Archive for category REHABILITATION


Mobile Measures is a mobile app that offers physical therapists and other providers access to outcome performance measures that assess fall risk, risk of hospitalization, frailty, and more. The app guides users to the best test for more than 40 different patient populations, calculates scores automatically, offers immediate interpretation of the results using the most up-to-date research, and shares results via email to enhance documentation and improve communication. With Mobile Measures, users can visualize the impact of their patient’s condition, track progress, and determine the effectiveness of treatments directly at the point of care, while improving efficiency. Mobile Measures is available on the App Store and Google Play. A free trial is available.

via PHYSICAL THERAPY MEASUREMENT APP | Lower Extremity Review Magazine

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Virtual reality video games, activity monitors, and handheld computer devices can help people stand as well as walk, the largest trial worldwide into the effects of digital devices in rehabilitation has found. The study was undertaken at hospitals in Sydney and Adelaide, Australia, and had 300 participants ranging from 18 to 101 years old. Those who exercised using digital devices in addition to their usual rehabilitation were found to have better mobility (walking, standing up, and balance) after 3 weeks and after 6 months than those who just completed their usual rehabilitation. The results were published in PLOS Medicine.

Trial participants were recovering from strokes, brain injuries, falls, and fractures. Participants used on average 4 different devices while in hospital and 2 different devices when at home. Fitbits were the most used digital device but also tested were a suite of devices like Xbox, Wii, and iPads, making the exercises more interactive and enabling remote connection between patients and their physical therapists. Having a selection meant the physical therapist could tailor the choice of devices to meet the patient’s mobility problems while considering patient preferences.

Lead author Leanne Hassett, PhD, from the Faculty of Medicine and Health at the University of Sydney, said benefits reported by patients using the digital devices in rehabilitation included variety, fun, feedback about performance, cognitive challenge, that they enabled additional exercise, and the potential to use the devices with others, such as family, therapists, and other patients. “These benefits meant patients were more likely to continue their therapy when and where it suited them, with the assistance of digital healthcare,” she said.

Participants reported doing more walking at 6 months, meaning their rehabilitation was improved, but this was not detected in the physical activity measure (time spent upright) generally. In the younger age group, the devices also increased daily step count. Distinctions between physical activity were made through measurements with an activPAL, a small device attached to the thigh that records how much time is spent in different positions (sitting, standing, lying) as well as number of steps taken each day.

This study used research physical therapists to deliver the study; the next step will be to trial the approach in clinical practice by incorporating it into the work of physical therapists.

via VIRTUAL GAMES HELP PEOPLE STAND, WALK IN REHAB | Lower Extremity Review Magazine

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[ARTICLE] Brain-Machine Neurofeedback: Robotics or Electrical Stimulation? – Full Text

Neurotechnology such as brain-machine interfaces (BMI) are currently being investigated as training devices for neurorehabilitation, when active movements are no longer possible. When the hand is paralyzed following a stroke for example, a robotic orthosis, functional electrical stimulation (FES) or their combination may provide movement assistance; i.e., the corresponding sensory and proprioceptive neurofeedback is given contingent to the movement intention or imagination, thereby closing the sensorimotor loop. Controlling these devices may be challenging or even frustrating. Direct comparisons between these two feedback modalities (robotics vs. FES) with regard to the workload they pose for the user are, however, missing. Twenty healthy subjects controlled a BMI by kinesthetic motor imagery of finger extension. Motor imagery-related sensorimotor desynchronization in the EEG beta frequency-band (17–21 Hz) was turned into passive opening of the contralateral hand by a robotic orthosis or FES in a randomized, cross-over block design. Mental demand, physical demand, temporal demand, performance, effort, and frustration level were captured with the NASA Task Load Index (NASA-TLX) questionnaire by comparing these workload components to each other (weights), evaluating them individually (ratings), and estimating the respective combinations (adjusted workload ratings). The findings were compared to the task-related aspects of active hand movement with EMG feedback. Furthermore, both feedback modalities were compared with regard to their BMI performance. Robotic and FES feedback had similar workloads when weighting and rating the different components. For both robotics and FES, mental demand was the most relevant component, and higher than during active movement with EMG feedback. The FES task led to significantly more physical (p = 0.0368) and less temporal demand (p = 0.0403) than the robotic task in the adjusted workload ratings. Notably, the FES task showed a physical demand 2.67 times closer to the EMG task, but a mental demand 6.79 times closer to the robotic task. On average, significantly more onsets were reached during the robotic as compared to the FES task (17.22 onsets, SD = 3.02 vs. 16.46, SD = 2.94 out of 20 opportunities; p = 0.016), even though there were no significant differences between the BMI classification accuracies of the conditions (p = 0.806; CI = −0.027 to −0.034). These findings may inform the design of neurorehabilitation interfaces toward human-centered hardware for a more natural bidirectional interaction and acceptance by the user.


About half of all severely affected stroke survivors remain with persistent motor deficits in the chronic disease stage despite therapeutic interventions on the basis of the current standard of care (Winters et al., 2015). Since these patients cannot use the affected hand for activities of daily living, novel interventions investigate different neurotechnological devices to facilitate upper limb motor rehabilitation, such as brain-machine interfaces (BMI), robotic orthoses, neuromuscular functional electrical stimulation (FES), and brain stimulation (Coscia et al., 2019). BMI approaches, for example, aim at closing the impaired sensorimotor loop in severe chronic stroke patients. They use robotic orthoses (Ang et al., 2015Kasashima-Shindo et al., 2015Belardinelli et al., 2017), FES devices (Kim et al., 2016Biasiucci et al., 2018), and their combination (Grimm et al., 2016cResquín et al., 2017) to provide natural sensory and proprioceptive neurofeedback during movement intention or imagery. It is hypothesized that this approach will lead to reorganization of the corticospinal network through repetitive practice, and might ultimately restore the lost motor function (Naros and Gharabaghi, 20152017Belardinelli et al., 2017Guggenberger et al., 2018).

However, these novel approaches often result in no relevant clinical improvements in severe chronic stroke patients yet (Coscia et al., 2019). Therefore, recent research has taken a refined and rather mechanistic approach, e.g., by targeting physiologically grounded and clinically relevant biomarkers with BMI neurofeedback; this has led to the conceptional differentiation between restorative therapeutic BMIs on the one side (as those applied in this study) and classical assistive BMIs on the other side like those applied to control devices such as wheel-chairs (Gharabaghi, 2016): While assistive BMIs intend to maximize the decoding accuracy, restorative BMIs want to enhance behaviorally relevant biomarkers. Specifically, brain oscillations in the beta frequency band have been suggested as potential candidate markers and therapeutic targets for technology-assisted stroke rehabilitation with restorative BMIs (Naros and Gharabaghi, 20152017Belardinelli et al., 2017), since they are known to enhance signal propagation in the motor system and to determine the input-output ratio of corticospinal excitability in a frequency- and phase-specific way (Raco et al., 2016Khademi et al., 20182019Naros et al., 2019).

However, these restorative BMI devices differ from their predecessors, i.e., assistive BMIs, by an intentionally regularized and restricted feature space, e.g., by using the beta frequency band as a feedback signal for BMI control (Gharabaghi, 2016Bauer and Gharabaghi, 2017). Such a more specific approach is inherently different from previous more flexible algorithms that select and weight brain signal features to maximize the decoding accuracy of the applied technology; restorative BMIs like the those applied in this study have, therefore, relevantly less classification accuracy than classical assistive BMIs (Vidaurre et al., 2011Bryan et al., 2013). As the regularized and restricted feature space of such restorative BMI devices leads to a lower classification accuracy in comparison to more flexible approaches, it may be frustrating even for healthy participants (Fels et al., 2015). IN the context of the present study, we conjectured that such challenging tasks will increase the relevance of extraneous load aspects like the workload (Schnotz and Kürschner, 2007). Furthermore, the modulation range of the oscillatory beta frequency band is compromised in stroke patients, proportionally to their motor impairment level (Rossiter et al., 2014Shiner et al., 2015). That means that more severely affected patients show less oscillatory event-related desynchronization (ERD) and synchronization (ERS) during motor execution or imagery (Pfurtscheller and Lopes da Silva, 1999). To our understanding, this underlines the relevance of beta oscillations as a therapeutic target for post-stroke rehabilitation. At the same time, however, this poses a major challenge for the affected patients and may, thereby, compromise their therapeutic benefit (Gomez-Rodriguez et al., 2011a,bBrauchle et al., 2015).

To overcome these hurdles that are inherent to restorative BMI devices, we have investigated different approaches in the past: (i) Reducing the brain signal attenuation by the skull via the application of epidural interfaces (Gharabaghi et al., 2014b,cSpüler et al., 2014), (ii) Augmenting the afferent feedback of the robotic orthosis by providing concurrent virtual reality input (Grimm et al., 2016a,b), (iii) combining the orthosis-assisted movements with neuromuscular (Grimm and Gharabaghi, 2016Grimm et al., 2016c) or transcranial electrical stimulation (Naros et al., 2016a) to enhance the cortical modulation range (Reynolds et al., 2015), and (iv) optimizing the mental workload related to the use of BMI devices.

In this study, we focus on the latter approach, i.e., optimizing the mental workload related to the use of BMI devices. For the latter approach it would be necessary to better understand the workloads related to different technologies applied in the context of BMI feedback (robotics vs. FES). We, therefore, investigated the mental demand, physical demand, temporal demand, performance, effort, and frustration of healthy subjects controlling a BMI by motor imagery of finger extension. Motor imagery-related sensorimotor desynchronization in the beta frequency-band was turned into passive opening of the contralateral hand by a robotic exoskeleton or FES in a randomized, cross-over block design. The respective workloads were compared to the task-related aspects of active hand movement with EMG feedback. We conjectured a feedback-specific workload profile that would be informative for more personalized future BMI approaches.



We recruited 20 healthy subjects (age = 23.5 ± 1.08 yeas [mean ± SD], range 19–27, 15 female) for this study. Subjects were not naive to the tasks. All were right-handed and reached a score equal or above 60 in the Edinburgh Handedness Inventory (Oldfield, 1971). The subjects gave their written informed consent before participation and the study protocol was approved by the Ethics Committee of the Medical Faculty of the University of Tübingen. They received monetary compensation.

Subject Preparation

We used Ag/AgCl electrodes in a 32 channel setup according to the international 10-20 system (Fp1, Fp2, F3, Fz, F4, FC5, FC3, FC1, FCz, FC2, FC4, FC6, C5, C3, C1, Cz, C2, C4, C6, TP9, CP5, CP3, CP1, CPz, CP2, CP4, CP6, P3, Pz, P4, O1, O2 with TP10 as Reference and AFz as Ground) to examine the cortical activation pattern during the training session. Electrode impedances were set below 10 kΩ. All signals are digitalized at a sampling frequency of 1,000 Hz (robotic block) or 5,000 Hz (FES block) using Brain Products Amplifiers and transmitted online to BCI2000 software. BCI2000 controlled in combination with a custom-made software the respective feedback device, i.e., either the robotic orthosis or the functional electrical stimulation. Depending on the task, one of the following preparations was performed. Either the robotic hand orthosis (Amadeo, Tyromotion) was attached to the subject’s left hand (Figure 1A), fixated with Velcro strips across the forearm and with magnetic pads on the fingertips (Gharabaghi et al., 2014aNaros et al., 2016b); or functional electrical stimulation (FES, Figure 1B) was applied to the M. extensor digitorum communis (EDC) by the RehaMove2 (Hasomed GmbH, Magdeburg) with two self-adhering electrodes (50 mm, HAN-SEN Trading & Consulting GmbH, Hamburg). First an electrode was fixed to the distal end of the EDC’s muscle belly serving as ground. Then a rectangular electrode prepared with contact gel was used to find the optimal place for the second electrode where maximal extension of the left hand could be achieved. Here a custom written Matlab script was executed to detect the current threshold needed for the extension. Starting at 1 mA, the current was increased in steps of 0.5–1 mA. During each trial, FES was applied for 3 s with a pulse width of 1,000 μs and a frequency of 100 Hz. At the beginning of stimulation, a ramping protocol was implemented for 500 ms. Once, the correct position and threshold of stimulation were found, the temporary electrode was replaced by the second stimulation electrode and both were fixed with tape. A mean stimulation intensity of 6.5 mA (SD = 2.27) was required to cause the desired contraction in this study.

Figure 1. Experimental set-up. (Left) Robotic hand orthosis as feedback device (Amadeo, Tyromotion GmbH, Graz). (Middle) Neuromuscular forearm stimulation as feedback device (RehaMove 2, Hasomed GmbH, Magdeburg). In both cases, a brain-machine interface (BMI) detected motor imagery-related oscillations in the beta frequency band by an electroencephalogram (EEG) and provided via a BCI2000-system contingent feedback by moving the hand with either the robot or the electrical stimulation. (Right) The EEG montage used in this study.


Continue —-> Frontiers | Brain-Machine Neurofeedback: Robotics or Electrical Stimulation? | Bioengineering and Biotechnology

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[Abstract + References] Improving wrist imaging through a multicentre educational intervention: The challenge of orthogonal projections

In relation to wrist imaging, the accepted requirement is two orthogonal projections obtained at 90°, each with the wrist in neutral position. However, the literature and anecdotal experience suggests that this principle is not universally applied.

This multiphase study was undertaken across eight different hospitals sites. Compliance with standard UK technique was confirmed if there was a change in ulna orientation between the dorsi-palmar (DP) and lateral wrist projections. A baseline evaluation for three days was randomly identified from the preceding three months. An educational intervention was implemented using a poster to demonstrate standard positioning. To measure the impact of the intervention, further evaluation took place at two weeks (early) and three months (late).

Across the study phases, only a minority of radiographs demonstrated compliance with the standard technique, with an identical anatomical appearance of the distal ulna across the projections. Initial compliance was 16.8% (n = 40/238), and this improved to 47.8% (n = 77/161) post-intervention, but declined to 32.8% (n = 41/125) within three months. The presence of pathology appeared to influence practice, with a greater proportion of those with an abnormal radiographic examination demonstrating a change in ulna appearances in the baseline cohort (p < 0.001) and the late post-intervention group (p = 0.002) but not in the examinations performed two weeks after staff education (p = 0.239).

Assessment of image quality is critical for diagnosis and treatment monitoring. Yet poor compliance with standard anatomical principles was evident. A simple educational intervention resulted in a transient improvement in wrist positioning, but the impact was not sustained over time.

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via Improving wrist imaging through a multicentre educational intervention: The challenge of orthogonal projections – Beverly Snaith, Scott Raine, Lynsey Fowler, Christopher Osborne, Sophie House, Ryan Holmes, Emma Tattersall, Emma Pierce, Melanie Dobson, James W Harcus,

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[WEB PAGE] ReStore Powered Exo-Suit Study Achieves Positive Results

Posted by  | Jun 23, 2020  

ReStore Powered Exo-Suit Study Achieves Positive Results

The majority of participants in a multi-center clinical study of the ReStore Soft Exo-Suit for the rehabilitation of individuals with lower limb disability due to stroke achieved meaningful walking speed improvements, according to ReWalk Robotics Ltd, in a media release.

The study examined patient safety and explored functional walking outcomes in stroke survivors who completed a series of gait training sessions with the ReStore device.

This research was conducted primarily to support the Company’s successful application to the U.S. Food and Drug Administration (FDA) for clearance of the ReStore Exo-Suit, which was issued in June 2019. The company also received CE Marking for the device in May 2019.

The study’s findings were published in the June issue of the Journal of NeuroEngineering and Rehabilitation, and were the result of investigation by five leading U.S. rehabilitation institutions:

  • Shirley Ryan AbilityLab in Chicago;
  • Spaulding Rehabilitation Hospital in Boston, in partnership with Boston University College of Health and Rehabilitation Sciences: Sargent College;
  • MossRehab Stroke and Neurological Disease Center in Elkins Park, Pa;
  • TIRR Memorial Hermann in Houston; and
  • Kessler Foundation in West Orange, NJ.

“This multi-site clinical trial of the safety and feasibility of the ReStore Exo-Suit is an important milestone in the field of rehabilitation technology,” Lou Awad, PT, DPT, PhD, Director of Boston University’s Neuromotor Recovery Laboratory and the site investigator at Spaulding Rehabilitation Hospital for this study, says in the release.

“Physical therapists have historically relied on passive assistive devices to help patients with post-stroke hemiparesis walk safely. As an active assistive device, the ReStore soft robotic exo-suit offers new opportunities to retrain walking after stroke.”

Thirty-six study participants with hemiplegia due to stroke each completed seven total study visits with the ReStore Exo-Suit. In addition to establishing device safety, which was the primary outcome for the study, several exploratory outcome measures were investigated, including a pre- and post-assessment of walking speeds, in which 64% of participants increased their unassisted walking speed by a clinically meaningful margin, the release continues.

Related Stories:
ReWalk Robotics Initiating Clinical Studies of Restore Exoskeleton for Stroke Patients
ReWalk Robotics Introduces Exoskeleton Designed for Stroke Patients
Wyss Institute Collaborating with ReWalk Robotics to Develop Soft Exosuit

“We are thrilled to see the results from the ReStore clinical trial being published in a joint paper authored by the primary investigators from all five of our highly regarded study sites,” says Kathleen O’Donnell, Director of Product Management and Strategy at ReWalk Robotics, headquartered in Marlborough, Mass.

“This work summarizes the first results from the largest soft exo-suit trial to date, and the positive findings in terms of safety and improved walking speeds showcase the potential of this technology to dramatically impact patient outcomes post stroke,” she adds.

The first-of-its-kind ReStore Exo-Suit was unveiled in 2017 and was designed to be a versatile, cost-effective gait therapy solution to train for improved gait by providing coordinated plantarflexion and dorsiflexion assistance to a patient’s impaired foot and ankle, according to the company.

[Source(s): ReWalk Robotics Ltd, PR Newswire]

via ReStore Powered Exo-Suit Study Achieves Positive Results – Rehab Managment

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[Abstract + Referrences] Developing Technique for Arm Movement Rehabilitation of Post Stroke Patient – Proceedings


There are numerous studies and efforts to improve rehabilitation programs for stroke sufferers. Mostly, the sufferers are usually suffered from temporary or permanent paralysis. This leads to rehabilitation as a recommended program to implement so that the sufferers could return to a near-to-normal and independent life. Traditionally, rehabilitation to a certain paralyzed body part, i.e. arms, uses periodic and routine therapy. It is intended to make it pliable doing joint muscle coordination movements. Therefore, this study examines and develops progressive movements to optimize the therapy result. An economical movement principle in assembling systems that is Therbligh motion is applied to the therapy of arm stroke patient movements. The principle of this movement will be compared with the traditional motion therapy used by physiotherapists. From kinematics and biomechanics analysis, it can be known which parts of the joints and muscles which play a role in the movement and how much burden occurs on the muscles or joints. The results of measurements of muscles strength with EMG to both principles of the movement of therapy for arm stroke patients, it was found that the principle of Therbligh movement produced greater muscle strength. Muscles strength is measured in position passive and active muscles.


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via Developing Technique for Arm Movement Rehabilitation of Post Stroke Patient | Proceedings of the 2020 10th International Conference on Biomedical Engineering and Technology

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[Abstract + Similar articles] Interventions for Sexual Dysfunction Following Stroke


Background: Sexual dysfunction following stroke is common but often is poorly managed. As awareness of sexual dysfunction following stroke increases as an important issue, a clearer evidence base for interventions for sexual dysfunction is needed to optimise management.

Objectives: To evaluate the effectiveness of interventions to reduce sexual dysfunction following stroke, and to assess adverse events associated with interventions for sexual dysfunction following stroke.

Search methods: We conducted the search on 27 November 2019. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; from June 2014), in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers.

Selection criteria: We included randomised controlled trials (RCTs) that compared pharmacological treatments, mechanical devices, or complementary medicine interventions versus placebo. We also included other non-pharmacological interventions (such as education or therapy), which were compared against usual care or different forms of intervention (such as different intensities) for treating sexual dysfunction in stroke survivors.

Data collection and analysis: Two review authors independently selected eligible studies, extracted data, and assessed study quality. We determined the risk of bias for each study and performed a ‘best evidence’ synthesis using the GRADE approach.

Main results: We identified three RCTs with a total of 212 participants. We noted significant heterogeneity in interventions (one pharmacological, one physiotherapy-based, and one psycho-educational), and all RCTs were small and of ‘low’ or ‘very low’ quality. Based on these RCTs, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the use of sertraline, specific pelvic floor muscle training, or individualised sexual rehabilitation.

Authors’ conclusions: Use of sertraline to treat premature ejaculation needs to be tested in further RCTs. The lack of benefit with structured sexual rehabilitation and pelvic floor physiotherapy should not be interpreted as proof of ineffectiveness. Well-designed, randomised, double-blinded, placebo-controlled trials of long-term duration are needed to determine the effectiveness of various types of interventions for sexual dysfunction. It should be noted, however, that it may not be possible to double-blind trials of complex interventions.

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[Abstract + Similar articles] Evidence of Chronic Stroke Rehabilitation Interventions in Activities and Participation Outcomes: Systematic Review of Meta-Analyses of Randomized Controlled Trials


Introduction: Stroke is a leading cause of long-term disabilities worldwide. A great deal of meta-analyses of randomized controlled trials (RCTs) address rehabilitation in chronic stroke, several of them with focus on activities and participation, considered critical outcomes of successful rehabilitation. Nevertheless, substantial heterogeneity might exist between studies, the reported associations may be causal, but they might also be flawed, as inherent study biases such as residual confounding and selective reporting of positive results may exaggerate the effect of interventions in chronic phase. Furthermore, most RCTs might focus on specific rehabilitation domains, not paying the same attention to others.

Evidence acqusition: Formal evaluation of published systematic reviews of meta-analyses (January 2008 to November 2018) of rehabilitation in chronic phase to 1) assess the strength of evidence: participants, publication biases, heterogeneity, prediction intervals (PIs) 2) grade the evidence to perform qualitative analysis on effects sizes and heterogeneity, 3) perform meta-regressions and sensitivity analysis on relevant covariates 4) map outcomes to activities and participation domain of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). Systematic review on meta-analyses of RCTs addressing activities and participation will be performed in Medline, Web of Science, Scopus, Cochrane and Google Scholar.

Evidence synthesis: A total of 97 meta-analyses on 31 different rehabilitation interventions involving 25,275 participants were included. Thirty-nine meta-analyses (40.74%) reported statistically significant findings (P<0.05) in both fixed and random effects sizes. Their magnitude was small in 62.96% cases, moderate in 19.75% and large in 17.28%. Heterogeneity was low in 48,48%, moderate and high in 21.2%. The mean number of participants is 815, far away from the convincing, highly suggestive, or suggestive required evidence levels. All PIs include the null value. Mobility is addressed by 87% of the identified meta-analyses, with 75% of them focusing exclusively in mobility.

Conclusions: The findings of this study show a clear need for high quality RCTs examining the effectiveness of rehabilitation interventions addressing activities and participation. The ICF framework may contribute to a holistic approach in chronic stroke rehabilitation, including not only motor functioning but also the ability to participate in everyday life activities.

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[WEB PAGE] Stay Mobile with the New myRehabMedical App

Stay Mobile with the New myRehabMedical App


Rehab Medical, Indianapolis, launches myRehabMedical. Available on both Android and Apple devices, the app provides customers with instant access to order updates, service requests, contact information, live chats, and product tutorials.

“Rehab Medical has a mission to improve lives, and one way we intend to accomplish this is through innovation and the use of technology,” President Kevin Gearheart says, in a media release. “This app provides our patients with a number of tools and options that will make the patient experience second to none.”

Additional app features such as live chats, virtual service support, and mobility-focused content designed to connect those within the complex rehab community will be introduced in the coming months. The app is also HIPPA compliant, requiring multi-factor identification to protect customer information.

“This organization has made a strong commitment to be our industry leader in technology, and this app is proof of that commitment,” Chief Technology Officer Kenny Hicks comments. “We’ve implemented a robust road map for improving our technology. Soon we will be launching additional features to this app, as well as adding new technology to help both our patients and partners.”

Related Content:
Rehab Medical Acquires Mobility Specialists
Rehab Medical Rises to No 12 Among Indiana’s Top 25
Rehab Medical Named One of Indiana’s Best Places to Work

From the initial launch, customers will have a complete listing of all their orders along with a brief overview of the order once they complete registration. A comprehensive library of training videos will also provide tips and tricks on how to get the most out of their equipment.

The myRehabMedical app is now available for download in both the Google Play Store and the Apple Store, as well as online via the web.

For more information, visit Rehab Medical.

[Source: Rehab Medical]

via Stay Mobile with the New myRehabMedical App – Rehab Managment

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[ARTICLE] Reinforced Feedback in Virtual Environment for Plantar Flexor Poststroke Spasticity Reduction and Gait Function Improvement – Full Text



Ankle spasticity is a frequent phenomenon that limits functionality in poststroke patients.


Our aim was to determine if there was decreased spasticity in the ankle plantar flex (PF) muscles in the plegic lower extremity (LE) and improvement of gait function in stroke patients after traditional rehabilitation (TR) in combination with virtual reality with reinforced feedback, which is termed “reinforced feedback virtual environment” (RFVE).


The evaluation, before and after treatment, of 10 hemiparetic patients was performed using the Modified Ashworth Scale (MAS), Functional Ambulatory Category (FAC), and Functional Independence Measure (FIM). The intervention consisted of 1 hour/day of TR plus 1 hour/day of RFVE (5 days/week for 3 weeks; 15 sessions in total).


The MAS and FAC reached statistical significance (P < 0.05). The changes in the FIM did not reach statistical significance (P=0.066). The analysis between the ischemic and haemorrhagic patients showed significant differences in favour of the haemorrhagic group in the FIM scale. A significant correlation between the FAC and the months after the stroke was established (P=−0.711). Indeed, patients who most increased their score on the FAC at the end of treatment were those who started the treatment earliest after stroke.


The combined treatment of TR and RFVE showed encouraging results regarding the reduction of spasticity and improvement of gait function. An early commencement of the treatment seems to be ideal, and future research should increase the sample size and assessment tools.

1. Introduction

Stroke patients suffer several deficits that affect (mildly to severely) the cognitive, psychological, or motor areas of the brain, at the expense of their quality of life []. Although rehabilitation techniques do not only act on the motor deficits [], the effects associated with the interruptions of the corticospinal tract, as well as the subsequent adaptive changes, commonly require specific interventions. Among them, the most important changes are muscle weakness, loss of dexterity, cocontraction, and increased tone and abnormal postures [].

Hemiparesis is the most common problem in poststroke patients, and its severity correlates with the functional capabilities of the individual [], being that impairment of gait function is one of the most important limitations. Furthermore, weakness of the ankle muscles caused by injury to supraspinal centres and spasticity are the most frequent phenomena that limit functionality []. The degree of spasticity of the affected ankle plantar flex (PF) muscles primarily influences gait asymmetry [], which is, in addition to depression, another independent factor for predicting falls in ambulatory stroke patients []. Physiological changes in the paretic muscles, passive or active restraint of agonist activation, and abnormal muscle activation patterns (coactivation of the opposing lower extremity (LE)) have been shown to occur after a stroke and can lead to joint stiffness (foot deformities are present in 30% of stroke patients) [], deficits in postural stabilization, and reduced muscle force generation []. To enhance this postural stability during gait, it seems that poststroke patients with impaired balance and paretic ankle muscle weakness use a compensation strategy of increased ankle muscle coactivation on the paretic side [].

Scientific evidence shows that the use of mixed techniques with different physiotherapy approaches under very broad classifications (i.e., neurophysiological, motor learning, and orthopaedic) provides significantly better results regarding recovery of autonomy, postural control, and recovery of LE in the hemiparetic patient (HP) as compared to no treatment or the use of placebo []. Within the latter techniques, we may emphasize the relearning of motor-oriented tasks [], as well as other approaches based on new technologies (e.g., treadmill [], robotics [], and functional electrical stimulation (FES) []), which are often used as additional treatments to traditional rehabilitation (TR). However, some of these emerging therapies, such as vibratory platforms [], have not been shown yet to produce as positive results as the prior ones. Thus, obtaining better results with mixed and more intensive rehabilitation treatment has been demonstrated []. Therefore, we propose to add the use of virtual reality (VR) techniques to TR to optimize results. We can use the label “VR-based therapy” because it acknowledges the VR system as the tool being used by the clinician in therapy, not as the therapy itself. It is essential to transfer the obtained gains in VR-based therapy to better functioning in the real world []. In this way, the intersection of a promising technological tool with the skills of confident and competent clinicians will more likely yield high-quality evidence and enhanced outcomes for physical rehabilitation patients [].

The application of VR to motor recovery of the hemiparetic LE (HLE) has been addressed by several authors in the last decade [], obtaining satisfactory results, in general terms, in the increase of walking speed [], cortical reorganization, balance, and kinetic-kinematic parameters. Other authors have reported improvements in the balance of patients treated with nonimmersive VR systems based on video games, using specific software and with the guidance of a therapist []. A recent study showed that VR-based eccentric training using a slow velocity is effective for improving LE muscle activity to the gastrocnemius muscle and balance in stroke []; however, the spasticity of PF muscles was not analysed in any of these studies.

Virtual reality acts as an augmented environment where feedback can be delivered in the form of enhanced information about knowledge of results and knowledge of performance (KP) []. There are systems that use this KP through the representation of trajectories during the execution of the movement, as well as visualizing these once performed, to visually check the amount of deviation from the path proposed by the physiotherapist. Several studies demonstrated that this treatment enriched by reinforced feedback in a virtual environment (RFVE) may be more effective than TR to improve the motor function of the upper limb after stroke []. In our study, the use of a VR-based system, together with a motion capture tool, allowed us to modify the artificial environment with which the patient could interact, exploiting some mechanisms of motor learning [], thus allowing greater flexibility and effective improvement in task learning. This system has been highly successful in the functional recovery of the hemiparetic upper extremity [], but its combined effect with TR on the LE has not yet reported conclusive data []. The continuous supply of feedback during voluntary movement makes it possible to continuously adjust contractile activity [], thus mitigating increments in spasticity and cocontraction processes of the patient. These settings are of great significance in motor control, and certain variables (such as the speed of the movement) can be controlled, having a direct influence on spasticity. In this line, the aim of this study is to determine if there is a decrease in the spasticity of the PF muscles and improved gait function, following a program that includes the combination of TR and VR with reinforced feedback, which is called “reinforced feedback virtual environment” (RFVE).

Moreover, as a complementary aim, we analysed the modulatory effects of demographic and clinical factors on the recovery of patients treated with TR and VR. The analysis of the influence of these modulatory variables was focused on better highlighting what type of patients would benefit most from the combined treatment of TR and VR. Particularly, we looked into the effects of age and time elapsed from the moment the stroke occurs until the patient starts neurorehabilitation. As shown in various studies, a better outcome for treatment can be expected for younger patients and for those who start the treatment earlier []. Also, comparisons were made between patients with an ischemic and haemorrhagic stroke, since differences in their recovery prognostic have been reported elsewhere, with better outcomes for the latter group [].[…]

Continue —-> Reinforced Feedback in Virtual Environment for Plantar Flexor Poststroke Spasticity Reduction and Gait Function Improvement

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Figure 2. Patient carrying out a task set out by the physiotherapist in front of the RFVE equipment.

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