W elico !!!ling•..th ~ if0b 0.tin~r..~j§t

® April 20th, 2010 by David E. Williams of the Health business blog

_A~S ~tte.n, th~ Nev: Engler-adJournal ofl'v(edici~e article (BoDoc-Assisted Theroov [or Long-TerrrtjUDDer-Lzmb In:Dazrmen! a[c~r Sr;roke) ~larms qUIte modest results for robot therapy. Between the_lIles, though, he p_owe~l hints of the rmpendmg robot revolution. (The article is free and Icncourage you to read It.) . .

Research~rs recruited Veterans Ac1.w~stratio'U (VA) patients who"d suffered strokes an average of 5years ec:rber. Volunteers were rando~ed to 12 weeks ofrobQt-assisted therapy, intensivecompanson therapy, or usual ?are (medical management a.nd. some rehabilitation services available to

...-...----- .._--------_.-'1- .._._-...- ..--.------.-.-- --.__ ...._- .-- '-'--'-'--_._---all patients). The primary outcome was change in motor function at 12 weeks as measured by theFugl-Meyer score. Patients were also evaluated after Q, 24 ap,d 36 weeks.

Results showed that robot-assisted therapy did not significantly improve motor function at 12 weekscouJ.Pared to usual care or intensive therapy, although there was significant improvement on theSrroke Impact Scale (SIS). At 36 weeks robot-assisted therapy and intensive therapy performed abo'",,::(he sa..me, and both were superior to usual care.

So what's the big deal? Actually a few tbings:

• Intensive therapy -whether performed by a robot or a human- demonstrated its superiority tousual care. The intensive therapy delivered by therapists ii"l tbis trial was so intensive: >1000movements in a session compared to 45 fOTtypical stroke treatment -that it's really onlyavailable under controlled conditions with a researcher standing over the therapist with astopwatch. If you want this Yind of intensive' therapy for ycurself you'd better hire someonewith a whip (or bring John Hen.;::yback from the dead' and '~ake the haIT'~merout oft>js har'.d).

. A close read of Table 2 (Changes in Pri..mary and Second§rv Otltcomes at 12 Weeks) st!"o~glysuggests better results for the robots thdn the authors are willing to clalm explicitly. The le5:side of the table measures robot-assisted therapy vS.usual care. The right columns rneaS'.lre:obot-assisted therapy vs. intensive comparison therapy. The performance of the robot grQU':=' i.smuch better on the right side ofthe table than the left. If we compare the robot numbers or'. (heright wi.th the usual care numbers on the le£\ the comparisQns look much better for the robots,including a 5 point improvement on the Fugl-Meyer score (wbich is extremely impressive fo:someone 5 years after a stroke). .

So why is the table set out this way? It appears that patients were only enrolled LT"J. usual care fo~(he first 16 months of recruitment, whereas the recruitment lJeriod for robot-assisted andmtensive therapy con,tinued for 24 months. I don't understand why the usual care :ec!'l.litrneD.twas stopped -perhaps the study was on a tight budget? In any case it's likely that the therapisl'3operating the robots followed a lea..ruing curv,~ du...ringthe srudy and were better able r.oopeTatethe robots in the second part of the study thaJ:l.the first, wbich is the portion of the studyanalyzed on the left side of the table. The authors state that the robot manufacturer (lnteracti'./eMotion Tech...nolo2:ies) had "no role in the st?dy," which could mean the therapists had to ng1...creout the robot Tor themselves and would not ne.ve been as good at first.

The fact that tms information is presented inf.'1e same table appears to be a tacitacknowledgment that the researchers also be,lieve in the Gomparison I am suggesting .

. Labor savings were large. One-hoUl' sessions required only. 15 ITJ..inutesof contact wiLh t.1-}emeranist for the robot versus 60 minutes TOT,theintensive comnanson theTanv. Th?_1 h?l."

~e.spite ~e ~$lO.K cost ofus'ingtJ.le robot. That means the robot group patients used only one-~~ of th~.medlcal resou:r:ces ofllie/usual care group ($5K versus $15K) while makingslgmfica.r:Lrmprovements m heal¢ status. Thilt'S 'incredibly g00d news and must have been abIg surpnse to the researchers. '.

An a?companying editorial (BrClin :Be12c:ir c:fr.er Stroke) acknowledt;es the acc-omplishments of thisstudy and emphaslzes the broader lill.pl1catlOns. . . %'

In the :Oigge~picture, the potentialf6r robotic therapy after suoke remains enormous.RobotJ.c deVlces can provide therapy in different functional modes, a po'int that was not

-ex~~db,YL~ et ai Rob~ts work~'~-~onsistent"and p-;':eciser;'~nnerand over-iOng- _P

periods vvithout fatigue. They can modulate timing, content, and intensity of trainillg inreproducible ways, vvith a reduced need for human oversight. Robotic devices can alsomeasure the performance of patients during therapy. In addition, robot-based therapy caninterface with computers in brain-stimulation treatment or to provide simultaneouscognitive training. .

You C311 also check out a video of the robot in action.-,.--.-

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"Robot-Assisted Therapy for Long-Term Upper-LimbImpairment after Stroke"

Albert La, M.D., et al.The New England Journal of Medicine, May 13, 2010

FREQUENTLYASKEDQUESTIONS

Why is this research so important?"We've shown that with the right therapy, [stroke patients] can see improvementsin movement, everyday function and quality of life - this is giving stroke survivorsnew hope." Dr. Albert Lo, Principal Investigator. The implications for stroke recoveryand study design were so powerful that this was the first article ever published in theprestigious NEJM on the topic of rehabilitation.

Why were InMotion Robots selected for the study?The unique assist-as-needed exercise delivered by InMotion robots is the optimal way to

drive recovery through neuro-plastic remapping of sensory-motor pathways. InMotibninteractive robotics actively engage neurologically injured patients in repetitive tasks that

reinforce normal movement pattems and improve everyday function, even years postinjury.

Is InMotion interactive robot-assisted therapy an established practice?Yes, many leading rehabilitation hospitals and VA hospitals are using InMotion Robotsevery day to improve arm function following stroke, brain injury and other neurological

diagnoses. The NEJM article, the 1A level of evidence cited in Stroke*, and over 15years of prior research gives a large evidence base for the treatment effectiveness.

*"ComprehensiveOverview of Nursingand InterdisciplinaryRehabilitationCare of the Stro~ePatient:A ScientificStatementfrom the American heart Association, Miller, et.al, Stroke

2010;412402-2448

What improvements in functional abilities do patients or therapists report?Some examples of new abilities using the affected arm following robot-assisted therapy:

Put on a shirt or jacket Hold a shopping bagPush a door open Pick up a laundry basket

Turn on a light switch Do household choresPick up a cup of coffee Put a leash on a dog

What treatment methods were compared? Patients were randomly assigned to threestudy groups: 1) usual VA care 2) intensive InMotion robot-assisted therapy and 3)

(robot) intensity- matched treatment delivered by a therapist. Patients in both the robot-assisted and the intensity-matched treatment group received 1024 exercise repetitions

per session, a level of intensity that is only practical with robot assistance.

Clinical ResearcJh With InMotion Robots

IMT tec'inology has undergone more than a decade of clinical ir1V8SllgatlonsInvolving more than 600 patients.

There is compelling evidence from clinical evaluations involving IMT technologythat interactive robotic therapy significantly enhances motor recovery

in a multi-center, randomized, controlled trial involving 127 ~·.troke patients with mod,::;r2H0:to severe upper-limb impairment, InMotion robot-assisted therapy patients demonstratedsignificant improvement in arm movement, function and qUcllity of lite.

(LO. A.C . etal "Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke". New Eng'iinrj )outnC! 01.Al1edicine, ~,621772, May 13, 2010.)

In a clinical study involving 56 stroke inpatients, the motor skills of the robot-treatedgroup improved significantly more than the control group. An analysis of impairmentmeasures showed that (1) interactive robotic therapy significantly reduced molO"Impairment of the treated limbs, and (2) added to con\/entional therapy Imeii.:lClive

iobotic therapy provided about double the impairment reduction.

Volpe 8 T.. Krebs, H I. Hogan, N ::delstein. O.L, Diels, C and Aisen, M . A novel apDroach '0 Slroy.""rC'h2'J1:'I;~!:O"

;obot-aldec! sensorimotor stimulation, Neurology, 54 (2000) 1938-44 )

Patients from an early clinical s\udy were rec2lled up to three years later, and It wasfound that patients who rece;ved robotic therapy sustained their improvement over thosewho did not. Moreover, sub.;equent follow-up studies re-examining these patients alsoconfirmed the finding.

(Jolpe, B.T , Krebs, H.\., Hogan, N., Edelsteinn, L., Oiels, C.M. and Alsen, M.L., Robot lralnln<;: enhanced motor OU,((""1(

:n pal,p.nlS With stroke maintained over 3 years, Neurology, 53 (1999) 1874-6)

(vOIP~. 8 T . Krebs. H I., Hogan, N., "Is robot-aided sensorimotor training In stroke rcl,al)lllallon a reah::,.,c c,ro:,c,:-. ~

Currant OpJl1l'In JI1 Neurology, Lippincott Williams & Wilkins, 14:745- 752,2001)

A multi-center VA study of 127 patients with long-term upper-limb Irnpairment from astroke 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 potentiallong-term bc;nefits of rehabilitation and challenge the widely held clinical belief that gainsIn motor fur,ction are not possible for long term stroke survivors."

(Lo. p, C . eta!, 'Robot-Assisted Therapy for !.ong-Term Upper-Limb ImpC:lIrmenl after Stroke", New England .i0u,-;-:':; ,:

r';'ee},c,ne. 362 1772, May 13, 2010)

Patients who had suffered a single unilateral stroke one to five years earlier, and whowere demonstrated to be in a "stable phase," showed significant improvement afterreceiving robotic therapy three times a week for six weeks.

These findings also suggest that such patients have a potential for further recoverywhich conventional therapy has been unable to tap into.

\Fasoil, S.D., Krebs, H.l., Stein, J., Frontera, WR. and Hogan, N., Effects of Robotic Thcrap: \,n MCIlO:

impau-menl and Recovery in Chronic Stroke, Archives of Physical MediCine and K'e;w!JilI/a{IOI1 , S.:i(~('il:".; -- .•.•• ~J

0- )

(['as,);" S L, Kicbs, H i., Stein, J., Fronlera, Vv'.R, Hughes. R., and Hogan, N., "RobotiC Therapy (or ChroniC tv!Oi",impalrmen<s after Stroke. Follow-Up Results, " Archives 0/ Physical MediCine and Rehabtl,IalIQI1. 85 1106-1111, 2()()" ')

(Fer.aro, tv1, PaJauolo, J.J., Krol, 1., Krebs, H.t., Hogan, N., Volpe, B.T., "Robot Aided ScnSOrtmOlOr Arm Tr~lnlnf..improves Outcome in Patients with Chronic Stroke," Neurology, 61: 1604-1607, 2003.)

12 children ages 5-12 with cerebral palsy and upper limb hemiplegia recelvecJ rol)otlcthuapy rvVlce a week for 8 weeks. The children showed significant InlprovenJ(~nl In tOi';;,

Quality of Upper Extremity Skills Test (Ouest) and Fugl-Meyer Assessment Scores

A questionnaire qdministered to the children's parents also showed significan:Improvement In "how much" and "how well" the children used thE~paretic arrT1dUrliI(.]functional tasks at home

(r-asoll. S.E .. rrClgala-Pinkham. v.., Hughes, R. Hogan. N.. Krebs. HI.. Stein. J, "Upper Limb RoboliC Therapy iOI

Children with Hemiplegia," Americen Journal of REhabilitation. 87: 11:929-936 (2008)

A pilot s.tudy of two patients with incomplete spinal cord injuries, level C4-6 thoi hadoccurred greater than two years ago, was conducted at Burke Rehabilitation HospitalPatients received treatment in the shoulder-elbow robot for 18 sessions over 6 weekswith one arm followed by 18 sessions over 6 weeks with the other arm. Patients showedchanges greater than 10% in Fugl-Meyer Scores and 20% in the Motor Power scalesThe study also showed that while one arm was treated both arms showed comparableImprovement.

,Krebs.HI. Dlpletro.L, Levy-Tzedek,S. Fasoli,S, Rykman,A, Zipse.J. Fawcett.J. Steln.J. PQlzncr.H. Lo '-. '/t)IPf:: 6:riogan.N. ",; Pi;lredigm Shift for Rehabilitation Robotics." IEEE-EMBS Magazine. 27461-70 (2008',

A pilot study of two MS patients at the West Haven VA Medical Center has shown thattreatment with the InMotion AnkleBot twice a week for twelve total sessions resulted insignificant improvement in torque production at the ankle and movement acc1.JracyAlthough the training did not include gait activities the researchers noted carry O'l'2r

Improvement in gait function when measured through six minute walk tests

(Krebs.HI. Dlpletro.L. Levy-Tzedek,S, Fasoli.S. Rykman.A. Zipse.J. Fawcen.J. Stein.J. Poi::n:::r.H. Lo. r... \/010(: [;,'

Hogan.N, -A Paradigm Shift for Rehabilitation Robotics." IEEE-EMBS Magazine. 274:61-70 (2008)

VVHi\T ACCOUI\JTS FOR THE BENEF!TS OF

1 the repetitive exercise, which may evoke and enhance a neuro-plastic recover; procec;s.whereby new neural pathways replace some of the neural pathways lost due ;0 r)r3!!i

InJury;

2 the continuously interactive nature of robotic therapy, which ensures patient participationby assisting only as needed;

~ the adaptive nature of robotic therapy, which adjusts the degree of movernenl challengeand rotlotic assistance to accommodate each patient's individual needs and presentabilities:

(F'asoll, S,E.., rrClgala-Pinkham, "10., Hughes, R, Hogan, N, Krebs HI, Stein. J., "Upper Limb Robotic Therapy iOI

Children with Hemiplegia," Amencen Journal of REhabilitatJon, 87: 11:929-936 (2008)

A pilot ~tudy of two patients with incomplete spinal cord injuries, level C4-6 that hadoccurred greater than two years ago, was conducted at Burke Rehabilitation HospitalPatients received treatment in the shoulder-elbow robot for 18 sessions over 6 weekswith one arm followed by 18 sessions over 6 weeks with the other arm. Patients showedchanges greater than 10% in FU'gl-Meyer Scores and 20% in the Motor Power scalesThe study also showed that while one arm was treated both arms showed comparableImprovement.

,KrE:bS,HI, D,pletro,L, Levy-Tzedek,S, Fasoli,S, Rykman,A, Zipse,J, Fawcen,J, Steln.J, POI!':ncrH, La ,..., '/()I~t- 6;Hogan,N, ",c, Pi;lredigm Shift for Rehabilitation Robotics," IEEE-EMBS Magazine, 27461-70 (2003',

A pilot study of two MS patients at the West Haven VA Medical Center has shown thattreatment with the InMotion AnkleBot twice a week for twelve total sessions resulted insignificant improvement in torque production at the ankle and movement, accuracyAlthough the training did not include gait activities the researchers noted cerry ovr:;rImprovement in gait function when measured through six minute walk tests

(Krebs.HI, Dlpietra,L, Levy-Tzedek,S, Fasoli,S, Rykman,A, Zipse,J. Fawcen,J. Stein.J, Poi:cn,,;r.H. La. ;.., \/Qll)r; [:T

Hogan,N, "A Paradigm Shift for Rehabililation Robotics," IEEE-EMBS MagaZine, 27-'\61-70 (2008)

1 the repetitive exercise, which may evoke and enhance a neuro-plastic recover! proce<::s,whereby new neural pathways replace some of the neural pathways lost due ;0 [Jr;;:'nInJury;

:2 the continuously interactive nature of robotic therapy, which ensures patient participationby assisting only as needed;

:; (he 3daptive nature of robotic therapy, which adjusts the degree of movemenl challengeand rot>oticassistance to accommodate each patient's individual needs and presentabilities;

'1/ the Informalio/7 Age: 10S Press, AS~;istlve Technology Researc'l ,Series, Am:;((;'ld21rn r2001;

IKrebs, HI , Hogan, N, Hening, W., AdC',movich, S, Poizner, H.; "Procedural Motor Learning InParkinson's Disease"; Exp Brain Res ,41 :425-437 (2001).

Krebs, HI; Volpe, B.T.; Ferraro, M.; Fasoli, S; Palazzolo, J.; Rohrer, B.; Edelstein, L : Hogan, N ."Robot-Aideci Neuro-Rehabilitation: From Evidence-3ased to Science-Based Rehabilitation":(OpICS in Stroke Rehabilitation; 8:4:5'1·70, (2002)

rlugan. N. "Skeletal Muscle Impedance in the Contrsl of Motor Actions"; Journal of Mech2n,cs in,'\I7ec/iCtneand Biology 2(3 & 4):359-373 (2002)

r::ohrer. 8 , Fasoli, S" Krebs, H.I , Hug;les, R, Volpe, B Frontera, W R , Stein, J . Hoger' f\J"Movement Smoothness Changes dUring Stroke Recovery", J Neurosci, 22 18 8297 -330~(2002)

Malfait, N, Sniller, O.M : Ostry, O.J ; "Transfer of Motor Learning Across Arm Configurations"Journel of Neuroscience; 22(22):9656-9660, November 15, (2002)

I::::soli, S D, Krebs, HI, Stein, J., Frontera, W.R. and Hogan, N, Effects of RobotiC Therapy Oil

Motor Impairment and Recovery in Chronic Stroke, Archives of Physical Medicme and R(:i"la!],34477 -82 (2003)

Krebs, HI, Volpe, BT., Aisen, ML., Hening, W, Adamovich, S., Poizner, H, SubrahrnanY2n, v.,Hogan, N , Robotic Applications in Neuromotor Rehabilitation, Roborica. 21 3-11 (2003)

Hogan, N, Krebs, HI, Rohrer, B, Fasoli, S, Stein, J, Volpe, 8T, Technology for Recover-y aft.erStroke, In JBogousslavsky, MP Barnes, B. Dobkin (Eds.), Recovery after Stroke, Cambrldg':::;r)ress (2003).

Krebs, HI, Palazzolo, JJ, Dipietro, L., Ferraro, M., 'Krol, J., Rannekleiv, K, Volpe B T , HoganN , RehatJilitation Robotics: Performance-based Progressive Robot-Assisted Therapy,:3,utonomous Robots, Kluwer Academics 15:7 -20 (2003).

r::erraro, M : Palazzolo, JJ : Krol, J: Krebs, H I., Hogan, N; Volpe, B T , Robot AidedSensorimotor Arm Training Improves Outcome in Patients with Chronic Stroke Neuro/ogv0'11604-1607 (2003).

rlenriques, D , Soechting, J ; "Bias and sensitivity in the haptic perception of geometry", E/[)

3rain Res (2003) 150 95-108

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MIT-MANUS;" In Z. Bien and 0 Stefanov (Eds.); Advances in Human-Friendly Roboticfechnologies for Movement Assistance / Movement Restoration for People with DisabilitlcsSpringer-Verlag (2004)

i:::lsoli, SO, Krebs. HI, Stein, J, Frontera, WR, Hughes R, and Hogan, N, RobotiC Th'2r2r.~/ forChronic Motor Impairments after Stroke: Follow-Up Results, ArchPhysMedRehab 851106-1 ~1-(2004)

'.~

Fasoll, SO, Krebs, H I, Ferraro, M , Hogan, N., and Vofp'e, B.T , Does Shorter Rehabilitation

Hogan, N, Krebs, H,I.; "Interactive Robots for NeL .o-Rehabilitation;" In Platz (ed), Spec/a; /'<:'<;/1(-

on Motor System Plast:ity, Recovery, and Rehab",'tation, Restorative Neurology & Ncurosc.(2COLl )

Krebs, H I. Volpe, BT, Lennmhan, L., Fasoli, S., I ynch, D., Dominick. L, Hogan, N . "Not.::,s 00:

f-<ehabliltatlon Robotics end Stroke," In. F. Lofaso, ii, Roby-Brami, J F. RavCiud (Eds )Fel:hno;oglcal Innovations and Hanc1:cap, Frison R:)che, pp. 177 -194 (200.1).

,iOqJ8. B T , Ferraro, M , Lynch, D, Christos, P , Kr()I, J, Trudell, C, Krebs. HI, Hogan ~~ .'R00o,lcs and Olrier DL;vlces In the ~-reatment of F'8tients Recovering from Stroke," CurAnneroscler Rep, 6314-319 (2004')

Krebs. H I I Ferraro. rV1" Buerger, S P., t\Jevvbery, ~V'.J'I Makiyama, A, Sandrnann, M., Lynch. 0Volpe, B T , Hogan, N.; "Rehabilitation Robotics: Pilot Trial of a Spatial ExtenSion for MIT-Ma:l'is'Journal of NeuroEngineering and Rehabilitation, E;:ornedcentral, 1:5 (2004)

Stein, J, Krebs, H.I., Frontera, Vv.R., Fasoli, S.E., Hughes, R, Hogan, N., "Comparison of TvvoTechniques of Robot-Aided Upper Limb Exercise Training After Stroke," American JournalPI:YSICrJlMed,ctne Rehabilitation, 83.9 720-728 (2004) .

.' I,

ROhrer, 8, Fasoll, S, Krebs, H.I., Volpe, B, Frontera, W.R., Stein, J., Hogan, N, "SubmovernentsGrow Larger, Fewer, and More Blended During Str,pke Recovery," Motor Control, 8.472-483(200.1) I, ,I

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Finley, MI\, Fasoli, S.E., Dipietro, L., Ohlhoff, J" MacClellan, L., Meister. C, Whltall, J , M;,c":(,R Dever, C T , Krebs, HI., Hogan, N, "Short Duration Upper Extremity Robotic Therapy Ii,

Stroke Patients with Severe Upper Extremity Motor Impairment," VA Journal RehabilitationREsearch and Development, 42(5):683-692 (2005).

Daly ,J , Hogan, N, Perepezko, E., Krebs, H.I., Rogers, J., Goyal, K, Dohrlng, M , FredricksonE Nethery, J , Ruff, R, "Re'sponse To Upper Limb Robotics and Functional NeuromuscularStimulation Following Stroke," VA Journal of Rehabilitation Research and Development {j2(6\/2J-735 (2005) ,

f'J1acClellan, LR , Bradham, 0.0-., Whitall, J., Volpe, B., Wilson, PO, Ohlhoff. J , Meister. CHogan, N, Krebs, HI, Bever, CT, " Robotic Upper Extremity Neuro-Rehabilltatlon In ChroniCStroke Patients," VA Journal of Rehabilitation Pesearch and Development 42(6) 717 -722 (2005,

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- ----------Inte'-rictive Motior1 Technologies, Inc. © (:.

'-<;15011, SE, Krebs, hi, Hughes R, Stein J, and Neville Hogan, N; "Functiona!ly-BasedR,zJ,abllitation Robotics: A NeX1 Step?," International Journal of Assistive Robotics andMechatronics, 7(2)26-30 (2006)

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C;lflgnan, CR, Krebs, H. I. "Telerehabilitation Robotics: Bright Lights, Big Future?", VA Journal ()'Rehabilitation Research and Development, 43(5)695-710 (2006)

I<.rebs, H I, Hogan, N, "Therapeutic Robotics A Technology Push," Proceedings of IEEE, Spew;'Issue on Medical Robotics, 94(9)1727-1738 (2006).

Palazzolo, J,.J, Ferraro, M., Krebs, H.I., Lynch, D, \/olpe,. BT, Hogan, N, "Stochastic Esllmatlonof Arm Mechanical Impedance during Robotic Stroke Rehabilitation," IEEE Transaction NeuralSystems and Rehabilitation Engineering, 15(1 )94-1 03 (2007)

Levy-Tzedek, S, Krebs, HI., Shils, J.L., Apetaurova, D., Arle, J.E "Parkinson's Disease r--, MotorControl Study Using a Wrist Robot," Advance Robotics, 21 (10) 1201-1213 (2007)

Krebs, HI, Volpe, ST, Williams, D., Celestino, J, Charles, SK, Lynch, 0 , Hogan. ~~. "~obC'i·';Ided NeurorehabilitatJon. A Robot for Wrist Rehabilitation," IEEE Transaction Neural Syswms,JncJ Rehabilitation Engineering, 15(3)327-335 (20C7)

I\tlasla, L, Krebs, HI, Cappa, P, Hogan, N. ""Design and Characterization of Hand Module forWhole-Arm Rehabilitation Following Stroke," IEEEI..4.SME Transactions on MechatronIC'S,12(4 )399-40? (2007).

Dipietro L, Krebs HI, Fasoli SE, Volpe BT, Stein J, Bever C, Hogan N' Changing mOlOr Slnc:'~:-::sIn chroniC stroke, J Neurophysiology, 98:757-768 (2007).

L_cvy-Tzedek, S, Krebs, H.I , Shils, J.L, Apetaurova, D, Arle, J.E "Parkinson's Dlseas0 ;, ~.~O:CJrControl Study Using a Wrist Robot," Advance Robotics" 21 10 1201-1213 (2007)

Krebs, HI, Volpe, ST, Williams, 0 , Celestino, J, Charles, S K, Lynch, 0, Hogan, N "Rabol.-Aided Neurorehabilitation A Robot for Wrist Rehabilitation," IEEE Transaction Neural SystemsClod Rehabilitation Engineering 15(3)327 -335 (2007).

Dipietro L, K-ebs HI, Fasoli SE, Volpe ST, Stein J, Bever C, Hogan N "Changing motor "::",j,,,=rg'-:;':11'1 chroniC stroke," J Neurophysiology 98757-768 (2007).

Whole-Arm Rehabilitation Followin~;j Stroke,")EEElASME Transactions on Mechatronics12 .1 399-407 (2007)

KrE;GS HI. Volpe, BT, .:;teln J, Mernoff, S. Fasoli, SE, Hughes, R , ~rontE:ra. W F . f-Iogan N"Robol,c Rehabdltallor in Sub-Acu~e Stroke A CNy,parison of Robotic Therapy In f\i1ulllplE :-,;i'- r.;

M((},mond (2007)

Volpe, 8T, Lynch, D , r~ykman-8el':and, A, Ferraro, M., Galgano, f\i1, Hogan, N ,Krebs, H I''In,enSlve sensorimotcr arm training mediated by therapist or robot Improves hemiparesIs Inpatients with chronic stroke," Neurorehabilitation end Neural Repair 223305-310 (2008)

Kwakkel. G, Kollen, BJ., Krebs, H.I., "Effects of Robot-assisted therapy on upper 11mb recoveryafter stroke A Systematic ReView," Neurorehabilitation and Neural Repair 22:2111-121 (2008)

Fasoll. S E, Fragala-Pinkham, M, Hughes, R, Stein, J., Krebs, HI, Hogar-;, N, "Robotic therapyand botulinum tOXin type A: A novel intervention approach for cerebral palsy" Amencan JOlJr!~21 (;:P'6'habJllialiOn, 8781-4 (2008)

Krebs. HI, Mernoff, S, Fasoli SE, Hughes, R, Stein, J, Hogan, N, "Transport of the Arm andManipulation of Objects in Chronic Stroke: A Pilot Study," NeuroRehabilitalJon, 2381-8, (2002,':

Hesse, S, Werner, C., Pohl, rv1., Mehrholz, J., Puzich, U., Krebs, H.I. "A mechanical arm trainerfor the treatment of the severely affected arm after stroke: a single-blinded randomized tnal.'American Journal of Rehabilitation, 87: 10: 779-788 (2008).

Fasoli, S.E .. Fragala-Pinkham, M, Hughes, R, Hogan, N., Krebs, H.I, Stein, J, "Upper Limbf=;cbotlc Therapy for Children with 'Hemiplegia," American Journal of Rehabilitation, 87 11 929-936,:2008)

Krebs,HI Olpletro,L, Levy-Tzedek,S, Fasoli,S, Rykman.A, Zipse,J, Fawcett), Steln.J. POlzn'2r H1.0, A. Volpe,BT, Hogan,N, "A Paradigm Shift for Rehabilitation Robotics," IEEE-EMBS Milc;r:J7,;/r:27 4 61-70 (2008)

Dipietro, L, Krebs, HI, Fasoli, SE, Volpe, BT, Hogan, "Submovement chan(~es charactenzegeneralization of motor recovery after stroke," Motor Cortex 45(3)318-24 (:2009)

Edwards OJ, Krebs HI, Rykman-Berland A, Zipse J, Thickbroom GW, Mastaglia FL, Pascual-Leone A, Volpe, B , "Raised Corticomotor Excitability of M1 Forearm Area ;:ollowlng Anodal ,DCSIS Sustatned DUring Robotic Wrist Therapy in Chronic Stroke," Restorative NeurologyNC'urosc/ence, 27199-207 (2009)

RO'!. A , Krebs, H.I, Williams, D, Bever, C.T., Forrester, L.W, Macko, RM , Hogan N . "Roho;·Aided Neurorehabilitation: A Robot for Ankle Rehabilitation," IEEE - Transaction RobotiCS25 3 569-582 (2009)

Lc,nlnl, L, Dipietro, L , Zollo, L., Guglielmelli, E, Krebs, H. I., "An Internal Model for ACqUISltlOiiand Retention of Motor Learning during Arm Reaching," Neural Computation 21.72009-2027(2009)

Ftnley, M A . Dipietro, L. Ohlhoff J, Whitall, J, Krebs, H.I., Bever, CT, "The Effect of RepeJiC:cMeasurements using an Upper Extremity Robot on Healtr1Y AdUlts," J BIOmechaniCS 25 2 1r:~-110(2009)

aMer Stroke" In Bogousslavski, J., Barnes, M.P., Dobkin, B. (eds), Recovery arter Stroke, Chap\er

30, Cambridge University Press 2003

Krebs, H.I ; Celestino, J,; Williams, D.; Ferraro, M.; Volpe, B.T.; Hogan, N; "A WrISt ExtenSion toMIT-MANUS;" In Z Bien and D. Stefanov (Eds.); Advances in Human-Friendry Robotic:Technologies for Movement Assistance / Movement Restoration for People Wl(h Drsabrl!\IesSpringer-Verlag 2004.

Hogan, N ; Krebs, HI; Interactive Robots for Neuro-Rehabilitation; In Platz (ed), Speci8! Issue orMotor System Plasticity, Recovery, and Rehabilitation, Restorative Neurology and N,=U'OSCI'2nc::-2004

}<Jebs, HI. Volpe, B.T, Lenninhan, L, Fasoli, S, Lynch, D., Dominick, L , Hogan, N , "Notes or:f--~ehabilitation Robotics and Stroke:" In. F. Lofaso, A. Roby-Brami, J F Ravaud IEds:Technological Innovations and Handicap, Frison Roche, 177-194,2004

Krebs, HI: Hogan, N; Durfee, W; Herr, H.; "Rehabilitation Robotics, Orthotics, and Prostrletrcs.'Iii Selzer, ME, Clarke, S, Cohen. L G, Duncan, PW, Gage, F H (Eds), TextbooK of NeuralRepair and Rehabilitation; Chapter 48, Cambridge University Press 2006

Krebs, HI, Hogan, N. "Robotic Rehabilitation Therapy," Editor Metin Aka)'. Wyl"::y Encyc1opec'cof Biomedical Engineering 2006

Slell'. J .. Hughes, R, Fasoll, SE., Krebs, HI, Hogan, N, "Technological ,f).les fOI' f,.f1(':I'.~"

r-;ecovery." ~hapter 19 in Stroke Recovery and Rehabilitation. Demos Press 2008

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