for the robot treated group After 3 Years: Patients Continued to Improve * Robot training enhanced motor outcome in patients with stroke maintained over 3 years. Neurology. Volpe BT, Krebs HI, Hogan N, Edelsteinn L, Diels CM, Aisen ML. 1999;53:1874 1876 22

Evidence-based neurorehabilitation technology InMotion Robotic Therapy Protocols OUTpatient setting 3x/week, 1 hour per day At least 18 sessions Measured Clinical Outcomes VA-Robotics RCT Impairment Fugl Meyer Function Wolf Motor Function Quality of Life Stroke Impact Scale InMotion Robotic Therapy Superior to Conventional Therapy in ALL Clinical Outcomes. 23

INMOTION Inmotion eval Worlds first Intelligent evaluation system Quantifies upper extremity motor control and movement recovery Establishes a baseline and measures progress to Determine medical necessity Justify continuation of treatment based upon measurable gains Measures effectiveness of treatment intervention (robotic and other) Five evaluation tests Takes about 20 minutes Robot generates 4 evaluation reports Uses technology to objectively measure motor control more consistently, reliably and efficiently then a human-administered clinical scales. First step towards a unified, automated measure of the outcomes Robot records kinematic and kinetic elements of upper extremity movement. (Position, Direction, Distance, Area, Time, Force) Robot calculates 13 evidence-based measures of motor control that are highly correlated with Fugl-Meyer, Motor Power and NIH Stroke Scale performance. Performance translates to function. five EVALUATION TESTS EFFICIENT 1. Circle tests Set of 4 trials, total 20 circles 2. Point-to-Point 80 Movements towards a target 3. Playback Static stabilization, isometric hold 4. Round Dynamic Movement against resistance, isotonic 5. InMotion Maximum Force (optional feature) The InMotion robot calculates 13 new measures of motor control and movement recovery Circle Tests InMotion Circle Size measures the size of the circle which indicates the patient s range of motor coordination. To perform a functional extremity task: dressing, bathing, feeding etc. A patient must plan, sequence, and time movements over a broad range or area. InMotion Joint Independence measures the patient s ability to freely coordinate their arm purposefully in all directions. Joint independence is required for functional tasks: placing an arm in a sleeve, grooming hair, giving a hug, etc. Playback Static InMotion Stabilization measures a patient s ability to employ shoulder and elbow muscles to stabilize position when external force is applied. Upper extremity weight bearing requires the shoulder and elbow muscles to co-contract to maintain a position. Shoulder and elbow stabilization is essential for resting on an elbow, pushing up from a chair, opening a door, automatic reactions such as protective extension, etc. 24

Evidence-based neurorehabilitation technology Inmotion eval Worlds first Intelligent evaluation system The InMotion robot calculates 13 new measures of motor control and movement recovery Point to Point InMotion Path Error measures the patient s ability to move accurately along a straight path towards a goal/target/object. Safe, functional reaching requires a person to move their arm directly and efficiently towards an object avoiding other objects along the path. Simple tasks such as reaching for a book and knocking over a glass or reaching for a spoon and bumping into a hot pan would create a safety risk and threaten a person s ability to live independently. Controlling the movement path is critical to function and safety. InMotion Peak Velocity measures the patient s ability to achieve a maximum velocity. There is safety and efficiency in the ability to move quickly when needed. Moving with greater speed demonstrates the greater ability; however, speed without accuracy and efficiency is not desirable. InMotion Mean Velocity measures the patient s ability to move at a functional speed to complete the task in a reasonable period of time. InMotion Reach Error measures the patient s ability to precisely reach towards the center of a target. An analogy is the archer hitting a bull s eye. Putting on glasses, placing a hat on a head and picking up a grape all require motor control accuracy. InMotion Smoothness measures the patient s ability to control changes in acceleration (increases and decreases of speed). Poorly coordinated changes in acceleration result in jerky movements and affects timing. Smooth motor control is required to lift or carry a full cup or eat soup with a spoon. ROund Dynamic InMotion Displacement measures the ability to move the arm through or against resistance. Reaching while wearing a heavy coat, pushing a baby carriage, opening a door requires a person to function in the presence of resistance. InMotion Maximum Force (optional feature) InMotion Maximum Force Measures maximum strength a patient can exert in shoulder flexion, extension, adduction and abduction. The four shoulder tests: shoulder flexion/extension and shoulder adduction/abduction measure the patient s ability to generate a maximum force. Applying forces with shoulder muscle groups is essential for functional independence. Examples include using a hammer, opening a can, push up from a chair, stabilizing balance with a cane, giving a hug, cutting food, etc. INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 25

INMOTION Evidence-Based Neurorehabilitation Technology According to the American Heart Association, the Department of Veterans Affairs and the latest Cochrane Report, upper extremity robot-assisted therapy can make a modest but significant clinical impact in the functional outcomes (FIM ) of stroke patients in the inpatient and outpatient settings. Drawing circles with the InMotion Robot is part of the clinical evaluation protocols included in the InMotion Eval software. The following are circles drawn by a chronic stroke patient. On the Left is the admission plot and on the right is the discharge plot following 6 weeks of InMotion Therapy. (The robot does not provide assistance during evaluation) admission plot discharge plot What improvements in functional abilities do patients or therapists report? Examples of new abilities using affected affected arm following robot assist-as-needed therapy: Put on a shirt or jacket Hold a shopping bag Push open a door 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 The goal of reaching towards a target is part of the clinical evaluation protocols included in InMotion Eval. The following reaching movements were performed by a chronic stroke patient. On the Left is the admission plot and on the right is the discharge plot following 6 weeks of InMotion Therapy. (The robot does not provide assistance during evaluation) admission plot discharge plot By applying the latest research in neuroscience, neurorehabilitation and biomedical engineering, IMT is Redefining Recovery for neurorehabilitation professionals, patients and their families. Our mission is to improve function and quality of life to the broadest possible range of neurologic patients. 26

Evidence-based neurorehabilitation technology Clinical Application Case: INMOTION Wrist Robotic wrist therapy Chronic stroke patient before therapy patient can t extend the left wrist Does NOT qualify for Constraint-Induced Movement Therapy After wrist therapy with the InMotion WRIST patient can now reach all targets Qualifies for Constraint-Induced Movement Therapy Robotic wrist therapy severely impaired patient CIMT mildly impaired patient 27

INMOTION 2D Gravity compensated therapy is more effective than 3D Spatial therapy Better outcomes with gravity compensated planar InMotion ARM robot. Conroy, SS, et al., Effect of Gravity on Robot-Assisted Motor Training After Chronic Stroke: A RandomizedTrial, Archives Physical Medicine Rehabilitation Vol 92, November (2011) 2D Planar Therapy Spatial 3D Therapy IMT s modular, gym-of-robots systems approach to neurorehabilitation is the only system designed to optimize the use of robotics for neurorehabilitation in a manner that is consistent with the latest clinical research and neuroscience, taking into account the latest understandings on motor learning interference and motor memory consolidation. For instance, training planar and vertical (anti-gravity) movements in alternate days leads to significant functional improvements 1. By measuring patient kinematic and kinetic data objectively, IMT s robots have shown that for severe to moderate brain injury the effectiveness of therapy is optimized by allowing the robots to focus on reducing impairment and allowing the therapist to assist on translating the gains in impairment into function. (1) Krebs, H.I., et al., Rehabilitation Robotics: Pilot Trial of a Spatial Extension for MIT-MANUS, Journal of NeruoEngineering and Rehabilitation, Biomedcentral, 1:5 (2004) Klein Julius, Spencer Steven J,Reinkensmeyer David J. Breaking It Down Is Better: Haptic Decomposition of Complex Movements Aids in Robot-Assisted Motor Learning ieee Transactions On Neural Systems And Rehabilitation Engineering, VOL. 20, NO. 3, MAY 2012 Krakauer John W, Carmichael Thomas S, Corbett Dale, Wittenberg George F, Getting neurorehabilitation right: What Can Be Learned From Animal Models? Neurorehabilitation and Neural Repair, published online March 30 2012 L. Dipietro, H.I. Krebs, B.T. Volpe, J. Stein, C. Bever, S.T. Mernoff, S.E. Fasoli, and N. Hogan Learning, not Adaptation, Characterizes Stroke Motor Recovery: Evidence from Kinematic Changes Induced by Robot-Assisted Therapy in Trained and Untrained Task in the Same Workspace. IEEE transactions on neural systems and rehabilitation engineering 2012 Jan:20(1):48-57 INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 28

Evidence-based neurorehabilitation technology INMOTION ANKLE INTERACTIVE THERAPY SYSTem Examples of trajectory changes on 10 repetitions of a standard unassisted plantar flexion and dorsiflexion ankle targeting tasks before and after 6 weeks of performance based training with the InMotion ANKLE Robot. Note the improved consistency of responses, increased velocity (steeper slope) and smoother trajectories. Ankle Training With a Robotic Device Improves Hemiparetic Gait After a Stroke, Larry W. Forrester, Anindo Roy, Hermano Igo Krebs and Richard F. Macko, Neurorehabil Neural Repair published online 29 November 2010 Partial list of Research Partners: Bambino Gesu, San Marinella, Italy Veterans Administration Hospital, Baltimore, MD (USA) Veterans Administration Hospital, Providence, RI (USA) Franciscan-Mount Sinai, Hartford, CT (USA) North Shore Jewish Long Island, NY (USA) University Sao Paulo, Sao Carlos,Brazil More Detail: The InMotion ANKLE can deliver a continuous net torque of ~23 Nm in dorsi-plantarflexion and 15 Nm in eversion-inversion. The robot can estimate ankle angles with an error less than 1 in both planes of movement (maximum 1.5 ) over a wide range of movement (60 in dorsi-plantarflexion and 40 in eversion-inversion) and can measure ankle torques with an error less than 1 N m. It has low friction (0.744 N m) and inertia (0.8 kg per actuator for a total of 1.6 kg at the foot) to maximize the backdriveability. Although the device adds some weight to the leg, a previous study has shown that unilaterally loading the impaired leg with the additional mass of the In- Motion ANKLE had no detrimental effect on the gait pattern in subjects with chronic hemiparesis (Khanna et al. 2010). USA MADE INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 29

INMOTION INMOTION Arm INTERACTIVE THERAPY SYSTem INMOTION HAND Inmotion ARM The InMotion ARM Robot is evidence based, intelligent interactive technology that is capable of continuously adapting to and challenging each patient s ability. This allows the clinician to efficiently deliver optimum intensive sensorimotor therapy to neurologic patients. Robotic arm with two active degrees of freedom Elbow flexion/extension Shoulder protraction/retraction Shoulder internal/external rotation Shoulder flexion/extension Shoulder abduction/adduction The most thoroughly researched device for upper extremity neurorehabilitation 800+ patients Large multi-site randomized controlled clinical trials Easy to use technology allows for high repetition 400-1000 reps/session Task specific to reduce impairments in the affected limb(s) focusing on improving patient s: Range of Motion Coordination Strength Movement Speed Movement Smoothness Easy-to-use, grab and go set up Direct wheel chair access Print patient progress reports directly from the robot Broad clinical application shown to improve functional outcomes across the continuum of care. 1 The InMotion HAND Robot senses patient forces and assists the patient as needed, continuously adapting to each patients abilities allowing the clinician to deliver optimum intensive sensorimotor grasp and release hand therapy. The InMotion HAND is an add-on optional module that attaches to the InMotion ARM Robot. Clinical research has shown improved patient outcomes Stroke Cerebral Palsy Traumatic Brain Injury Today the American Heart Association, American Stroke Association and the Department of Veterans Affairs include robot-assisted therapy in their stroke rehabilitation guidelines for moderate to severe patients with upper extremity disability. 30

Evidence-based neurorehabilitation technology INMOTION Arm INTERACTIVE THERAPY SYSTem InMotion ARM software Intensive 1024 movements per therapy session Evidence-based treatment protocols. Therapy protocols allowing clinicians to customize treatment. Therapeutic exercise Games for: Motor planning Eye-hand coordination Attention, visual field deficits/neglect Massed practice Performance feedback metrics InMotion eval Quantifies upper extremity motor control and movement recovery allowing clinicians to distinguish true recovery from compensation Establishes a baseline and measures progress to: Determine medical necessity Justify continuation of treatment based upon measurable gains Quantifiable measures for: Shoulder stabilization Smoothness of Arm movement Arms ability to move against resistance Mean and Maximum arm speed Arm Reaching error Joint independence Correlated with traditional assessment scales: Fugl-meyer, Motor-Power and NIH stroke scale performance* MAXIMUM SHOULDER FORCE Optional InMotion Eval module. Allows clinicians to measure a patient s ability to generate maximum shoulder flexion/extension, adduction/abduction force. Custom Designed Technology 6 degree-of-freedom force-torque sensor monolithic aluminum device containing analog and digital electronics systems. Module attaches to the InMotion ARM Robot. Sample Circle Plots for a stroke patient at admission and discharge following six weeks of InMotion robotic therapy admission plot discharge plot InMotion ARM Dimensions Workstation: 51 (1.4m)(W) x 76 (2.0m)(D) x 45 (1.2m)(H) at lowest position Chair: 27.5 (.7m)(W) x 24 (.61m)(D) Weight 598 lbs. (271kg) Electrical Requirements 100 240VAC, 50/60Hz, automatic <1250VA. To see how Interactive Motion Technologies is redefining recovery visit www.interactive-motion.com or call 617.926.4800 * Bosecker Caittlyn MS, Dipietro Laura, Volpe BT, Krebs HI Kinematic Robot-Based Evaluation Scales and Clinical Counterparts to Measure Upper Limb Motor Performance in Patients With Chronic Stroke Neurorehabilitation and Neural Repair 24(1) 62-69, 2010. 1 Robot training enhanced motor outcome in patients with stroke maintained over 3 years. Neurology. Volpe BT, Krebs HI, Hogan N, Edelsteinn L, Diels CM, Aisen ML. 1999;53:1874 1876. 175. Does shorter rehabilitation limit potential recovery poststroke? Neurorehabilitation Neural Repair. Fasoli SE, Krebs HI, Ferraro M, Hogan N, Volpe BT. 2004;18:88 94. 176. The effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke. Arch Neurology Aisen ML, Krebs HI, Hogan N, McDowell F, Volpe BT.1997;54:443 Neurorehabil Neural Repair Volpe BT, Lynch D, Rykman-Berland A, Ferraro M, Galgano M, Hogan N, Krebs HI. Neurorehabil Neural Repair. 2008;22:305 310. USA MADE INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 31

INMOTION INMOTION Wrist INTERACTIVE THERAPY SYSTem Clinical research has shown improved patient outcomes Stroke Cerebral Palsy Traumatic Brain Injury Evidence-based Neurorehabilitation technology Enhancing Neurorecovery The InMotion WRIST is capable of lifting even a severely impaired neurologic patient s hand against gravity, overcoming most forms of hypertonicity. The InMotion WRIST accommodates the range of motion of a normal wrist in everyday tasks. Flexion/Extension 60º/60º Abduction/Adduction 30º/45º Pronation/Supination 70º/70º Clinicians may use the InMotion WRIST as a stand-alone treatment option, or it may be used in addition to the InMotion ARM to offer progressive modular robotic neurorehabilitation. It may also be used to carry patients to qualify for CIMT. Independent clinical trials have shown progressive, modular robotic neurorehabilitation to be more effective at reducing impairment and improving function 1 even in severely impaired chronic patients. 32 Today the American Heart Association, American Stroke Association and the Department of Veterans Affairs include robot-assisted therapy in their stroke rehabilitation guidelines for moderate to severe patients with upper extremity disability. INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery

Evidence-based neurorehabilitation technology INMOTION Wrist INTERACTIVE THERAPY SYSTem Overview of a typical InMotion WRIST robotic therapy session: 1. Therapist selects appropriate treatment protocol 2. Robot prompts patient to initiate movement 3. Patient initiates or attempts movement 4. Robot senses patient movement and provides continuous adaptive real-time assist-as-needed support ensuring movement is completed successfully. 5. Robot provides performance feedback to both patient and therapist 6. Therapist determines next treatment protocol System Components InMotion WRIST hardware Robotic wrist with 3 active degrees-of-freedom Universal design for fast and easy patient setup Adjustable-height robot and workstation Adults and small-body people may use the same device InMotion WRIST software Intensive 1024 movements per therapy session Evidence-based treatment protocols. 25 different therapy protocols allowing clinicians to customize treatment for adults and children Therapeutic exercise Games for: Motor planning Eye-hand coordination Attention, visual field deficits/neglect Massed practice Performance feedback metrics To see how Interactive Motion Technologies is redefining recovery visit www.interactive-motion.com or call 617.926.4800 USA MADE * Bosecker Caittlyn MS, Dipietro Laura, Volpe BT, Krebs HI Kinematic Robot-Based Evaluation Scales and Clinical Counterparts to Measure Upper Limb Motor Performance in Patients With Chronic Stroke Neurorehabilitation and Neural Repair 24(1) 62-69, 2010. 1 Extensive bibliography, for more information please contact IMT or visit our website. 2 Robot Training Enhanced Motor Outcome in Patients with stroke maintained over 3 years, Neurology, 53(1999) 1874-6. 3 Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after stroke The New England Journal of Medicine May 13, 2010. 4 An Economic Analysis of Robot-Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke. Stroke 2011, 42:2630-2632. INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 33

INMOTION New hope for neurologically impaired children Cerebral Palsy Clinical research studies with Interactive Motion Technologies (IMT) advanced robotic systems are helping children with cerebral palsy and other neurological diseases reduce impairment and improve function. 1 Child on InMotion ARM robot The new robotics therapy program is retraining children s brain and nervous pathways so they can live a more normal physical life then ever before. Just 10 or 20 years ago they were non-existent now they are in place, here now at Rileys childrens hospital Dan Fink President and CEO, Riley s Children s Hospital A childs brain is much more plastic than an adults brain, so if adults can make gains perhaps children with CP can make even larger gains. In our initial studies we saw gains that were completely unexpected! I think there is tremendous hope for cerebral palsy Dr. Joelle Mast Chief Medical Officer, Blythedale Children s Hospital To learn how you can start redefining recovery at your facility, visit www.interactive-motion.com or call 617.926.4800. 1 Frascarelli, F, et al., The impact of robotic rehabilitation in children with acquired or congenital movement disorders, European Journal of Physical Rehabilitation Medicine, (2009) 45: 135-41 Fasoli, S.E., et al., Robotic therapy and botulinum toxin type A: A novel intervention approach for cerebral palsy, American Journal of Rehabilitation, 87:8:1-4 (2008) Krebs, HI, et al., Robot-assisted task-specific training in cerebral palsy, Developmental Medicine and Child Neurology, 51 (Suppl. 4) Mast, J., et al., Robot Assisted Therapy in Pediatrics: A Pilot Study. Developmental Medicine and Child Neurology Supplement, Sept (2009) Krebs, H.I., et al., Robot-Assisted Task Specific Training, Development Medicine & Children Neurology. October, 51(4): 140-145. Fasoli, S.E., et al., Upper Limb Robotic Therapy for Children with Hemiplegia, American Journal of Rehabilitation, 87:11,929-936(2008) INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 34

Evidence-based neurorehabilitation technology NOTES 35

INTERACTIVE MOTION TECHNOLOGIES Redefining Recovery 80 Coolidge Hill Road Watertown, MA 02472 P 617.926.4800 F 617.926.4808 info@interactive-motion.com www.interactive-motion.com