I am, hi, this is Dr. Tina Kwasnika. I'd like to introduce you or welcome you to this discussion of technology and how we can incorporate technology in our daily life and acute inpatient rehabilitation. I'm joined by Dr. Seema Desai and Trent Mariyama. And I'm gonna start first with talking about upper extremity robotics. And then we're gonna move on to lower extremity robotics. And finally, going to go on to how we can help our therapists better integrate the use of robotics in their daily practice. There we go. So that's kind of our roadmap. And we'll be taking questions at the end, but if you put them in the chat box, we'll be monitoring that to be ready for those questions. So I'm gonna start with what are the benefits of upper extremity robotics and inpatient rehabilitation. As a disclosure, I'm on the Speaker's Bureau for Allergan Abbey. The objectives here are to identify the principles used in upper extremity robotic devices that are commercially available for us on our rehab units, compare and contrast the different devices and understand the adjustability of devices during real world use. I've got some embedded videos looking at the devices themselves. And then Trent will kind of put this all together at the end with how we can help our therapists better incorporate them. The devices we're going to explore are the Arm Modus M2, the MyoPro, which is a power-driven arm lymphosis, Raphael Smart Glove, and the Tyramotion Diego. There are other ones that we use in our inpatient rehabilitation, but this kind of gives you a varying degree of different devices that work in a little bit different ways. So the common themes in robotic technology that you'll hear in the upper and lower extremity robotics is how does the patient interface with the device? Do they interface with the device by using the device free from hooking up to a machine or do they use it in concert with some sort of machine they are actually physically hooked up for? How much strength do they need to be able to activate it? Is it got a passive mode to it? How does it provide the patient feedback? So I think the patients really benefit from getting the feedback generally that the gamification of rehabilitation really does help the patients be able to see how they're improving over time and engages them better. Gamification is using those elements of gameplay in other areas of activity. When I first started using these devices, one of the things I thought was, well, the younger patients are gonna love it, the older patients, they're not gonna quite get it. But honestly, we've seen that across the board, the patients have had some interaction with the device and really like that immediate feedback and it helps motivate them to continue to work, especially when things are difficult for them. So we started game technology and rehab back with very simple devices, things such as the Nintendo Wii and the balance board. Xbox Kinect uses cameras and infrared projectors to detect movements and patients would then interact in somewhat of a virtual environment with movement in front of the camera. There was the ability to adapt to those two patients that might be at different levels, being using a wheelchair or whatever to be able to interact on the Xbox Kinect. But both of those were really platforms that were not made for people with impairment. They were primarily programmed for patients without neurologic impairment. It wasn't until the robotic, the upper extremity robotic devices came out of the research mode and into the clinical use mode that we started to see that we could really help these patients engage in the use of these robotics. The first one we're gonna talk about is the Arm Modus M2. It's made by Fourier Intelligence. It's an upper extremity robotic. It has a reward-based game that can motivate the patient to complete task-oriented movements. We use it in stroke. We also use it in brain injury, MS, and in spinal cord injury. And one of the things that I think that I've learned as we've incorporated these devices in is that we can not only address upper extremity movement, we can also address cognition, visual perception, and some core strength because you're able to stand or sit when you're using the device. So you can actually incorporate balance and core strength in your use of this device. Here's the video of its use. The Fourier Intelligence Arm Modus M2 is an evidence-based robotic upper extremity end effector device that assists the therapist in delivering intervention for neuromuscular training, functional endurance for task, visual perceptual training, upper extremity motor strengthening, and hand-eye coordination. It is a smart haptic feedback technology based on force feedback and other core technologies. The robot can sense the strength of the movement and adjust the auxiliary force accordingly and provides intelligent force feedback. This allows the robot to assist the patients from flaccidity to recovery. It has a user-friendly interface and has a quick setup time. There is an assessment function for range of motion, strength, and some cognitive abilities. Therapists can customize training protocols based on the patient's needs. It can simulate different levels of resistance, force, inertia, elastic force, and obstacles, creating an interactive training environment. Built-in sensors measure every movement with accuracy. It replaces tedious physical activity and replaces tedious manual therapy with fun and interactive exercises that help motivate the patient during therapy session to increase dosage of therapy for optimization of neuroplasticity. The M2 has the ability to work in passive, active assist, assistive, and resistive modes. The patient is provided a real-time feedback for training data. It allows the therapist to see when the patient is actively engaging with the device and also helps give feedback and motivation to the patient. Each training session ends with a report that provides a statistical reference for therapy. The system has the ability to generate reports and save them for tracking and trending information. The device has developed to show utilization from various positions, standing, sitting, tall kneeling, or in combination with bound devices like foam or Swiss balls based on the condition of observation the therapist chooses and the targeted therapy chosen. So that last one, one of the things I like about that is it actually shows the patient not just doing a physical task with the reach with the arm, but they're also doing a language-based task. So you can combine the two under the umbrella of one sort of therapy. So as we've talked about, it has four training modes. It has a passive mode, it has an assistive, an active, and it can actually provide resistive force. The graphics are very engaging. So as you saw, as it came across the bottom there, there's lots of different options for the therapist to use and it's pretty easy for the therapist to choose which option to engage in. And the patient can also give you an idea, like if they would rather find the coins, something more that looks like a, you know, traditional Mario Brothers sort of game versus would they rather go and try to touch objects. It does have some spasm detection, so it's not going to actually pull against a spastic muscle and it can be used in the standing position. And I think it's always fascinating when I watch them use this, because sometimes I don't realize how much balance difficulty a patient has when they walk simple distances without any foils in their environment. And then you put them on this and you really see how much they're moving on the balance pad or the Bosu. So the next one is the MyoPro. This is a very different device. It has my electric signals via surface electrodes and activates motors to move the limb as intended. It works on the elbow, wrist, and fingers. It can be worn free during functional tasks. The nice thing about this device is this is a device that patients can then transition to use in the home. And I have a few users that have actually been very successful at doing that. We'll show you the device. The MyoPro by Myomo is a powered arm orthosis designed to restore function to the patient's paralyzed or weakened upper extremities. This helps patients perform activities of daily living and facilitate rehabilitation with neuromuscular retraining and increasing range of motion. The MyoPro is an EMG-based device that reads the nerve signals and through the software of the device, manipulates those signals and helps activate the device and assist the patient to move their elbow or perform a three-point pinch. You need to have some degree of muscle activity such as a one or one plus out of five, at least to use the device as it works on volitional effort. We have also used this device to assist in tone management by teaching the patient how to work on decreasing the activation of the severity of their tone. The therapist has the ability to manipulate the amplification of the EMG signals and adjust thresholds of the robotic assist to customize the session to meet the needs and then continue to adjust in real time based on the patient's performance and optimize the session. We have used this to help patients realize they have emerging volitional movement and once that is accomplished, we have found that patients start to move their upper extremity more effectively. As patients progress, this device can be used as daily living assist or a neuroprosthesis. We have also delineated other opportunities and use cases to utilize the device. There are times we've connected electrodes to the arm but left the device off to show the patient that their motor activity is really affecting the robot and it helps by giving this feedback to the patient. We have used this with people who have brachial plexus injuries as well as another use case. There is a shoulder harness that can use to offset the weight while patients standing or using the device. And this device is available for home use and there has been some success in getting insurance to help cover its cost. I would say that the device is a little heavy. So even with the shoulder harness, most of my patients who've gotten it for home use it actually for training rather than for a functional assist. It uses that three draw chuck Palmer type prehension and the cost obviously is pretty significant. Electrode positioning can sometimes be an issue but that's similar to what would be an issue in a traditional electrical STEM device or putting electrical STEM electrodes on for home use as well. So the Raphael Smart Glove is designed for both common clinic use. It's a Bluetooth enabled glove to train strength while playing interactive games. You have to have baseline strength to use. It's actually more of a treatment for fine motor function which is one of the things that patients oftentimes feel frustrated that so much of this training is for gross assist that they really want us to find something that can help them with more fine motor function. This is another one that actually has a home use potential. The Raphael Smart Glove by Neofect is a sensor based device that measures movements of the forearm, wrist and digits with accelerometer and bending sensors. The device is supported by evidence-based practice that has shown improvements in upper extremity function over time. It requires active movement of the user as an inclusion factor for the device. It utilizes an entertaining virtual reality environment in which occupation based hand exercises are done. The gamification helps to increase the motivation and thus increase dosage completed by the patient and targets the utilization thresholds shown to optimize neuroplasticity. The device has many programs and games that let you work on isolated movements distal to the elbow. There are also some complex joint combination games. The setup time is under five minutes to get the patient engaged in the task. One of the most important things is that it allows you to set a baseline movement ability which can be translated to the virtual world as full motion. And that's every level of patient ability provided that they have some minimal movement can use the glove. It can be helpful to use the lower level patients as well with emerging range of motion abilities to those with higher level patients needing endurance type tasks. The user interface allows for real time changes by the therapist as they assess the need to increase or decrease the task based on the amount of movement demonstrated by the patient. The device also has a tracking and trending function for reporting processes that are based locally on the device. As you can see, it takes very small movements and then can put them on the screen as much bigger movements. So it allows you to really amplify those movements. It's lighter weight so there's less stress on the shoulder and the software is gonna learn with the patient. So it's gonna adapt to their improvements. Now, granted that patient was doing a lot of assist for the supination pronation function but it's something that the myeloma cannot do in supination pronation but this actually can do some of that training. And finally, the Tyramotion Diego is a shoulder arm rehabilitation device that allows you to strengthen in a gravity eliminated position. And it can really be adapted easily for the available active and passive range of motion. It can be done unilaterally and bilaterally. So it can be used for stroke and brain injury patients as well as incomplete spinal cord injury patients. The Diego by Tyramotion is an arm shoulder robotic and sensor based device for neurological and orthopedic conditions. It can be used unilaterally or bilaterally and is an end effector device that allows hands-on facilitation as needed by the therapist and task oriented training. It is applicable for a wide range of patients, ages and diagnoses. The Diego utilizes three-dimensional space to interact in a virtual environment to work on functional training that is targeted by the therapist to meet the needs of the patient. The Diego can assist with its unique intelligent gravity compensation and the sensors capture the arm's position as well as joint angle. The device allows you to set a baseline movement of ability that is translated virtually to the ability of the fully interact in all the games. This is adjusted by the therapist per their assessment of the patient's therapeutic needs. The device is very therapy friendly as the therapist makes most any movement, the output movement displayed on the virtual screen. Thus you can be very inventive as a therapist and use the device and add off-label activities to enhance training session. This helps bring other cognitive interventions into the session. They have a device with range of motion assessments. The local storage of the patient data with trending reports of the patient data is available. It is quick to set up in under five minutes and this can be accessible from either wheelchair or standard chair for treatment. The Diego as well as other tire motion suite of devices work off a similar gaming platform and limited training is needed when translating to other tire motion devices. So you can set the available range of motion as the range of motion that you expect somebody to make. So you can record even small movements, senses movements over the entire screen. And you can also see that they were, again, the last thing they did was actually a cognitive task. And there are cognitive benefits to working two hands in the midline and doing bimanual tests that some of these other devices don't really have for you. So to be able to incorporate these robotics, you really need a dedicated space. You need to be able to use the wheelchair, chairs and standing position. You need your therapist to be engaged in learning the technology. You can't just keep throwing up the same program each time. You need to be able to think about that patient, what their baseline exam is and what engages them. It can't take the place of ADL retraining. One of the things that we saw early on was that people got excited about robotics and then they weren't doing ADL retraining. And as we know in inpatient rehab, a lot of what we are measured on is improvement in function, which is improvement in activities of daily living. So we had to then go back to the drawing board and say, you have to be providing ADL training as well. And then some patients respond better to one device versus the other. And you really have to kind of work with the individual patient, as well as recognize how comfortable they are with technology. Though, as I said, I'm oftentimes shocked at how my elderly population still really engages well. It's fun, they enjoy it. And so they really do some things that I would not have expected them to do. So I am gonna pass off to Seema Desai, who's gonna talk with us right now about the use of lower extremity robotics. And take it away, Seema. All right, good morning, everybody. I'm gonna be talking to everyone today about lower extremity robotics and the technology behind that. I'm an assistant professor at Carolinas Rehab in the Department of PM&R. I have no disclosures. So the first thing I'm gonna be talking about is lower extremity exoskeletons. And I do just wanna preface that there's really no way I'd be able to cover all the lower extremity robotics today, but I'm just gonna be highlighting probably the most popular ones, maybe that you've seen or at least heard of. So today I'm gonna be talking about just exoskeletons and a couple other different devices. An exoskeleton is just a rechargeable bionic machine that attaches to your lower extremities and that enables the patient, a lot of times with a spinal cord injury, but you can also use this in other populations, stroke, brain injury, to obtain better gait, endurance, and work on mobility. These are controlled by a computing system. So I'm gonna be talking about the Indigo, the Exo, which you see here being worn by Amy Van Dyken-Ruyn, who's an Olympic swimmer who has spinal cord injury, and the Rewalk. So the Exo is a great device, probably the most popular, I would say, that people have seen or at least heard of. It provides a variable as well as an adaptive power assistance on each extremity. So it ranges from anywhere from zero to 100% with an integrated tether attachment that then provides stability as well as your ability to work on mobility as well as valence impairment. It is able to actually gather data, gait data, and you can actually recalculate the assistance as needed. So you can actually apply this to research too. It does come in four different modes. So you can have a trained spotter mode, which then activates the steps with the button with the use of a therapist. You can have another mode where the patient themselves actually takes control of actuating the steps either by using a walker or some sort of crutches. Another mode is the patient's now starting to achieve the next step by moving their hips laterally and forward. And so then that triggers further steps by body weight shifting to initiate forward leg movement. It is a bit heavy. It's 54 pounds because it is like a full body with backpack design, but that backpack design actually allows for more control in the upper trunk and back, which is why it really can be used across the spectrum of injuries. Like all these devices today, they all cost, they're all expensive. The XO does take a little bit of time to put on and actually train your therapist on how to use it. And it does have a weight limit. So 220 pounds is the weight limit and can be time-consuming if your therapists are not familiar with it and haven't used it very often. But if you use it more frequently, the time-consuming setup does kind of drop. So then the Indigo. The Indigo I find with at least our therapists is easier to apply than the XO. It has two features that are specifically designed to aid in ambulation and the amount of robotic assistance adjusts automatically for patients who have some muscle control in their lower extremities, which then allows the patients to actually use that. And other great features that you can actually use functional electrical stimulation with this, which is really helpful. And the other design is that it can actually provide full support in addition to that partial support. It also has an adjustable stance support and the active swing mode. The active swing mode is just a mode that allows patients to practice and learn a more physiological gait pattern, which is really neat feature. It is lighter. It's about 26 pounds compared to the XO. But as a result of that, you do lose some of that upper body control. Because as you can see in this picture, it doesn't go as far up as the XO. So you may not be able to use it with some of your higher level spinal cord injuries because you do need to have pretty good upper extremity strength and good postural control, which can be a con. And then another con is the weight limit. So the Rewalk, the last kind of exoskeleton we'll talk about today, it's another type of motorized device. It can help with doing a sit to stand, stand to sit, and you can also work on ambulation and it's battery powered. So the Rewalk is lighter with the motors in terms of at the hip and knee joints, but overall it is a little bit heavier than the other two devices, the Indigo and the XO. But the way it works is it actually controls movement with changes in the patient's center of gravity, which I think is always pretty cool. So a forward tilt of the upper body is like sensed by the system, which then initiates the first step. And then the repetitive body shifting is actually what generates the sequence of steps, which then mimics a more natural gait of the lower extremities. Again, cons are that it's pretty heavy and it has a pretty significant weight limit. And it's not as adjustable as the other two, the XO and the Indigo. And it doesn't have a great upper body control. So again, you're not gonna be able to use it in your higher level spinal cords or patients which is not very good upper trunk control. So lower extremity end effectors. The nice thing about the end effectors are that they're both systems, that they share a harness and they also use body weight support. With end effector devices, basically the patient's feet are positioned on two foot plates, and then the movements help stimulate stance and swing phase. So the GEO is a very popular one, the Locomat, and then I didn't put it here because I didn't have time to also add another one, but the Tyramotion Lexo is another type of end effector. And the nice thing about end effectors is you really can use them across the spectrum of injuries, spinal cord, brain injury, Parkinson's, cerebral palsy, stroke, and other sort of traumatic injuries. So the GEO system controls the movement of the foot while the hip, the knee, and the trunk move more freely during ambulation. So this is actually great because it helps challenge the muscles to use all these joints. Other devices out there do attach at the hip and knee so that this is a major difference between this and some other devices. It's great because you can use it for stair climbing, stair descent. It also has virtual scenarios, which I find both the younger patients as well as the elderly patient population do really like. The nice thing, at least that my therapists love about this is that they only need one person to use this during a therapy session. So they're able to transfer the patient from their wheelchair to this device, control it and oversee the entire session themselves. It's relatively low setup time and you can use variable assistance, which is great. You can also integrate this with functional E-STEM as well, which I always find is really helpful. And you can also use this to like help build the endurance of your patients with more lower level patients. So like I said, it really is a great device to be used across the spectrum of injuries. Again, one of the cons of this is I would say the main con that my therapists find with this is that it really doesn't facilitate great hip extension. And so it actually causes patients to sometimes overuse their hip flexors. So that's probably one of the big cons I would say with this. And sometimes the ideal setup can be difficult to achieve, but I think the more that you use it, you get comfortable with it and your therapists are trained on using it, the easier it is. And then the Lokomat. So the Lokomat's a little bit different. It is a harness suspension and the harness actually raises and lowers with each step that the patient takes. It does also provide this active hip, knee actuation along with passive ankle control and does provide variable assistance along with accurate visual feedback. However, you must kind of keep in mind it does only provide this primary sagittal movements, but it's able to provide a large number of reproducible, like high quality repetitive walking pattern, which I find pretty helpful. The Lokomat in general does take longer to set up than the GEO and it's less adjustable. You don't have stair training, ascent or descent. And you're limited to this sagittal plane. And you typically do have to suspend these patients for a little bit of time to actually get them in there, which can be uncomfortable. And that again, takes away from some of the therapeutic time and therapy. And then large extremity body weight supported devices. I would say these are probably the most popular and what most people want to see and what patients I think get most excited about when we talk about working on gait training. So the Zero-G, which is by Airtac, the Vector by Bioness and the C-Mill, which is by Motec-Hakoma. All of these body weight supported treadmill training have been proposed and gained tons of attention for its advantage to allow patients to start training very early in the recovery process as a result of this great harness support system. You can work on stepping sequences with high intensity gait training safely. And that's actually an advantage as well to help improving posture and gait pattern and really can be used again in any population. So the Zero-G, probably one of those popular ones I would say that I see often, you can use this in spinal cord brain injury, cerebral palsy, amputee patients, stroke patients, MS, orthopedic injuries. I mean, really the spectrum is you can really use it across the board. It's great because it's a secure harness that's connected to 160 foot track, typically mounted into your ceiling and the computerized control is customized at the patient's weight and their ability. And then you can actually monitor progress as the patients practice more functional abilities, which then hopefully result in improved performance in their daily activities. You move in all different planes, so you can move forward, backward, and sidestep, and you're actually getting real time biofeedback to actually challenge their postural control along with their dynamic stability. One of the great things about the Zero-G is that it has data collection, so you can actually translate this into research. By pulling distances on your patient, you can look at the weight percentages and you can compare the previous sessions as well. The active trolley is another great thing. It actually helps minimize the horizontal forces that the patients tend to experience during gait training and has the ability to not only facilitate, but also resist the movement, which includes this perturbation function, which is great for anticipating falls, which we are always trying to prevent in rehab. Another great thing is that you don't also have to use this for gait training. You can use this for transfers and working on loss of balance. And then for higher things, you can work on even obstacle training. One of the cons I would say is that it has a limited path distance, but I would say 160 foot track is pretty good. And there's no pelvic frame to actually support the pelvis if you need that. The other most popular one is a vector. This, again, is movement, again, in this predefined kind of unidirectional trajectory, but again, you can move forward, you can move backward, you can move side to side. It also has a customizable track along with gait data, which is the same as the Zero-G. The nice thing about the vector is that it has what we call an intuitive body weight support, so this helps keep the harness, the rope taut, to provide selected unloading, so that actually can prevent falls. And then during the normal gait, the patient's center of mass moves in all three planes, so you actually get sagittal, frontal, and transverse, just like the Zero-G. The nice thing is that the overground body weight support also enables the patient to actually practice a natural kinematic movement in all three planes without the fear of falling, which we all see a lot in rehab. And you can work on pre-gait activities, again, balance, stair climbing, obstacles, surface changes, and you actually can use this with more than one patient at a time, so this is a great inpatient, outpatient device. Again, the same kind of cons as the Zero-G is that it doesn't necessarily have a pelvic frame and you're just walking in a predefined circuit, but I still think it's a great device. And the C-Mail. So the C-Mail is another type of great body weight supported treadmill. It's an oversized integrated force plate treadmill that also has this LCD screen, as you can see in this picture, and it displays actual virtual reality applications, which is very different from the other two. You can actually augment the experiences, which I find really neat, so you can actually change the exercise variables to match the task and training intensity for the patient. So patients can score points for making an accomplishment or they can lose points. So I find that it's really interactive, more so for both for our younger patients and our elderly patients, which I also had assumed that maybe the elderly patients wouldn't like this as much, but they do really well with it. Again, you can do extensive data collection with this, which you can then integrate into your research because it does gait analysis during and after to monitor performance. So you can track your patients over time. It allows you to monitor not only short-term gains, but also long-term results for your patients. And another thing I love is that it can actually integrate with the functional electrical stimulation too. It also does provide partial body weight support, which is pretty neat. Another great thing I think about the C-Mail is that you can use this with more lower level patients who are having difficulties with initiation or motivation because you can actually have an externally paced cue in this. So that's it for me. I'm gonna pull this off to Trent Mayamura to talk about how we integrate all these things. Hello, everybody. My name is Trent Mariama, and I am the Program Manager for Rehabilitation Technology at Barrow Neuro Rehabilitation Centre. My talk will center around the clinical implementation of robotics in a rehabilitation program and the journey we've undertaken to get where we are today. So my objectives are threefold. One, I want to state the method for operationalizing a robotics program to the rehabilitation continuum of care, and be able to name two upper and two lower extremity robotics devices that are currently commercially available, as well as state the evidence-based clinical use guidelines for upper and lower extremity robotics in stroke rehabilitation. So at Barrow, why did we choose robotics? Basically, we were following our mission statement for both Barrow and rehab services, where we're looking at integrating as much innovation from clinical techniques and technology and through the research and evidence-based practice. So the American Stroke Association puts out guidelines that's usually every four or five years for stroke rehabilitation and recovery. And what I want to kind of go over is how they classify things. So if you look at the green column, class one are conditions which there's evidence for and or general agreement that the procedure or the treatment is useful or effective. Where class two is conditions which are conflicting evidence, where there's divergence of opinion about the usefulness of efficacy of the procedure or the treatment. And the class two can be divided into two different ways. Class 2A shows the weight of evidence or opinion is in favor of the procedure of the treatment, where class 2B shows the usefulness and efficacy is well less established by clinical evidence or opinion. So when you look at lower extremity robotics, they fall under a class 2B and level A, which means multiple populations are evaluated. And so you see that they don't have as much clinical evidence, but they still say that it's a viable opportunity to use this. So that's how we end up looking at using the things such as ReWalker, Exo, or Indigo. For upper extremity robotics, it comes as a class 2A, which the benefit is bigger than the risk and the recommendation is in favor of treatment or procedure being useful or effective. So we find that we do a lot of these types of things and use the robotics based on clinical evidence. So when we look at adding new robotics and technology to our current model, we identify the need to develop a plan on how to identify and operationalize the deployment of these devices. Because if you don't have a good plan, then it's hard to have the devices given to the clinicians and then they sit in the gym and collect dust. So originally we came up with what we call the Barrow Assistive Technology, the BAC committee. And we formed this to help assist us to find and evaluate devices that are either currently commercially available for use or those that are in development. By looking at these analytically from our rehab perspective, we discovered new opportunities that may help us improve outcomes to our patients across our continuum. This committee also helps disseminate new robotic technology and information to our staff so we can evaluate it for the ability to fill the gaps where we see that we have ability to provide interventions. And besides just looking over the internet, we felt it was really important to give the staff the ability to get hands-on experience, to make a good assessment of these devices. So we always try to start with an in-house trial, if at all possible. And this grew to having what we call our technology day, where we invite not just therapists, but physicians and administration down to see what kind of technology we currently have or what we're looking at. This way the staff gets knowledge of what we currently have and it helps broaden the ability to do things such as referrals to the program or retention for our patients. They also get a chance to look at what we're currently exploring as options so that they have the opportunity to assess the devices and give their opinions, because it's also important to make sure all the end users are good with using the devices. We can't just force them to use them. And this committee is also our centralized forum for device acquisition. So without an implementation plan, you really don't have anything that's a viable opportunity. So by putting the technology in a gym doesn't ensure that it's going to get used or the longevity of its use. We try to identify those staff members who are champions, who show a strong interest in the device and see the potential of how it will help our patients. We task them to drive the implementation of the device. And if you do not have this, the smooth implementation may kind of fall by the wayside. So when we also look at assessing how to operationalize the device, we identify the potential use cases and determine the gaps it fills in our delivery of service. We look at how many patients it might affect, who can we use it with, and how does it get used. So with ongoing assessment of the devices, we continue to search the globe for the best opportunities and provide better intervention for our patients. Unfortunately, these devices just aren't only in the U.S. They've come from many places. All the ones that Tina as well as Sima talked about, not all of them are from the U.S. Most of them are from outside companies. So we look at advanced clinical practices. And so in therapy, we look at advanced clinical training, such as things like neuroephra, NDT, PNF, and those types of things. But in line with our mission statement, our goals, we're adding the latest advancements in robotics and technology, because a lot of these advanced clinical practices aren't really new. They started back in the 60s. So with this, we're trying to assist to help get the best products to market. We do this by looking at what is being developed all over the globe and partnering with those people. As an example here in ASU, we partnered with them to help build a soft robotic knee device to help the swing phase engage. And we're continuing to look at opportunities to advance those to full lower extremity use. But it's important to be associated with companies that have similar values and mission and the end goal of making a difference in our patients' lives. So why do we use robotics? Well, we look at the potential of increasing functional outcomes. And not only does it allow us to compare ourselves to others, but it also tracks our internal benchmarks. Things that are important are things like early intervention, where robotics allow us to intervene earlier in the patient's stay. There's powerful algorithms and software that allow us to mimic appropriate movement patterns, provide a great intervention, as well as assess the progress of the patient. By having increased repetitions, it's shown by evidence-based practice that to facilitate neuroplastic change, the doses of interventions needs to be higher than what we are traditionally being able to do in conventional therapy. And the robots help us provide this. It has to be motivating, kind of like Seema and Tina said, that we're obtaining a dosage that's motivating for the patients to do the task. The interaction with the robot and added gamification enhance the patient's desire to do and continue therapy. We also want to help minimize compensations. The robot can be programmed to follow a more appropriate movement pattern and not allow the compensations that a patient may normally use if they're able to use their limb's property. And lastly, looking at marketing. People choose where they want to go for health care. By showing the people with a breadth of the therapy options we have here, we hope they can choose to come to see us. It's also a big factor in staff retention, bringing patients to the clinic, patient satisfaction, and again, return on investment. So let me show you a video. And this is a video of Alec who presented with a lot of compensatory gait patterns right after his traumatic brain injury. And in this case, the therapist chose not to do traditional overground gait training because he was not able to help or help change his altered gait pattern. So he treated him only using the XO for the first little while until he felt a more normal walking pattern. When I first got admitted into inpatient rehab at Barrow, I wasn't able to walk, talk, eat, to say the least. And I got fitted for a wheelchair a couple of weeks before I got discharged from Barrow. But by the time I was discharged, I was not, I didn't need the wheelchair anymore. I walked out of the hospital with a cane. So it's nice to show that people progress pretty well. Still he has a little bit of an altered gait pattern, but improved immensely from where he started. So the clinical utilization of robotics at BNI, and again, we believe that conventional therapy is a very valuable part of the program. And when possible, we try to add robotics to the conventional therapy as an adjunct. And by doing this, we are working to determine what the optimal balance of conventional therapy robotics is, is the right mix. And we're still working to figure that out. And this varies not only for diagnostic groups, such as SCI or stroke, but it also changes on an individual basis as well, depending on the patient's needs and their personality. So these are some of the robotics we use in our clinic at the moment. We have the Bionic Arm Hand, the Recesso Esso Glove, Myoma MyoPro, Tyramotion Diego, ExoBionics BNR, Indigo, Fourier Intelligence Arm Modus M2, ReWalk Restore, and the Airtek Zero-G are just some of the ones we have. And we use these a lot and they get used intermittently with patients and depending on their needs. But on top of those robotics, we also have tons of other technologies. We're very fortunate to have that. So I see this as like having the right tool to treat your patient. Having the variety of tools gives the therapist more options to customize their interventions in the most appropriate manner to meet the needs of the patients, because not all these devices work in the same manner. So even the exoskeletons, they basically do the same task, but each of them have a different way of use case. So having the right device for the right patient at the right time, we feel is very appropriate and important. So challenges with implementation. From a program development standpoint, there are some hurdles you must consider. So the adoption of technology by the staff. And if some staff do not even have the aptitude or desire to want to use this technology, and some do, so finding the right people to use it is important. For us, we have a high volume of devices, and to learn how to use all of these devices and keep that information, it's hard to retain. So making sure you have a good training program is important, and how you set that up. And some staff have varying interests and biases that work with how they work with their patients. Some like to use the ExoGT over the Indigo, just because they're more familiar with it, and that's what we've had for longer than we've had the Indigo. Staff training. Indigo, you have to have an investment for your staff to train them to use these devices. We have balance between education with treatment of the patients. Our managers and leadership is very supportive of the needs of training of the staff, and to provide staff development. So adding robotics and technology to our current model also has its challenges. It's scheduling extra time within the full day of already a full rehab day can be problematic, just based on the rehabilitation needs of the patients. Besides therapy, there's nursing needs, rehab psychology, dietary, respiratory therapy, recreational therapy, and mealtimes, which are not included in the standard requirement three hours of therapy a day. But finding the balance of what works best for the patients, and there's some patients who want to do as much as we had, and one day we had someone who did eight hours of therapy. And when we look at that, then you talk about, well, how do you get reimbursement? Well, reimbursement for robotics and technology is still, I will say, hard to figure out. We're currently held to standards by health care governing bodies to make improvements in the patient's functional status over a time frame. And in inpatient rehab facilities, there's really no billing codes for technology, except for e-STEM. And I'm talking in this, especially in IRFs. So when we're looking at how you build these things, we can't bill a robotics. So sometimes we'll bill whatever functional classification they're working on, if it's therapeutic exercise, neuromuscular training, or those types of things. Other models like outpatient, there goes a fee for service. There may be different opportunities, but right now for inpatient rehab, we're just really looking at how do we bill and make sure we get the right services for the fees. So we will make it an adjunct to conventional therapy. So as you all know, we have to give three hours a day, five days a week. And there's no reimbursement for exceeding the treatment. So our goal is to use robotics as an adjunct. There's times when it's getting used as part of their three hours of therapy, but our goal is to use mostly as adjunct to provide the extra therapy to progress them along. And again, we're lucky to have that ability and get the resources to make sure we can provide those services. And in some occasions, we have patients doing therapy more than their regular time, as well as throughout the day, we sometimes we have patients doing therapy five days a week. So we're looking at implementing and just started implementing a rehab robotics program on the weekend run by occupational therapy students and OTs to, again, provide more services. So as we talked about earlier, what's changing in rehab? Things like NDT and PNF and constraint-induced movement therapy are all 30 years old and more. What is changing more now are materials and technology. Materials such as smaller and lighter motor and actuators, new textiles, power supplies are all example of areas where material science continues to push the boundaries of what we think materials can do. Technology is a rapidly changing field. And the ability of what's being able to be done by new technologies is allowing us to use some of these devices. So the future of robotics in rehab. In speaking with a lot of the experts around the globe, they feel that robotics will play a big role. The current data shows that once you leave the rehab, many patients fall back to the outcome of level of conventional therapy. And so they say, why do you use robotics? Well, there's a lot of issues with that because a lot of times people don't have access to the robotics post-leaving therapy. Some of them decide not to continue with their therapy. Some don't have the same frequency that they do the therapy when they go home. And there's other things such as social acceptance, which become a problem. But one of the things we're also looking at is how do we make this better? So we're looking at using big data. Robots can do one thing that humans can't do very well, and that's collect data. We want to use the data and artificial intelligence to hopefully drive making of clinical treatment pathways and outcome prediction models. And this may affect how we currently do our rehab services and then hopefully how we get reimbursed. Here's a quick reference for the stroke stuff that we presented earlier. And I'd like to thank you so much for your time. I'm going to ask Tina and Seema to come back on and we will answer any questions you have. Again, thank you. I don't see any questions in the chat box, so if there's any questions now would be time. If you have any, we can type them up and do our best to answer them. And as we're waiting for the chat box, I want to kind of echo, Trent talked about it only a little bit, but we have started a new program with our therapy schools here, OT schools, where OT students can come in on the weekend and provide robotic therapy with patients. And I'm very excited about it. First of all, it teaches the students more of the technology. It allows us to offer more hours of therapy. And really one of the complaints I get on the weekend is I didn't have enough to do. And so it helps fill that time in a way that I think can be very beneficial for patients. And hopefully we'll be able to do some case series and then eventually some research, look at how that impacts their outcomes as well. I don't see any questions from anyone. You guys have any questions, you're welcome to email us or reach out to us. And the final thing I would say is that I was not a, I was a huge fan of lower extremity robotics, was not really sure about upper extremity until I really got to see how the patients engaged with them. And I am now convinced that we can really get a great treatment for these patients with a lot of variability. And really, honestly, they do love, if the therapists are learning how to use the device well, the patients get a lot of benefit and they enjoy it. And it's the thing they tell me about when we're seeing them in an outpatient setting, they remind me about things they did on the robotics as an inpatient. So it's very memorable to them. We do have one question, I think it's from Andrew. Andrew, if you want to unmute and ask your question because I don't see it in the chat box. I was having trouble finding a way to message everyone. Sorry about that. And so I'm Andrew Cicillianos, I'm a fourth year resident at Burke Rehabilitation Hospital. Our facility is mostly, it's a standalone inpatient and we have many technologies, robust programs, including inclusive of walk bots and new zero G technologies. And I was wondering how would you scale an already robust technology and cybernetics inpatient program to fill in gaps in the therapies? For instance, let's say we have ways to have patients get lots of steps in from being able to be supported from ceiling or having the walk bot or other types of technologies that can get the steps in, but may not have the vibroplates or any type of vibrational therapies or maybe an upper extremity program. How would you try to scale that type of program to be able to incorporate those technologies while still being cognizant of the business and monetary aspects of a program to get buy-in from the business administration? Trent, you want to take that? Well, when I look at how we end up utilizing device and when we're looking at different gaps that we have, we're trying to find the right device for the right time, but you always balance off the monetary issues, right? Some of these devices are 100, $250,000 and it's hard to manage some of those types of things. As we scale, we look at scaling issues is find the thing that will give you the most benefit in the shortest amount of time. And if that's the next thing you're gonna end up looking at, that's kind of where I'd go to. There's certain tools such as, let's just say the Rapiel, which is a hand sensor glove, is where it only works on one thing, right? Whereas if you use the Zero-G, you can work on balance, gait, functional activities. So something that provides you a little more bang for your buck that covers more of the opportunities is the thing I target next. So after that, I think you start looking at what fills the needs that you're having the most lagging in the way of your devices. So essentially, if I'm understanding you correctly, find technologies that fill in gaps in your therapy programs, things that can address multiple issues. And then from there, have them invited. I know you mentioned earlier, it's better to have hands-on demonstrations, have them at the hospital, see if it would be useful for the patient populations that you have. And then from there, pitch the device to business administration. Yeah, and I would invite business administration to the demo as well as to the patient sessions. So they see the outcomes because sometimes they don't understand those outcomes. And the patient goes, tells them, hey, this worked great, right? So the feedback from the patient is important as well. So if they can see those things, I would include those in some of those trials as well. Nice, all right. Thank you so much. And I would add two other things. First of all, don't be afraid to negotiate. Rather than, we wouldn't just go out and buy something that costs $250,000 without trying it. Use your power to at least have trial periods that patients get in, not just that we see it in some sort of therapy setting like they come out and pitch it to us. And the other thing is don't be afraid to say no. So there's also something, a glove, the music glove that's available in home use. And we brought the device in and frankly, it really didn't have a lot of use. The patients weren't excited about it. That doesn't mean my patients, I don't have some at home who end up getting the device, but the use in inpatient rehabilitation was minimal. So it was okay to say, no, this device is not what we want and we moved on. So there may be one or two therapists that say, oh, you took that away from us, but in the end you gotta make the best decision because too many devices is actually not a good thing either because they become overwhelmed and they don't want to use the devices. So you gotta have, they all have to have a purpose. Right, exactly, yes. Another question from the audience is, are there any grants or foundations that we're aware of to help fund some of these devices? Cause yeah, like the zero G and some of those are close to $300,000 and can be very costly. Oh, we've used local foundations. So our hospital has a foundation. Frankly, it's a very exciting, sexy thing to get funded for rehab. We've done things where we've had people walk around in the exoskeleton at these fancy cocktail parties. Let me tell you, that's a good way to get high-end donors to get excited about something is to see it in person. We've used our local sports teams. They oftentimes, rehabilitation to them is rehabbing injuries. So we've applied for grants multiple times in those areas to be able to maybe not fund the entire but a portion of one. And then really when you get a portion funded it's a lot easier than to go to your administration and say, hey, I got 75% funded. Can you kick in the last 25%? So it is actually the thing that gets me to wanna go to these fundraising shake hands, cocktail party things is when we're talking about robotics and technology. So I think that actually that's the easiest thing to sell to donors. And then the other thing is think about like that video clip that Trent used with that patient. Like those stories are really, I hate to say sexy again but they are for the news media. That is the kind of things that give you free marketing for your institution. And if you start to embed robotics in those now it becomes something that you're known for which then makes it easier to fund it. There was one other question from Susan McDowell why vector over zero G? And I think we're running out of time but really vector over zero G it's really depending on what you like better and what company you have a better relationship with. They're basically, they do the same thing. They both have similar types of software systems but you also may look at who's gonna give you the best deal and definitely talk with the companies about what they have. I'd be glad to answer more of that if you wanna reach out to me separately. Okay, thank you guys for attending. Have a good afternoon. Thanks everybody. Bye.

technology

robotics

inpatient rehabilitation

upper extremity robotics

lower extremity robotics

neuromuscular training

gamification

core strength

implementation plans

big data