Archive for category Tele/Home Rehabilitation
[WEB SITE] Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke – JAMA Neurology
It’s probably not news to physical therapists (PTs) when research backs up the idea that patients who experience arm impairments poststroke will tend to make greater functional improvements with larger and longer doses of rehabilitation. Unfortunately, PTs are also familiar with the fact that what’s optimal isn’t necessarily what’s typical, with challenges such as payment systems, logistics, and clinic access making it difficult to achieve the best possible results. That’s where telerehabilitation could make a big difference, say authors of a new study that found an entirely remotely delivered rehab program to be as effective as an equal amount of clinic-based sessions.
The findings lend further support to the ideas behind APTA’s efforts to increase telehealth opportunities for PTs and their patients—a significant component of the association’s current public policy priorities. In addition, APTA provides multiple telehealth resources on a webpage devoted to the topic, and has created the Frontiers in Research, Science, and Technology Council that provides interested members and other stakeholders with an online community to discuss technology’s role in physical therapy.
The study, published in JAMA Neurology (abstract only available for free), involved 124 participants who experienced arm motor deficits poststroke. All participants were enrolled in a rehabilitation therapy program that included 36 70-minute treatment sessions, half of which were supervised, over a 6- to 8-week period. The only major difference: one group’s supervised sessions were face-to-face with a physical therapist (PT) or occupational therapist (OT), while the other group received telerehab from a PT or OT via a computer with video capabilities, accompanied by the use of a gaming system.
Researchers were interested in finding out how patients fared in each approach, using scores from the Fugl Meyer (FM) assessment of motor recovery poststroke as their primary measure. Authors of the study also measured patient adherence with therapy as well as levels of patient motivation related to how well they liked the therapy they were receiving and their degree of dedication to treatment goals.
Using a treatment approach “based on an upper-extremity task-specific training manual and Accelerated Skill Acquisition Program,” researchers set up matched programs that included at least 15 minutes per session of arm exercises from a common set of 88 possible exercises, at least 15 minutes of functional training, and 5 minutes of stroke education. The clinic-based participants received in-person instruction on the exercises and used “standard exercise hardware”; the telerehab patients received instructions via video link and engaged in functional exercise via a videogame interface. Here’s what the researchers found:
- Both groups improved at about the same rate, with the telerehab participants averaging a 7.86 FM gain, compared with an average gain of 8.36 points for the clinic-based group.
- Improvements were also about the same for the subgroup of participants who entered rehabilitation more than 90 days poststroke, with these “late” participants averaging a 6.6-point gain for the telerehab group and a 7.4-point increase for the clinic-based group.
- While both groups reported high levels of dedication to treatment goals, the clinic-based group tended to report better levels of motivation and satisfaction. Adherence was also high for both groups, with a 93.4% adherence rate for the clinic-based group and a rate of 98.3% for the telerehab group.
- Both groups increased their knowledge of stroke at similar rates.
As for the technical details of the telerehab sessions, the system included a computer linked to the internet, a table, a chair, and 12 “gaming input devices.” Keyboards were not necessary. The supervised sessions began with a 30-minute videoconference between the patient and therapist, and the functional training games used were designed to match the functional task work being done with the clinic-based participants. Unsupervised sessions adhered to the same content but didn’t include contact with the therapist.
“In an era when prescribed doses of poststroke rehabilitation therapy are declining, adversely affecting patient outcomes, these and prior findings suggest that outcomes could be improved for many patients…if larger doses of rehabilitation therapy were prescribed,” authors write. “Our study found that a 6-week course of daily home-based [telerehab] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic.”
Authors acknowledged that patient satisfaction with telerehab might be improved by increasing the amount of time spent with the therapist—providing that therapist is properly trained. “Current results underscore the importance of maintaining a licensed therapist’s involvement during [telerehab],” they write.
Ultimately, it’s still too early to determine just how generalizable the findings are to other populations and conditions, the researchers say, but all indicators seem to point to the need for increasing the availability of telerehab and its inclusion in health plans.
“The US Bipartisan Budget Act of 2018 expanded telehealth benefits,” authors write. “Eventually, home-based [telerehab] may plan an ascendant role for improving patient outcomes.”
Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.
Researchers at UK-based University of East Anglia (UEA), in collaboration with Evolv Rehabilitation Technologies, have created a new virtual reality (VR) gaming platform designed to help improve the lives of stroke patients suffering from complex neurological syndromes caused by their stroke.
The new technology, which has been funded by the National Institute for Health Research (NIHR), was recently unveiled at RehabWeek in Toronto.
Around 30% to 50% of stroke survivors experience hemispatial neglect, which leaves people unaware of things located on one side of their body and greatly reduces their ability to live independently.
“A stroke can damage the brain, so that it no longer receives information about the space around one side of the world,” lead researcher Dr Stephanie Rossit, from UEA’s school of Psychology, explains in a media release from UEA.
“If this happens, people may not be aware of anything on one side, usually the same side they also lost their movement. This is called hemispatial neglect.
“These people tend to have very poor recovery and are left with long-term disability. Patients with this condition tell us that it is terrifying. They bump into things, they’re scared to use a wheelchair, so it really is very severe and life-changing.”
Current rehabilitation treatments involve different types of visual and physical coordination tasks (visuomotor) and cognitive exercises, many of which are paper and pen-based.
The new non-immersive VR technology being showcased updates these paper and pen tasks for the digital age – using videogame technology instead, per the release.
“We know that adherence is key to recovery – so we wanted to create something that makes it fun to stick to a rehabilitation task,” Roissit adds.
In one such game, the patient sees a random series of apples, some complete and some with a piece bitten off. The apples vibrate and move to provide greater stimulation to the patient.
“The aim for the patient is to choose the maximum number of complete apples that they see in the quickest time possible,” states David Fried, CEO of Evolv.
“A person with visual neglect would quite often only see a small number of correct targets to the right-hand side of the screen. Therapists can control the complexity of the game by increasing or reducing the number of apples on screen.”
As well as aiding diagnosis, the new game aims to improve rehabilitation by including elements such as scoring and rewards to engage the patient and improve adherence to their treatment.
Fried said: “Traditional rehabilitation treatment is quite monotonous and boring, so this gamification aspect is really important to help people stick with their treatment,” Fried adds.
“Our goal is to use technology to make rehabilitation fun and engaging, and we have applied this to our Spatial Neglect therapy solution. The great thing about it is that it can be used not only in clinics but also in patients’ homes, thereby giving them access to personalized rehabilitation without leaving their living room.”
The team has previously worked with stroke survivors, carers, and clinicians to assess the feasibility, usability, and acceptability of new gaming technology, per the release.
Dr Rossit said: ³This technology has the potential to improve both independence and quality of life of stroke survivors,” Rossit shares.
“This innovative therapy could also improve long-term care after stroke by providing a low-cost, enjoyable therapy that can be self-administered anywhere and anytime, without the need for a therapist to be present on every occasion.”
[Source: University of East Anglia]
TRIUMPH TRAUMATIC BRAIN INJURY GUIDELINES 2019
Tele-Rehabilitation Interventions through University-based Medicine for Prevention and Health
[ARTICLE] Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial – Full Text
Virtual reality training (VRT) uses computer software to track a user’s movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery.
Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated.
The results of this study will be used to support the creation of a definitive randomized controlled trial on the efficacy of home-based VRT for rehabilitation post stroke.
Stroke causes approximately 17,600 hospital admissions per year in Ontario and 50% of individuals who have had a stroke are left with moderate to severe impairment [1, 2]. Most patients who are discharged from inpatient stroke rehabilitation are only 8–10 weeks post stroke and have not completely recovered. Their central nervous systems are still in a period of enhanced neuroplasticity, during which great functional change can be made [3, 4]. Therapy outcomes are dose-dependent; intensive, high-repetition, task-oriented and task-specific therapies are most effective [5, 6]. Therefore, for the greatest recovery possible, these patients require ongoing, intensive therapy. Most are offered this on an outpatient basis. However, for many reasons (transportation difficulties, distance from the rehabilitation center, weather etc.), not all eligible patients are able to attend outpatient therapy. Also, there is a waiting list and a limited number of outpatient therapy sessions are offered to each patient. Home-based therapy may fill an important role towards increasing the availability of rehabilitation, enabling patients to enhance or prolong their therapy and potentially improving outcomes.
Non-immersive virtual reality training (VRT) uses computer software to track the user’s movements and allow him or her to interact with a game or activity presented on a TV screen. It is convenient, timely, enjoyable and may be used for an unlimited period post stroke [7, 8]. VRT has been shown to benefit upper extremity function, standing balance, gait and overall function in the sub-acute and chronic phases post stroke, at least as much as or more than conventional therapy [7, 9, 10, 11, 12, 13].
Home-based VRT offers a promising addition or alternative to existing rehabilitation programs that could make a significant difference in the lives of stroke survivors. A few preliminary studies have investigated the use of home-based VRT for standing balance and upper extremity recovery after stroke and shown potential feasibility of these systems for ongoing rehabilitation in the home [14, 15, 16, 17, 18]. Some VRT platforms allow the user to interface via tactile devices (for example, a dynamic standing frame  or robotic glove ) while others use motion-tracking via a camera . Some platforms use asynchronous monitoring to allow the therapist to monitor VRT usage and performance after the actual event  while others use synchronous monitoring to enable the therapist to watch in while the participant exercises; some even require constant real-time patient/therapist interaction [17, 19] throughout the therapy session. Users report high satisfaction with home-based VRT [16, 17], although actual usage can vary greatly . Barriers to the use of home-based VRT include technical issues and lack of previous technical experience . While some previous experience with computers is helpful, those who play video games regularly can become bored with VRT. Facilitators include the flexibility of home-based exercise, support from family and motivation from the VRT itself. Early results, available from a single randomized controlled trial (RCT) with 30 participants, suggest that home-based VRT improves standing balance and gait equally to in-clinic VRT, but that the costs are 44% lower .
We wish to add to these early studies of home-based VRT using a virtual reality system (Jintronix Inc.) that was initially developed for stroke rehabilitation and has also been used extensively with healthy and frail elderly individuals. The Jintronix system is marketed for institutional and home use and has a simple-to-use interface, but its home use has not yet been fully evaluated. The games are designed to incorporate motor learning principles such as multiple forms of feedback and task-specific practice that can be progressed to maintain an appropriate level of challenge. Unlike systems used in previous research, the Jintronix system includes a wide selection of games and exercises designed for the rehabilitation of sitting and standing balance, gait and upper extremity use. The system is simple to use and relatively inexpensive; a motion-tracking camera and software eliminates the need for gloves/controllers etc. It is straightforward enough for the patient to use independently; asynchronous monitoring is used to track usage and the therapist can change games and parameters remotely. The purpose of this study is to investigate the feasibility, acceptance and safety of this new, simple-to-use VRT system for use in the home, combined with asynchronous, remote support for the user. The results of this trial will support a definitive RCT in the future.
To estimate the recruitment rate of participants into the study;
To assess the ability and compliance of the participants with respect to the components of the research protocol (ability to learn VRT through the training program; ability to comply with the exercise protocol; participant retention);
To determine the safety of home-based VRT (presence of minor and major adverse events);
To assess the ability of stroke survivors and their study partners to use VRT technology in the home (i.e. technical difficulties, difficulty learning the games);
To assess the acceptability of the VRT intervention (enjoyment; perceived efficacy);
To estimate the cost for a future definitive RCT on in-home VRT.
To assess the feasibility and acceptance of a battery of outcome measures, including physical assessments, questionnaires, an interview and a log book;
To assess the potential that home-based VRT might maintain or improve physical outcomes of standing balance, gait and general function and community integration after discharge from hospital-based stroke rehabilitation, compared to those who perform a program of iPad apps designed for fine hand motor skills and cognitive training;
To determine the sample size required for a future definitive RCT on in-home VRT.
This study is a prospective, single-site, single-blinded, parallel-group (1:1 ratio) randomized, superiority feasibility trial on the use of VRT for ongoing stroke rehabilitation after discharge from inpatient or outpatient stroke rehabilitation. A feasibility RCT was chosen in order to provide the most useful results to prepare for a future definitive RCT on the efficacy of home-based VRT. iPad apps were chosen as a comparator to VRT because they provide a control group that has equal contact with the researchers and equal time spent in an engaging activity. The use of an active control group (rather than providing control group participants with nothing) was also chosen to facilitate recruitment. The iPad apps chosen to work on hand fine motor control and cognition were not deemed to have any influence on the physical outcome measures of standing balance, gait and gross motor function. The Standard Protocol Items: Recommendation for Interventional Trials (SPIRIT) checklist is available as Additional file 1: Figure S1.[…]
[REVIEW] Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review – Full Text
Transcranial electrical stimulation is a promising technique to facilitate behavioural improvements in neurological and psychiatric populations. Recently there has been interest in remote delivery of stimulation within a participant’s home.
The purpose of this review is to identify strategies employed to implement and monitor in-home stimulation and identify whether these approaches are associated with protocol adherence, adverse events and patient perspectives.
MEDLINE, Embase Classic + Embase, Emcare and PsycINFO databases and clinical trial registries were searched to identify studies which reported primary data for any type of transcranial electrical stimulation applied as a home-based treatment.
Nineteen published studies from unique trials and ten on-going trials were included. For published data, internal validity was assessed with the Cochrane risk of bias assessment tool with most studies exhibiting a high level of bias possibly reflecting the preliminary nature of current work. Several different strategies were employed to prepare the participant, deliver and monitor the in-home transcranial electrical stimulation. The use of real time videoconferencing to monitor in-home transcranial electrical stimulation appeared to be associated with higher levels of compliance with the stimulation protocol and greater participant satisfaction. There were no severe adverse events associated with in-home stimulation.
Delivery of transcranial electrical stimulation within a person’s home offers many potential benefits and appears acceptable and safe provided appropriate preparation and monitoring is provided. Future in-home transcranial electrical stimulation studies should use real-time videoconferencing as one of the approaches to facilitate delivery of this potentially beneficial treatment.
Transcranial electrical stimulation (tES) is a technique used to modulate cortical function and human behaviour. It involves weak current passing through the scalp via surface electrodes to stimulate the underlying brain. A common type of tES is transcranial direct current stimulation (tDCS). Several studies have demonstrated tDCS is capable of modulating cortical function, depending on the direction of current flow [1, 2, 3]. When the anode is positioned over a cortical region, the current causes depolarisation of the neuronal cells, increasing spontaneous firing rates . Conversely, positioning the cathode over the target cortical region causes hyperpolarisation and a decrease in spontaneous firing rates . This modulation of cortical activity can be observed beyond the period of stimulation and is thought to be mediated by mechanisms which resemble long term potentiation and depression . Along similar lines, transcranial alternating current stimulation (tACS) and transcranial random noise stimulation (tRNS) are also forms of tES. Both tACS and tRNS are thought to interact with ongoing oscillatory cortical rhythms in a frequency dependent manner to influence human behaviour [6, 7, 8].
The ability of tES to selectively modulate cortical activity offers a promising tool to induce behavioural change. Indeed, several studies have demonstrated that tES may be a favourable approach to reduce impairment following stroke , improve symptoms of neglect , or reduce symptoms of depression . While these results appear promising, there remains debate around technical aspects of stimulation along with individual participant characteristics that may influence the reliability of a stimulation response [12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22]. However, current evidence does suggest that effects of stimulation may be cumulative, with greater behavioural improvements observed following repeated stimulation sessions . Furthermore, tES has shown potential as a tool for maintenance stimulation, with potential relapses of depression managed by stimulation which continued over several months [23, 24]. Therefore, it may be that repeated stimulation sessions will become a hallmark of future clinical and research trials aiming to improve behavioural outcomes. This would require participants to attend frequent treatment sessions applied over a number of days, months or years. Given that many participants who are likely to benefit from stimulation are those with higher levels of motor or cognitive impairment, the requirement to travel regularly for treatment may present a barrier, limiting potential clinical utility or ability to recruit suitable research participants . In addition, regular daily treatments would also hinder those who travel from remote destinations to receive this potentially beneficial neuromodulation. Therefore, there is a requirement to consider approaches to safely and effectively deliver stimulation away from the traditional locations of research departments or clinical facilities.
One benefit of tES over other forms of non-invasive brain stimulation, such as repetitive transcranial magnetic stimulation, is the ability to easily transport the required equipment. This opportunity may allow for stimulation to be delivered in a participant’s home, which could represent the mode of delivery for future clinical applications. However, it may be unreasonable to expect that a participant would be capable of managing delivery of tES alone and would likely require some form of training and/or monitoring . Although tES is considered relatively safe , stimulation should be delivered within established guidelines to avoid adverse events . Inappropriate delivery of stimulation could result in neural damage, detrimental behavioural effects, irritation, burns or lesions of the skin [28, 29, 30, 31, 32, 33]. Therefore, in order to deliver stimulation safely to the appropriate cortical region, it is likely that in-home stimulation may require some form of monitoring .
It is currently unclear what the best approach is to implement and monitor in-home tES. An early paper proposed several guidelines to perform in home tES . However, these guidelines were not based on evidence from published clinical trials as there were none available at the time of publication. One recent systematic review sought to discuss current work in this area and highlighted the need for further research to investigate safety, technical monitoring and assessment of efficacy . Given the recent, and growing, interest in home-based brain stimulation, we felt it was now pertinent to conduct a review to specifically identify strategies employed to implement and monitor the use of in-home tES in neurological and psychiatric populations. The secondary questions were to report protocol adherence, adverse events and patient perspectives of in-home tES. Understanding optimal treatment fidelity for in-home brain stimulation will be instrumental to achieving higher levels of tES useability and acceptance within a participant’s home.[…]
via Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review | Journal of NeuroEngineering and Rehabilitation | Full Text
Motus Nova is expanding its list of partner hospitals and clinics using its FDA-approved robotic stroke therapy system. It also plans to introduce its system to the consumer market for home use in Q3 2019.
Twenty-five hospitals in the Atlanta area within Emory Healthcare, the Grady Health System, and the Wellstar Health System are now using the Motus Nova rehabilitation therapy system, which is designed to use Artificial Intelligence (AI) to accelerate recovery from neurological injuries such as strokes.
The system features a Hand Mentor and Foot Mentor, which are sleeve-like robots that fit over a stroke survivor’s impaired hand or foot. Equipped with an active-assist air muscle and a suite of sensors and accelerometers, they provide clinically appropriate assistance and resistance while individual’s perform the needed therapeutic exercises.
A touchscreen console provides goal-directed biofeedback through interactive games—which Motus Nova calls “theratainment”—that make the tedious process of neuro rehab engaging and fun.
“It’s a system that has proven to be a valuable partner to stroke therapy professionals, where it complements skilled clinical care by augmenting the repetitive rehabilitation requirements of stroke recovery and freeing the clinician to do more nuanced care and assessment,” says Nick Housley, director of clinical research for Atlanta-based Motus Nova, in a media release.
“And while we continue to fill orders for the system to support therapy in the clinic and hospital, we also are looking to use our system to fill the gap patients often experience in receiving the needed therapy once they go home.”
Clinical studies show that neuroplasticity begins after approximately many 10’s to 100’s of hours of active guided rehab. The healing process can take months or years, and sometimes the individuals might never fully recover. Yet the typical regimen for stroke survivors is only two to three hours of outpatient therapy per week for a period of three to four months.
“These constraints were instituted by the Centers for Medicare & Medicaid Services (CMS) in determining Medicare reimbursement without a full understanding of the appropriate dosing required for stroke recovery, and many private insurers have adopted the policy, as well,” states David Wu, Motus Nova’s CEO.
Motus Nova plans to offer a more practical model, the release continues.
“By making the system available for home use at a reasonable weekly rate as long as the patient needs it, the individual can perform therapy anytime,” Wu adds. “A higher dosage of therapy can be achieved without the inconvenience of scheduling appointments with therapists or traveling to and from a clinic, and without the high cost of going to an outpatient center every time the individual wants to do therapy.”
While the system gathers data about individual performance, AI tailors the regimen to maximize user gains, discover new approaches, minimize side effects and help the stroke survivor realize his or her full potential more quickly.
“By optimizing factors such as frequency, intensity, difficulty, encouragement, and motivation, the AI system builds a personalized medicine plan uniquely tailored to each individual user of the system,” Housley comments.
“Our system is durable, too, proven in clinical trials to deliver an engaging physical therapy experience over thousands of repetitions. We look forward to making it available on a much wider scale in the coming months.”
[Source(s): Motus Nova, PR Newswire]
[Abstract + References] A Preliminary Analysis of a Home-Based Stroke Rehabilitation Program in Windsor, Ontario
Community stroke rehabilitation (CSR) is an effective program for survivors to recover at home supported by a multidisciplinary team. A home-based, specialized CSR program was delivered in Windsor, Ontario, to stroke patients who faced barriers to accessing outpatient services following inpatient rehabilitation. Preliminary results show program patients made significant functional improvements from baseline to program discharge. A subgroup analysis revealed that, after adjusting for age and resource intensity, moderate to severe stroke patients made greater functional gains compared to mild stroke patients. The individualized focus of CSR delivered in the home provides an effective model of rehabilitation for continued stroke care in the community.
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Canadian Journal of Neurological Sciences | Cambridge Core
A new video game-led training device called a myoelectric computer interface (MyoCI), invented by Northwestern Medicine scientists, is enabling severely impaired stroke survivors to regain function in their arms after sometimes decades of immobility.
When integrated with a customized video game, the device helped retrain stroke survivors’ arm muscles into moving more normally. Most of the 32 study participants experienced increased arm mobility and reduced arm stiffness while using it, and retained their arm function a month after finishing the training, according to a study published recently in Neurorehabilitation and Neural Repair.
Many stroke survivors can’t extend their arm forward with a straight elbow because the muscles act against one another in abnormal ways, called “abnormal co-activation” or “abnormal coupling.”
The Northwestern device identifies which muscles are abnormally coupled and retrains the muscles into moving normally by using their electrical muscle activity (called electromyogram, or EMG) to control a cursor in a customized video game. The more the muscles decouple, the higher the person’s score, a media release from Northwestern University explains.
“We gamified the therapy into an ’80s-style video game,” says senior author Dr Marc Slutzky, associate professor of neurology and of physiology at Northwestern University Feinberg School of Medicine and a Northwestern Medicine neurologist. “It’s rather basic graphics by today’s standards, but it’s entertaining enough.”
“The beauty of this is even if the benefit doesn’t persist for months or years, patients with a wearable device could do a ‘tune-up’ session every couple weeks, months or whenever they need it,” adds Slutzky, whose team designed the original device. “Long-term, I envision having flexible, fully wireless electrodes that an occupational therapist could quickly apply in their office, and patients could go home and train by themselves.”
Slutzky also is studying this method on stroke patients in the hospital, starting within a week of their stroke.
Abnormal coupling of muscles leaves many stroke patients with a bent elbow, which makes it difficult to benefit from typical task-based stroke-rehabilitation therapies, such as training on bathing, getting dressed and eating.
Only about 30% of stroke patients in the United States receive therapy after their initial in-patient rehabilitation stay, often because their injury is too severe to benefit from standard therapy, it costs too much, or they’re too far from a therapist. This small, preliminary study lays the groundwork for inexpensive, wearable, at-home therapy options for severely impaired stroke survivors, the release continues.
“We’re still in the very early stages, but I’m hopeful this may be an effective new type of stroke therapy,” Slutzky states. “The goal is to one day let patients buy the training device inexpensively, potentially without even needing insurance and use it wirelessly in their home.”
Patients in the study were severely impaired – could only slightly move their arm and extend their elbow – and had had their stroke at least 6 months prior to beginning the study. The average patient was more than 6 years out from their stroke, and some were decades out.
After Slutzky’s intervention, study participants could, on average, extend their elbow angle by 11 degrees more than before the intervention, which was a pleasant surprise, Slutzky comments.
This type of treatment only requires a small amount of muscle activation, which is advantageous for severely impaired stroke patients who typically can’t move enough to even begin standard physical therapy. It also gives feedback to the patient if they’re activating their muscles properly.
To identify which muscles were abnormally coupled, study participants attempted to reach out to multiple different targets while the scientists recorded the electrical activity in eight of their arm muscles using electrodes attached to the skin. For example, the biceps and anterior deltoid muscles in the arm often activated together in stroke participants, while they normally shouldn’t.
Then, to retrain the muscles into moving normally (ie, without abnormally co-activating), the participants used their electrical muscle activity to control a cursor in a customized video game. The two abnormally coupled muscles moved the cursor in either horizontal or vertical directions, in proportion to their EMG amplitude, the release continues.
For example, if the biceps would contract in isolation, the cursor would move up. If the anterior muscles would contract in isolation, the cursor would move to the side. But if the muscles would contract together, the cursor would move diagonally.
The goal was to move the cursor only vertically or horizontally – not diagonally – to acquire targets in the game. To get a high score, participants had to learn to decouple the abnormally coupled muscles.
Muscles tend to produce more electrical muscle activity when contracting isometrically (without moving) compared to when moving the arm freely, but the ultimate goal of this training is to enable home use. One goal of this study was to see if participants could benefit without restraining the arm as much as with restraining the arm.
Participants were broken into three groups: 60 minutes of training with their arm restrained; 90 minutes of training with their arm restrained; and 90 minutes of training without arm restraints. Overall, arm function improved substantially, in all groups and there was no significant difference between the three groups, the release concludes.
[Source(s): Northwestern University, News-Medical Life Sciences]
[ARTICLE] A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems – Full Text
Innovation and technological advances involve the offering of valuable products and services to improve the quality of life of citizens. In recent decades, the domain of telemedicine has reported advances in the control, monitoring and evaluation of various clinical conditions . In the field of rehabilitation, numerous studies and state-of-the-arts from informatics perspective  and different areas of application [3, 4], show the effectiveness and advantages of the use of remote rehabilitation (or tele-rehabilitation) [5, 6]. Tele-rehabilitation aims to reduce the time and costs of offering rehabilitation services. The main objective is to improve the quality of life of patients . Tele-rehabilitation cannot replace traditional neurological rehabilitation . It is considered as a partial replacement of face-to-face physical rehabilitation . Tele-rehabilitation uses mainly two groups of technologies: (1) wearable devices and (2) vision-based systems based on depth cameras and intelligent algorithms . In , the authors describe and analyze some characteristics and typical requirements tele-rehabilitation systems.
Design and conception of tele-rehabilitations platforms that do not consider guidelines, metrics, patterns, principles, or practice success factors can affect the access to the service, the effectiveness, quality, and usefulness. It can cause problems of confusion, error, stress, and abandonment of the rehabilitation plan. Therefore, guaranteeing the correct use of these applications implies to incorporate different studies of usability in the life cycle of the interactive system. For this reason, aspects of human factors engineering in tele-rehabilitation systems have been studied with the aim of providing accessible, efficient, usable and understandable systems [11, 12].
User-centered agile development (UCD) approaches allows developers to specify and design the set of interfaces of any interactive system in a flexible and effective way [13, 14]. The agile development life cycle centered on user experience (UX-ADLC) allows iteratively evaluating system interfaces based on the results of the previous iteration. The evaluation also includes the errors and usability problems encountered . Thus, usability studies are an essential aspect of technology development . This is the reason why designers need to meet usability and user experience objectives while adhering to agile principles of software development. Formative and summative usability tests are methods of evaluating software products widely adopted in user-centered design (UCD)  and agile UX development lifecycle. Both approaches are frequently used in the development of software applications. Rapid formative usability should be carried out so as to fulfill UX goals while satisfying end users’ needs. Formative usability is used as an iterative test-and-refine method performed in the early steps of a design process, in order to detect and fix usability problems . Summative usability allows for assuring, in later phases of the design, the quality of the user experience (UX) for a software product in development. The focus is on short work periods (or iterations) where usability tests (formative and summative) must be contemplated. This means that quick formative usability tests should be carried out to fulfill UX goals .
The ISO 9241-11 standard  is a framework for understanding and applying the concept of usability to situations in which people use interactive systems and other types of systems (including built environments), products (including industrial and consumer products) and services (including technical and personal services). Likewise, the usability standard ISO 9241-11 facilitates the measurement of the use of a product with the aim of achieving specific objectives with effectiveness, efficiency and satisfaction in a context of specific use .
Usability can be studied through software evaluation methods widely accepted in user centered design (UCD) . It can be formative or summative . Formative usability consists of a set of iterative tests carried out in the early stages of the design process. The aim of the tests is to refine and improve the software product, as well as to detect and solve potential usability problems. As a complement, the summative usability allows to obtain an evaluation of the user experience (UX) for a software product in development. Formative usability facilitates decision making during the design and development of the product, while summative usability is useful when studying user experience (UX).
Tullis and Stetson  evaluated the effectiveness of the most used questionnaires to measure the summative usability. The authors found that the System Usability Scale (SUS)  and the IBM Computer System Usability Questionnaire (CSUQ)  are the most effective. SUS provides a quick way for measuring the usability through user experience. It consists of a 10-item questionnaire with 5-likert scale range from “Strong Agree” to “Strongly Disagree.” The CSUQ focuses on three main aspects: (1) the utility, which refers to the opinion of users regarding the ease of use, the ease of learning, the speed to perform the operations, the efficiency in completing tasks and subjective feeling; (2) the quality of the information which studies the subjectivity of the user regarding the management of system errors, the clarity of the information and the intelligibility; and finally, (3) the quality of the interface which measures the affective component of the user’s attitude in the use of the system.
Large part of the tasks in the tele-rehabilitation systems are carried out by patients who require to treat a temporary disability. Considering the special needs of these users, usability evaluations alone cannot guarantee an appropriate design of the system. On the contrary, accessibility studies can provide the mechanisms to offer the same means of use to all users of any interactive system. A study combining usability and accessibility was presented in . The study analyzes how remote and/or video monitoring technologies affect the accessibility, effectiveness, quality and usefulness of the services offered by tele-rehabilitation systems. To do this, the authors provide an overview of the fundamentals necessary for the analysis of usability, in addition to analyzing the strengths and limitations of various tele-rehabilitation technologies, considering how technologies interact with the clinical needs of end users such as accessibility, effectiveness, quality and utility of the service .
For many people, the Web is a fundamental part of everyday life. Therefore, a fundamental aspect to ensure the inclusivity of a Website is its accessibility. For example, people who cannot use their arms to write on their computer can use a mouth pencil . Or someone who cannot listen well can use subtitles to understand a video. Also, a person who has a low vision can use a screen reader to listen what is written on the screen . Therefore, Web accessibility means that people with disabilities can use the Web without any type of barriers . There are several standards related to accessibility that provide guidelines and recommendations . Some of the most important, according to the International Organization for Standardization (ISO), are the following ones:
ISO 9241: covers ergonomics of human-computer interaction.
ISO 14915 (software ergonomics for multimedia user interfaces): multimedia controls and navigation structure.
ISO CD 9241-151 (software ergonomics for World Wide Web user interfaces): designs of Web user interfaces.
ISO TS 16071 (guidance on accessibility for human-computer interface): recommendations for the design of systems and software applications that allows a greater accessibility to computer systems for users with disabilities.
ISO CD 9241-20: accessibility guideline for information communication, equipment and services.
The Web Accessibility Initiative (WAI)  from the World Wide Web Consortium (W3C)  develops Web Content Accessibility Guidelines (WCAG)  2.0 (at present 2.1) that covers a wide range of recommendations for making Web contents more accessible. These guidelines were considered a standard in 2012, the ISO/IEC 40500. Complementary to these guidelines are the W3C User Agent Accessibility guidelines  (UAAG) and Authoring tool Accessibility guidelines  (ATAG), which addresses the current technological capabilities to modify the presentation based on the device capabilities and the preferences of the user.
The World Wide Web Consortium (W3C) provides international standards to make the Web as accessible as possible. It comprises the Web 2.0 Content Accessibility Guidelines (WCAG 2.0) , also known as the ISO 40500 , which are adapted to the European Standard called EN 301549 .
The current version of the accessibility guidelines is “Web Content Accessibility Guidelines 2.1” (WCAG 2.1) . WCAG 2.1 consists of 4 principles, 13 guidelines and 76 compliance criteria. The four principles refer to .
Principle 1—perceptibility: refers to the good practices regarding the presentation of information and user interface components. It consists of 4 guidelines and 29 compliance criteria.
Principle 2—operability: the components of the user interface and navigation must be operable. It includes 5 guidelines and 29 compliance criteria.
Principle 3—comprehensibility: the information and user interface management must be understandable. It has 3 guidelines and 17 compliance criteria.
Principle 4—robustness: the content must be robust enough to rely on the interpretation of a wide variety of user agents, including assistive technologies. It includes a guideline and three compliance criteria.
Usability and accessibility can be combined to achieve the development of more accessible, efficient, equitable and universal tele-rehabilitation systems. This chapter presents a systematic literature review of summative and formative usability studies as well as accessibility studies in the context of tele-rehabilitation systems. The remaining of the manuscript is composed of four sections. Section 2 presents the method used to proceed with the systematic review. Section 3 is a description of the most relevant papers in usability applied to tele-rehabilitation. Section 4 describes the results regarding the accessibility. And Section 5 draws conclusions on the main findings of this literature review.[…]