Technology Series

Hello, Tomorrow!

Robotics have the potential to impact CRT in a big way. How are startups and researchers tackling the complicated landscape?

• By Haley Samsel
• Mar 01, 2020

When Dan Ding first started as a postdoctoral fellow at the University of Pittsburgh in 2001, she had never heard the term “rehabilitation robotics.” She attended robotics conferences while earning her Ph.D. in Hong Kong, but rarely saw sessions on healthcare applications, much less the type of work that would soon change the complex rehab technology (CRT) industry.

“I don’t think at the time the term was coined,” Ding, now an associate professor in the university’s Department of Rehabilitation Science and Technology, told Mobility Management. “I definitely witnessed the whole growth of this technology’s involvement in rehabilitation and assistive technology, so I feel very fortunate that, before that happened, I was able to get into this field.”

Ding’s early experiences are a far cry from the landscape of robotics in complex rehab today, where new startups have introduced technology ranging from eye-gaze wheelchair controls to blind-spot sensors that can be mounted on several parts of a power chair. Large manufacturers are following suit by integrating new developments, such as patient monitoring technology, into their seat cushions and chairs.

While there is a sense of unlimited possibilities for the applications of robotic technology, experts in the field say there are also immense challenges facing the industry, particularly in terms of the high costs for patients seeking the latest equipment and the regulatory hurdles for CRT companies trying to bring innovative products to market.

For Pooja Viswanathan, the CEO and founder of the Toronto-based blind-spot sensor manufacturer Braze Mobility, the CRT industry is just “skimming the surface” of what’s possible in terms of finding solutions for patients.

“I think there’s tremendous opportunity for growth as long as it’s customer-centric,” Viswanathan said in an interview. “The challenge in robotics is that it often ends up being a technology push. As long as the focus stays on the problems rather than the solutions and on the customer rather than the developer, there is tremendous opportunity.”

A WINDING ROAD FOR IBOT & TOYOTA

The path for robotics in complex rehab has been long and winding over the past two decades, including the widely publicized production (and later discontinuation) of the iBOT stair-climbing wheelchair system.

In 2003, Independence Technology — a division of healthcare giant Johnson & Johnson — introduced the iBOT to rave reviews from mainstream media, who hailed the wheelchair as a revolutionary device that “will force [wheelchair users] to reconsider virtually all the presumed boundaries in the world,” according to one Dateline NBC reporter.

But as Mobility Management reported at the time, Independence Technology hit several snags in its quest to sell the iBOT directly to consumers via clinician assessment and cut CRT providers from the distribution chain. The chair cost $26,000 at the time the company ceased production in 2009, and Medicare declined to classify its seat elevation or stairclimbing abilities as “medically necessary.” While popular with veterans and some clinicians, the iBOT also did not offer typical rehab functions, such as tilt, recline or elevating legrests. In addition, users needed the ability to use a traditional joystick.

In turn, Independence Technology struggled to sell the chair, citing low demand before dissolving in 2009. The iBOT has continued to be revived by other companies, including Toyota North America and most recently by Mobius Mobility, which began promoting the chair last year with some added rehab functions.

Toyota is no longer involved with the iBOT nearly four years after signing an agreement with inventor Dean Kamen to develop the “next generation” of iBOT, according to Doug Moore, GM, Technology for Human Support at Toyota North America. Instead, Toyota has been at work on several mobility-related projects, demonstrating the Japanese mega-corporation’s commitment to becoming a “mobility company” rather than an automotive company, Moore said.

“We have been spending a ton of time, especially in this complex rehab area, making sure that we understand the real needs,” Moore told Mobility Management in an interview. “We’ve been looking at the end customers, whether it’s direct users, caregivers, care receivers or ATPs, PTs, DMEs, all these individuals. We’ve been having conversations across the whole world to understand what are the real challenges and what are the real needs that are out there.”

At the Consumer Electronics Show (CES) 2020 in January, Toyota’s display featured examples of mobility products that would be included in the company’s ideal “Woven City.” Those products included the Human Support Robot (HSR), an AI robot with voice-control capability, and a wheelchair-link battery electric vehicle (BEV) designed for “those who have difficulty walking and those in wheelchairs,” according to a press release.

Moore, who has risen to the top of the robotics team since joining Toyota in 2011, stopped short of committing to any mobility product releases from the company. He noted his experience working on Project BLAID, a wearable device for blind and visually impaired people that the company first publicized in 2016. While that and other mobility products have not been released yet, showcasing that Toyota is focused on developing inclusive products is important, Moore said.

“I’ve intentionally tried to make sure we don’t over-promise and under-deliver, because there’s still a lot of thinking that has to go into these platforms to make sure we can execute it right,” Moore said. “We want to show people that we are thinking and considering the true needs and the true value of what it means to bring solutions to the whole broad community, but at the same time we have to be careful and cautious about what we put out there.”

ROBOTICS PRODUCTS COME TO COMPLEX REHAB

Robotics engineers in the CRT and mobility world have one trait in common: a desire to see their algorithms and technical work turn into an application that changes people’s lives.

For Jay Beavers, a co-founder and managing member of Seattle-based Evergreen Circuits, the inspiration came from Steve Gleason, the former NFL player turned ALS activist. When Gleason challenged a group of Microsoft employees to create a system allowing him to drive his wheelchair with his eyes, they answered the call.

After Microsoft decided not to proceed into the medical device sector, Beavers and his partners created their own company and began to sell the Independence Drive system, which combines a power wheelchair, tablet computer and eye-tracking camera, in 2018.

“The thing that I think robotics will do that will really impact this industry is provide for more independent living and reduce the need for 24-hour caregivers,” Beavers said in an interview. “Japan is kind of on the cusp of this because they’re ahead of us in terms of having an aging population and not having enough caregivers. We in the U.S. are going to need to address the same issue in the next 20 to 30 years. That’s the biggest opportunity.”

Prior to founding Braze Mobility, Viswanathan spent time researching and interviewing wheelchair users, often listening to their concerns about property damage in their homes and the myriad issues that come along with navigating tight spaces in power chairs.

She also recognized that previous attempts to solve the problem had relied too much on self-driving car technology, which is set in outdoor spaces and primarily focuses on getting from “point A to point B” through GPS, she said.

“We realized that the issues here were very, very different to what [previous engineers] thought they were,” Viswanathan said. “It was all indoors and tight spaces: getting through a doorway, getting in and out of an elevator, trying to get in a really tight parking spot, getting on and off public transit. It was very enlightening.”

In 2017, Braze conducted a beta launch of its Hydra and Sentina sensor systems, focusing on connecting with institutions and clinicians rather than customer marketing. Through working with users of the beta product, Viswanathan found that end users were used to being treated as “study participants” rather than feeling shared ownership in the process of developing a product.

“The participants often don’t get a sense that their input is really valued, and they don’t often see where that input is going,” Viswanathan said. “We really flipped that model around … and said: ‘We are the experts in the technology, we can execute, but we have no idea what it is that you need, so you’re really the experts in telling us what the challenge is. You’re the expert in the pain point, and we can execute.’”

Ding, the University of Pittsburgh professor and researcher, has also sought to ensure that engineers consider the experience of end users when developing technology for mobility applications. While working with some “hardcore” engineers on a robotic arm project, Ding noticed that the engineers were more focused on developing a newer algorithm than how the patient would react to it.

“Some of the newer algorithms will have a random component in it, and there is unpredictability because of how this random feed is given, so the user will feel overwhelmed,” Ding said. “They have no idea how this robotic arm is going to move around them, and they don’t like it at all. Even though it eventually helps them achieve the goal, they don’t feel comfortable.”

Once she pointed this out to the other engineers, they were sympathetic and said they had not thought about how this would affect the final application.

“They care about the final performance, but not the whole process, the user involvement, their acceptance or adoption,” Ding said. “Over the years I’ve learned, no matter how well the technology works, people may not use it, and there’s a lot of problems that come with that.”

OVERCOMING INDUSTRY OBSTACLES

Beyond working with end users to develop their products, both Viswanathan and Beavers said they have had to overcome several regulatory and business challenges to enter the CRT industry, whether that meant putting their product on the market without a Medicare code or convincing clinicians and distributors that their innovation brings value to patients.

“One of the things that makes this industry challenging is that it’s not customer acceptance, it’s acceptance of the whole CRT process,” Beavers said. “I’ve known from very early on that there is a high degree of customer desire for Independence Drive, but that does not necessarily mean that it’s going to be a success when it comes to coverage and regulation.”

But the startup founders also said that there are benefits of the system as it is currently laid out.

“A lot of times, it’s pretty easy for another company that’s bigger than you and better capitalized than you to copy your product if you come up with something innovative,” Beavers said. “Here, there are fewer people who are going to do that because you have to develop the knowledge of how to deal with Medicare and the FDA [U.S. Food & Drug Administration], and so it gives you a little more space to develop your product without just anybody copying you.”

As an academic researcher, Viswanathan heard comments about resistance from ATPs and the stereotypes that “clinicians are averse to new technologies.” But after working with clinicians to get them on board with the potential uses of the sensor systems, she came to a different conclusion.

“We found that it was completely false,” she said. “If anything, clinicians were our biggest advocates right from the beginning in terms of giving us critical feedback that was really important. It wasn’t just criticism, it was very constructive, telling us areas we needed to work on.”

Viswanathan noted that it’s easy to criticize the industry by saying that the high number of stakeholders involved stifles technological innovation. But the complexity in the field and the level of customization needed for each individual wheelchair makes innovation difficult in the first place, she said.

Rather than being bothered by the number of gatekeepers in the industry, her main concerns come from the lack of communication between stakeholders.

“I think we’re a very siloed industry where there’s not a whole lot of communication between the healthcare providers and the end users and the manufacturers,” Viswanathan said. “I do think that if we had more open sort of venues and forums for us to talk about these things, I think we could actually, as a community, move things forward a lot better and try to find a better use of resources.”

LIMITATIONS & OPPORTUNITIES FOR THE FUTURE

There is no question that there have been major developments in the use of robotic elements in complex rehab, ranging from the Obi robotic dining companion to the ReWalk exoskeleton systems to the wheelchair products designed by Braze and Evergreen.

Large manufacturers like Permobil have also been on the forefront, with the company’s “connected chair” integrating a tool called Virtual Seating Coach. Ding and other researchers at the University of Pittsburgh developed the technology, which allows patients to monitor how they use power seat functions and learn how to properly take advantage of those functions.

But Ding and her fellow robotic engineers are also some of the first to note the limitations of this technology to fit all users, as well as the challenges that come with high costs due to lack of insurance coverage and the limited market for CRT products.

“People with disabilities are so diverse, and it’s really hard to have one model fits all, and on the other hand, [products] are expensive and we have all these policy issues,” Ding said. “It makes it really hard to make this technology mainstream.”

There’s still work that needs to be done, particularly with how technology can address how people in wheelchairs transfer from one surface to another, Ding said. However, Viswanathan and Moore both pointed to technologies that are not currently being utilized to their full potential for people with disabilities, including computer vision.

“I think that’s where there’s room for growth, for us to re-look at stuff that hasn’t been touched for many years, and say: Is there low-hanging fruit in this world of robotics that allows something to be drawn out and be directly, immediately applicable to the needs of this community?” Moore said.

For Ding, the issue comes down to challenges with educating end users, their families and even clinicians about the technology that is out there. Even with smart home automation technology, it’s difficult for people without a technological background to navigate a confusing landscape of new models and differing reliability, she said.

“The education of the users needs to be somehow together with the technology development,” Ding said. “In one of the projects I have right now, we want to see how this smart home technology can be used by the user and if they continue to use it. A lot of times, you give them something and they use it once, twice, and they may not use it again. There must be something wrong.”

Products incorporating robotic technology will continue to come down the pipeline, including the kind of automation already available in the automotive industry, Viswanathan said. But it’s crucial for engineers, providers and clinicians to realize that a wheelchair is not a car, and many end users view it as an extension of themselves, she added.

“I think that’s really where the work needs to be done,” Viswanathan said. “I don’t think it’s really about pumping out new technologies. I think where the work needs to be done is really in making sure there is more communication and conversation going on between the end users and the people who are developing these products and sharing those lived experiences to create more empathetic designers.”

This article originally appeared in the March 2020 issue of Mobility Management.