Archive for category Tele/Home Rehabilitation
A PhD thesis by Michele Pirovano (Politecnico di Milano, Italy), studying the feasibility of at-home rehabilitation using exergames for stroke patients. It includes the results of a 3-months pilot test using an original exergaming system developed by the author.
Download the thesis for free at http://www.michelepirovano.com/pdf/MichelePirovano_Thesis_Final_2015_01_09.pdf
[Abstract] An Automated Game-Based Variable-Stiffness Exoskeleton for Hand Rehabilitation – Full Text PDF
In this paper, we propose and demonstrate the functionality of a novel exoskeleton which provides variable resistance training for human hands. It is intended for people who suffer from diminished hand strength and low dexterity due to non-severe forms of neuropathy or other ailments. A new variable-stiffness mechanism is designed based on the concept of aligning three different sized springs to produce four different levels of stiffness, for variable kinesthetic feedback during an exercise. Moreover, the design incorporates an interactive computer game and a flexible sensor-based glove that motivates the patients to use the exoskeleton. The patients can exercise their hands by playing the game and see their progress recorded from the glove for further motivation. Thus the rehabilitation training will be consistent and the patients will re-learn proper hand function through neuroplasticity. The developed exoskeleton is intrinsically safe when compared with active exoskeleton systems since the applied compliance provides only passive resistance. The design is also comparatively lighter than literature designs and commercial platforms.
After stroke, sustained hand rehabilitation training is required for continuous improvement and maintenance of distal function. In this paper, we present a system designed and implemented in our lab: the Home-based Virtual Rehabilitation System (HoVRS). Eleven subjects with chronic stroke were recruited to test the feasibility of the system and refine its design and the training protocol to prepare for a future efficacy study. HoVRS was placed at subjects’ homes, and subjects were asked to use the system at least 15 minutes every weekday for 3 months (12 weeks) with limited technical support and remote clinical monitoring. All subjects completed the study without any adverse events. Subjects on average spent 12 hours using the system. Nine out of the eleven subjects improved on the Box and Blocks Test (BBT), and ten improved on the Upper Extremity Fugl-Meyer Assessment (FM) and the Action Research Arm Test (ARAT). The outcomes of this pilot study warrant further investigation of the system’s ability to promote recovery of hand function in subacute and chronic stroke.
Stroke is a leading cause of serious long-term disability in the United States. The incidence of new or recurrent stroke in the US is 795,000 per year and the prevalence of chronic stroke is approximately 7 million (Go et al., 2014). Projections show that by 2030, an additional 3.4 million people or 3.88% of U.S. adults 18 and older will have had a stroke, a 20.5% increase from 2012 (American Stroke Association 2018). At six months post-stroke, about 65% of affected persons continue to have hand deficits that profoundly affect their ability to perform their usual activities and their independence (Dobkin, 2005; Lang, et al. 2006). This leaves a potential market segment of approximately 640,000 persons that may need long-term arm and hand rehabilitation. Restoration of hand function is of utmost importance since it is the loss of hand function that profoundly decreases quality of life by limiting the ability to perform feeding, dressing, and grooming, and further may limit the use of assistive as well as telecommunications technology (Brown et al. 1987, Grimby et al. 1998, Andren et al. 2004, Kwakkel et al. 2008).
Therapy in an inpatient rehabilitation center only lasts about 2-3 weeks. As outpatients, stroke survivors are typically only seen two to three times a week for short time periods. This volume of intervention falls far short of the hundreds of hours needed to re-establish normal hand function. Recently published results of innovative lab-based interventions appear to have a similar problem (Lang et al., 2015, Winstein et al., 2016). It is therefore imperative to develop an intervention that can be delivered at home over a sufficient period of time to elicit improvements.
Innovative telerehabilitation systems have been developed using information and communication technologies to provide rehabilitation services at a distance. Many studies have developed video-game driven systems from commercially available gaming consoles such as Wii and Microsoft Kinect (Metcalf et. al, 2013), however, these systems do not address hand rehabilitation. Other groups, including members of our own team, have examined the use of custom-made telerehabilitation systems (Adamovich et. al, 2005, Turolla et. al., 2013) but they are not commercially available. An ideal home-based telerehabilitation system has to be low cost, easy to setup, able to motivate the user for everyday use, generate progress reports for the user for self-tracking, and provide daily monitoring to remote clinicians. Exciting new technologies have now made this approach possible and hold promise for long-term benefit. These technological advances – for the first time – allow for virtual reality simulations interfaced with discrete finger and hand tracking that are affordable and easy to use.
Our product, the Home Virtual Rehabilitation System (HoVRS), provides intense upper extremity rehabilitation at home. It will allow patients to access hand/arm rehabilitation without the cost and transportation challenges associated with outpatient rehabilitation. HoVRS will consist of five elements: 1) an infrared camera specifically designed to capture finger and arm movements – a substantial improvement over rehabilitation activities provided by commercial game consoles like Kinect or Wii, 2) multiple engaging games that train the hand and arm using commercial gaming mechanics designed to optimize players’ motivation to perform these activities for long periods of time, 3) an optional exoskeleton designed to assist the patient’s arm as it moves against gravity (use of this support can be weaned and eliminated as patients get stronger), 4) monitoring and archiving software that will allow clinicians to design custom rehabilitation interventions, track a patient’s progress, and modify a patient’s rehabilitation program, in-person or remotely, and 5) a secure wireless data connector to collect detailed information on patient movement in real time. The secure communication channel will allow for remote monitoring by clinicians, remote technical support, and remote patient and clinician interaction face to face, while the patient uses HoVRS.
This study describes the experiences of the first eleven persons with stroke that participated in pilot testing of HoVRS in their homes.[…]
Continue —-> HoVRS: Home-based Virtual Rehabilitation System
[ARTICLE] Comparing Home Upper Extremity Activity with Clinical Evaluations of Arm Function in Chronic Stroke – Full Text PDF
[Abstract] Artificial intelligence-based interactive virtual reality-assisted gaming system for hand rehabilitation
Date: February 28, 2020, Source: University of Warwick
Summary: Virtual reality could help physiotherapy patients complete their exercises at home successfully thanks to researchers who managed to combine VR technology with 3D motion capture.
Virtual reality could help physiotherapy patients complete their exercises at home successfully thanks to researchers at WMG, University of Warwick, who managed to combine VR technology with 3D motion capture.
Currently prescribed physiotherapy often requires patients to complete regular exercises at home. Outside of the clinic, patients rarely receive any guidance other than a leaflet of sketches or static photographs to instruct them how to complete their exercises. This leads to poor adherence, with patients becoming anxious about not getting the exercise right, or simply getting bored by the repetitiveness of the movements.
The advent of consumer virtual reality technology combined with 3D motion capture allows real movements to be accurately translated onto an avatar that can be viewed in a virtual environment. Researchers at the Institute of Digital Healthcare, WMG, University of Warwick are investigating whether this technology can be used to provide guidance to physiotherapy patients, by providing a virtual physiotherapist in the home to demonstrate the prescribed exercises.
Their paper, ‘Timing and correction of stepping movements with a virtual reality avatar’ published today the 28th of February, in the Journal PLOS ONE, has focused on whether people are able to accurately follow the movements of a virtual avatar.
Researchers had to investigate whether people were able to accurately coordinate and follow the movements of an avatar in a virtual environment. They asked participants to step in time with an avatar viewed through a VR headset.
Unknown to the participants, the researchers subtly slowed down or speeded up one of the avatar’s steps, such that the participants would have to correct their own stepping movement to stay in time. The effect this correction had on their step timing and synchronisation with the avatar was measured.
Lead author, Omar Khan from WMG, University of Warwick commented:
“If participants were observed to correct their own stepping to stay in time with the avatar, we knew they were able to accurately follow the movements they were observing.
“We found that participants struggled to keep in time if only visual information was present. However, when we added realistic footstep sounds in addition to the visual information, the more realistic multisensory information allowed participants to accurately follow the avatar.”
Dr Mark Elliott, Principal investigator on the project at WMG, University of Warwick added:
“There is huge potential for consumer VR technologies to be used for both providing guidance to physiotherapy exercises, but also to make the exercises more interesting. This study has focused on the crucial question of how well people can follow a virtual guide.”
Prof. Theo Arvanitis, co-author and Director of the Institute of Digital Healthcare, said:
“Our work and digitally-enabled technological solution can underpin transformative health innovations to impact the field of physiotherapy, and have a direct benefit to patients’ rehabilitation. “We now plan to investigate other types of movements working closely in partnership with physiotherapists, to establish the areas of physiotherapy that will benefit most from this technology.”
- Omar Khan, Imran Ahmed, Joshua Cottingham, Musa Rahhal, Theodoros N. Arvanitis, Mark T. Elliott. Timing and correction of stepping movements with a virtual reality avatar. PLOS ONE, 2020; 15 (2): e0229641 DOI: 10.1371/journal.pone.0229641
[Abstract] Optimization of Upper Extremity Rehabilitation by Combining Telerehabilitation With an Exergame in People With Chronic Stroke: A Mixed-Method Study Protocol
Background: Exergames have the potential to provide an accessible, remote approach for post stroke upper extremity (UE) rehabilitation. However, the use of exergames without any follow-up by a health professional could lead to compensatory movements during the exercises, inadequate choice of difficulty level, exercises not being completed and lack of motivation to pursue exercise program, thereby decreasing their benefits. Combining telerehabilitation with exergames could allow continuous adjustment of the exercises and monitoring of the participant completion and adherence. Currently, there is limited evidence regarding the feasibility or efficacy of combining telerehabilitation and exergames for stroke rehabilitation.
Objective: 1) To determine the preliminary efficacy of using telerehabilitation combined with exergames on UE motor recovery, function, quality of life and motivation, in participants with chronic stroke, compared with conventional therapy (the graded repetitive arm supplementary program) 2) To examine the feasibility of using the technology with stroke participants at home 3) To identify the obstacles and facilitators for its use by stroke participants and therapists and understand the shared decision-making process.
Methods: A mixed-methods study protocol is proposed, including a randomized, blinded feasibility trial with an embedded multiple case study. The intervention consists of the provision of a remote rehabilitation program, during which participants will use the Jintronix exergame for UE training and the Reacts Application to conduct video conferenced sessions with the therapists (physical or occupational therapists). We plan to recruit 52 stroke participants, randomly assigned to a control group (n=26, 2 months on-paper home exercise program: the graded repetitive arm supplementary program with no supervision) and an experimental group (n=26, 2 months home program using the technology). A blinded trained evaluator will be responsible for the face to face administration of the outcome measures. The primary outcome is the Fugl-Meyer UE Assessment, a performance-based measure of UE impairment. The secondary outcomes are self-reported questionnaires and include the Motor Activity Log-28 (quality and frequency of use of the UE in 28 everyday tasks), Stroke Impact Scale-16 (impact on quality of life) and Treatment Self-Regulation Questionnaire (motivation). Feasibility data include process (recruitment and retention rates), resources (exercise adherence, time spent with therapist,), management (technical problems)and scientific (safety, simple size) outcomes. Qualitative data will be collected by interviews with both participants and therapists.
Results: We expect to: A) Collect preliminary efficacy data of this technology on the functional and motor recovery of the UE, following a stroke B) collect feasibility data with users at home (adherence, safety, technical difficulties, etc.) and C) identify the obstacles and facilitators for the technology use and understand the shared decision-making process.
Conclusions: This paper describes the protocol underlying the study of a telerehabilitation-exergame technology to contribute to understanding its feasibility and preliminary efficacy for UE stroke rehabilitation.
D Kairy et al. Contemp Clin Trials 47, 49-53. PMID 26655433. – Randomized Controlled TrialFindings will contribute to evidence regarding the use of TR and VR to provide stroke rehabilitation services from a distance. This approach can enhance continuity of car …
Mult Scler 22 (12), NP9-NP11. PMID 26041800.See Nilsagard et al.25Qualitative research approach. Interviewed (15-45 mins) within two weeks after the end of the intervention period. Interview covered refl …
Comparison of Kinect2Scratch Game-Based Training and Therapist-Based Training for the Improvement of Upper Extremity Functions of Patients With Chronic Stroke: A Randomized Controlled Single-Blinded TrialJW Hung et al. Eur J Phys Rehabil Med 55 (5), 542-550. PMID 30781936. – Randomized Controlled TrialKinect2Scratch game training was feasible, with effects similar to those of therapist-based training on UE function of patients with chronic stroke.
KE Laver et al. Cochrane Database Syst Rev 1 (1), CD010255. PMID 32002991. – ReviewWhile there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparat …
KE Laver et al. Cochrane Database Syst Rev 2013 (12), CD010255. PMID 24338496. – ReviewWe found insufficient evidence to reach conclusions about the effectiveness of telerehabilitation after stroke. Moreover, we were unable to find any randomised trials tha …
[Abstract] Effectiveness of home-based virtual reality on vestibular rehabilitation outcomes: a systematic review
Background: A 2015 systematic review evaluated the efficacy of utilizing virtual reality in vestibular rehabilitation programs. However, the biggest limitation with most of the included virtual reality systems was the associated cost of the equipment. In addition, home-based exercises are the preferred method of vestibular rehabilitation treatments.
Objectives: The purpose of this systematic review was to examine the effectiveness of home-based virtual reality systems on vestibular rehabilitation outcomes.
Methods: The following databases were examined: CINAHL Complete, ProQuest Medical Database, and PubMed. The following search terms were utilized: ‘video OR computer’ AND ‘vestibular’ AND ‘home’. The evidence level for all of the included articles was evaluated using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and the methodological rigor for all of the included articles was evaluated using a 10-item tool created by Medlicott and Harris.
Results: Based on the inclusion and exclusion criteria, seven articles were selected for inclusion in this systematic review. This systematic review found that home-based virtual reality interventions were able to effectively achieve the primary objectives of vestibular rehabilitation and that the use of these interventions was equally as effective as the use of a traditional vestibular rehabilitation program. In addition, it may be most beneficial to combine virtual reality with traditional vestibular rehabilitation.
Conclusions: Clinicians should consider using a combination of virtual reality and traditional vestibular rehabilitation when treating individuals who have been diagnosed with a vestibular dysfunction.
Background: Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face or when added to usual care.
Objectives: To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation or usual care. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self-care and domestic life and improved mobility, balance, health-related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions.
Search methods: We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists.
Selection criteria: Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation.
Data collection and analysis: Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings.
Main results: We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies. Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post-hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post-stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke.
Primary outcome: we found moderate-quality evidence that there was no difference in activities of daily living between people who received a post-hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) -0.00, 95% confidence interval (CI) -0.15 to 0.15)). We found low-quality evidence of no difference in effects on activities of daily living between telerehabilitation and in-person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI -0.43 to 0.48).
Secondary outcomes: we found a low quality of evidence that there was no difference between telerehabilitation and in-person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI -0.30 to 0.46). Pooling of three studies with 569 participants showed moderate-quality evidence that there was no difference between those who received post-discharge support interventions and those who received usual care on health-related quality of life (SMD 0.03, 95% CI -0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate-quality evidence that there was no difference in depressive symptoms when comparing post-discharge tele-support programs with usual care (SMD -0.04, 95% CI -0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI -2.17 to 4.64, low-quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in-person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial-related adverse events were reported.
Authors’ conclusions: While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate-level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short-term post-hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in-person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost-effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.
Telerehabilitation Services for StrokeKE Laver et al. Cochrane Database Syst Rev 2013 (12), CD010255. PMID 24338496. – ReviewWe found insufficient evidence to reach conclusions about the effectiveness of telerehabilitation after stroke. Moreover, we were unable to find any randomised trials tha …
Caregiver-mediated Exercises for Improving Outcomes After StrokeJD Vloothuis et al. Cochrane Database Syst Rev 12 (12), CD011058. PMID 28002636. – ReviewThere is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included s …
Educational Interventions for the Management of Cancer-Related Fatigue in AdultsS Bennett et al. Cochrane Database Syst Rev 11 (11), CD008144. PMID 27883365. – ReviewEducational interventions may have a small effect on reducing fatigue intensity, fatigue’s interference with daily life, and general fatigue, and could have a moderate ef …
Virtual Reality for Stroke RehabilitationKE Laver et al. Cochrane Database Syst Rev 11 (11), CD008349. PMID 29156493. – ReviewWe found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb functi …
Pharmacological Interventions for the Treatment of Depression in Chronic Obstructive Pulmonary DiseaseJ Pollok et al. Cochrane Database Syst Rev 12 (12), CD012346. PMID 30566235. – Meta-AnalysisThere is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD-related depression. New RCTs are needed; wi …
XRHealth, formerly known as VRHealth, announces the opening of reportedly the first virtual reality (VR) telehealth clinic. Patients can now obtain virtual reality treatment without leaving their homes.
VR telehealth clinicians providing care are currently certified in Massachusetts, Connecticut, Florida, Michigan, Washington D.C., Delaware, California, New York, and North Carolina and will be expanding their presence in additional states in the coming months. The XRHealth telehealth services are covered by Medicare and most major insurance providers.
XRHealth is designed to use virtual reality to help rehabilitate patients via an immersive and engaging experience in the comfort of their own home. It combines therapeutic software with virtual reality technology solutions to treat a variety of health conditions. VR therapy transports patients to an environment where they can view and experience treatment as a fun activity, increasing patient participation in prescribed therapeutic treatments, according to XRHealth in a media release.
The XRHealth VR telehealth clinicians will provide an initial patient assessment, ship a VR headset to patients who do not currently have access to one, train them on how to use the technology, provide ongoing telehealth care and remote monitoring, using video call and VR technology, and manage the insurance billing for patients. As the patient is using the XRHealth VR technology for therapeutic treatment, the clinical staff can control the unit remotely and see exactly what the patient is viewing and adjust the settings and treatment in real-time, remotely.
After the initial training session, the patient can then use the headset independently while data from the therapy is stored and analyzed in real-time so that clinicians can monitor patient status regularly while in compliance with the HIPAA privacy rules. Once a week, a report will be generated to the payor/provider that referred the patient.
“XRHealth is modernizing and revolutionizing the way healthcare is operating today,” says Eran Orr, CEO of XRHealth, in the release. “We are utilizing the most advanced forms of technology like virtual reality to provide patients with optimal care in the comfort of their own homes while providing top-notch clinicians with ongoing status of their progress. Patients can now ‘go’ to a virtual clinic without the need to leave their homes at all.”
The XRHealth VR telehealth clinics will open on March 1, and patients can join by submitting a request to enroll for the XRHealth services on the company website.