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

2. Standardized vs. Customized Interventions Studies examining robotically facilitated and virtually simulated rehabilitation have produced outcomes equivalent to optimized protocols of traditionally presented rehabilitation These studies utilize standardized protocols applied to large groups. Kwakkel 2007, Mehrholz 2008, Lo 2009, Laver 2012, Saposnik 2012 Fluet-Merians-Adamovich (Unpublished)

3. Standardized vs. Customized Interventions Multiple authors cite the flexibility of robotic systems as one of their major strengths. Adamovich 2009, Brewer 2009 Hypothesis Could studies of robotic rehabilitation that utilize a highly standardized protocol be underestimating the potential effectiveness of this modality?

4. Customized Interventions Task Parameter Adaptation Parameters for successful completion of a task are modified as the intervention is performed in an attempt to maintain the highest training intensity possible Merians 2011, Cameriao 2011 & 2012

5. Objectives Present an intervention utilizing robots integrated with virtual environments designed to address the specific impairments demonstrated by an individual subject. Discuss modifications of the intervention made based on the subjects responses to the intervention

6. Subject Uses a power wheelchair for mobility but is able to walk up to 150 feet with contact guard using a cane. Performs self care with 25-50% assistance Performs PT / OT 2-3 hours biweekly x 4 years in his home PM is an 85 year-old gentleman with left hemiparesis secondary to an intracerebral hemorrhage five years prior to his examination.

7. Case Timeline Pre Test 1 UEFMA WMFT JTHF MFR 24 Hour Activity 4Weeks Home PT & OT 3 Hours 2 x Week Pre Test 2 UEFMA WMFT JTHF MFR 24 Hour Activity Kinematics SIS 4 Weeks NJIT- RAVR Training 90 Minutes 3 X Week Post Test UEFMA WMFT JTHF 24 Hour Activity MFR Kinematics SIS

8. Intervention Three ninety minute sessions / week 4 weeks Six simulated activities Impairment chosen to address Initial configuration Modified configuration based on response

9. Reach Touch Synergistic extension of his trunk during shoulder flexion (Arm elevation AROM) Stable Trunk Workspace is increased daily Simulation recalibrated weekly

10. Cup Reach Synergistic extension of his trunk during shoulder flexion (coordination of trunk flexion and arm elevation) Encouraged a forward trunk flexion, then reach strategy Workspace is increased daily Simulation recalibrated weekly Helped subject challenge himself during final week calibration

11. Virtual Piano Trainer Inability to flex fingers individually Poor response to first week Added CyberGrasp 100% of second week 5 Minutes of CybeGrasp third week No CyberGrasp final week

12. Hammer Task Finger Extension (dynamic) Difficulty stabilizing hand while manipulating objects Increased or decreased target size based on success or failure of preceding rep 1.018 cm/sec 0.626 cm/sec x z x y z

13. Space Pong Difficulty controlling the aperture of his hand 100% Gain 30% Gain Small response to first week of training Scaled gain down Weaned back over balance of intervention

14. Hammer Task Pronation (fixed) Difficulty performing activities requiring pronation of his hand Poor initial response Scaled gain up No consistent response

15. Clinical Outcomes Impairment Level

16. Clinical Outcomes Activity Level

17. Synergistic trunk extension during arm elevation

18. Outcomes Kinematics during untrained activity start object 1 2 3 target

19. Outcomes Participation Level 24 Hour Activity Monitoring

20. Discussion No adverse responses Robust improvements Activity level Participation level Despite…….. chronic stroke advanced age multiple co- morbidities extensive rehab history

21. Customized Six activities chosen from a suite of 18 Modified 2 original configurations 4 modified configurations Discussion Correlation between improvements in simulation performance and functional improvements Rohafza 2012 Resulting in improved performance in 5/6 simulations

22. Conclusion Expansion of the examination of robotically facilitated / virtually simulated rehabilitation to include: Customized interventions Modified based on patient performance Leverage a larger percentage of the advantages unique to these training modalities ………..

23. Thank you !! University of Medicine and Dentistry of New Jersey New Jersey Institute of Technology NJIT NJIT-RAVR Lab Rehab Team Collaborators Alma S. Merians PT, PhD Gerard G. Fluet DPT, PhD Soha Saleh PhD Qinyin Qiu PhD Ian La Fond MS Sergei Adamovich PhD Andrea R. Delmonico OTR-L Vivianna Ruano PT Approval by the Institutional Review Boards of UMDNJ and NJIT Supported by NIH Grant RO1 HD58301