Archive for category Tele/Home Rehabilitation

[Abstract] Tele-health, wearable sensors and the Internet. Will they improve stroke outcomes through increased intensity of therapy, motivation and adherence to rehabilitation programs?

Provisional Abstract
Background and Purpose
Stroke, predominantly a condition of older age, is a major cause of acquired disability in the global population and puts an increasing burden on healthcare resources. Clear evidence for the importance of intensity of therapy in optimizing functional outcomes is founded in animal models, supported by neuroimaging and behavioral research, and strengthened by recent meta-analyses from multiple clinical trials. However, providing intensive therapy using conventional treatment paradigms is expensive and sometimes not feasible due to patients’ environmental factors. This paper addresses the need for cost-effective increased intensity of practice and suggests potential benefits of telehealth (TH) as an innovative model of care in physical therapy.

Summary of Key Points
We provide an overview of TH and present evidence that a web-supported program used in conjunction with Constraint Induced Therapy (CIT), can increase intensity and adherence to a rehabilitation regimen. The design and feasibility testing of this web-based program, ‘LifeCIT’ is presented. We describe how wearable sensors can monitor activity and provide feedback to patients and therapists. The methodology for the development of a wearable device with embedded inertial measurement units and mechanomyography sensors, algorithms to classify functional movement, and a graphical user interface to present meaningful data to patients to support a home exercise program is explained.

Recommendations for Clinical Practice
We propose that wearable sensor technologies and TH programs have the potential to provide cost-effective, intensive, home-based stroke rehabilitation.

Source: JUST ACCEPTED: “Tele-health, wearable sensors and the Internet. Will they improve stroke outcomes through increased intensity of therapy, motivation and adherence to rehabilitation programs?” |

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[ARTICLE] User-centered design of a patient’s work station for haptic robot-based telerehabilitation after stroke – Full Text

Abstract:

Robotic therapy devices have been an important part of clinical neurological rehabilitation for several years. Until now such devices are only available for patients receiving therapy inside rehabilitation hospitals. Since patients should continue rehabilitation training after hospital discharge at home, intelligent robotic rehab devices could help to achieve this goal. This paper presents therapeutic requirements and early phases of the user-centered design process of the patient’s work station as part of a novel robot-based system for motor telerehabilitation.

1 Introduction

Stroke is one of the dominant causes of acquired disability [1] and it is the second leading cause of death worldwide [2]. The high incidence of the disease and the current demographic developments are likely to increase the number of stroke patients in the future. Most of the survivors have physical, cognitive and functional limitations and require intensive rehabilitation in order to resume independent everyday life [3]. Therefore, the main goal of motor rehabilitation is relearning of voluntary movement capability, a process which takes at least several months, some improvement can occur even after years. In the rehabilitation clinic, patients usually receive a daily intensive therapy program. However, for further improvement of motor abilities, severely affected patients are required to continue their rehabilitation training outside the rehabilitation settings, after being discharged from the rehabilitation clinic. Langhammer and Stanghelle [4] found that a lack of follow-up rehabilitation treatment at home leads to deterioration of activities of daily living (ADL) and to motor functions in general. A possible solution is an individualized and motivating telerehabilitation system in the patient’s domestic environment. Some studies [5], [6] have confirmed the advantage of home rehabilitation after stroke and showed that telerehabilitation received high acceptance and satisfaction, both from patients, as well as from health professionals [7]. Most of the existing telesystems [7], [8] are based on audio-visual conferencing or on virtual environments and contain rather simple software for monitoring patients’ condition. However, in neurological rehabilitation the sensorimotor loop needs to be activated by provision of physiological haptic feedback (touch and proprioception) [3].

Robot-based rehabilitation is currently one of the most prevalent therapeutic approaches. It is often applied in hospitals alongside conventional therapy and is beneficial for motor recovery [9]. Rehabilitation training including a haptic-therapy device may therefore be even more promising for home environments than non-haptic telerehabilitation. Several telerehabilitation systems, which include not only audio and visual, but also haptic modality, already exist [10], [11] . Most of these solutions use low-cost commercial haptic devices (e.g. joysticks) for therapy training, with the goal of cost minimization and providing procurable technology. Nonetheless, devices specifically developed for stroke rehabilitation, which are already established in clinical settings, may have greater impact on motor relearning and could therefore also be more effective at home, compared with existing home rehabilitation devices.

In a previous paper [12], we presented a concept and design overview of a haptic robot-based telerehabilitation system for upper extremities which is currently under development. In the present work, we describe therapeutic requirements, user-centred development [13] and implementation of the patient’s station of the telesystem.

Continue —> User-centered design of a patient’s work station for haptic robot-based telerehabilitation after stroke : Current Directions in Biomedical Engineering

Figure 3 Implementation of the patient’s work station based on Reha-Slide (left) and Bi-Manu-Track (right).

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[Abstract] Delivering Remote Rehabilitation at Home: An Integrated Physio-Neuro Approach to Effective and User Friendly Wearable Devices – SpringerLink

Abstract

There is a global shortage of manpower and technology in rehabilitation to attend to the five million new patients who are left disabled every year with stroke. Neuroplasticity is increasingly recognized to be a primary mechanism to achieve significant motor recovery. However, most rehabilitation devices either limit themselves to mechanical repetitive movement practice at a limb level or focus only on cognitive tasks. This may result in improvements in impairment but seldom translates into effective limb and hand use in daily activities. This paper presents an easy-to-use, wearable upper limb system, SynPhNe (pronounced like “symphony”), which trains brain and muscle as one system employing neuroplasticity principles. A summary of clinical results with stroke patients is presented. A new, wireless, home-use version of the solution architecture has been proposed, which can make it possible for patients to do guided therapy at home and thus have access to more therapy hours.

Source: Delivering Remote Rehabilitation at Home: An Integrated Physio-Neuro Approach to Effective and User Friendly Wearable Devices | SpringerLink

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[Abstract] Delivering occupational therapy hand assessment and treatment sessions via telehealth

Telehealth offers a solution to assist delivery of occupational therapy (OT) services for hand therapy in rural and remote locations. However, there is currently no evidence to validate this service model. The aim of this study was to examine the validity of clinical decisions made during hand therapy sessions conducted via telehealth compared to a traditional clinical model (TCM) assessment, and explore patient and clinician satisfaction.

Eighteen patients referred for hand therapy to a rural/remote hospital-based outpatient service were assessed simultaneously via telehealth and a TCM assessment. An allied health assistant supported data collection at the patient end. Hand function was assessed using a range of objective measures, subjective scales and patient reported information. Minimal level of percent exact agreement (PEA) between the telehealth OT (T-OT) and the TCM-OT was set at ≥80%.

Level of agreement for all objective measures (dynamometer and pinch gauge reading, goniometer flexion and extension, circumference in millimetres) ranged between 82% and 100% PEA. High agreement (>80% PEA) was also obtained for judgements of scar and general limb function, exercise compliance, pain severity and sensitivity location, activities of daily living and global ratings of change (GROC) scores. There was 100% PEA for overall recommendations. Minimal technical issues were experienced. Patient and clinician satisfaction was high.

Clinical decisions made via telehealth were comparable to the TCM and consumers were satisfied with telehealth as a service option. Telehealth offers the potential to improve access to hand therapy services for rural and remote patients.

Source: Delivering occupational therapy hand assessment and treatment sessions via telehealth – Feb 13, 2017

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[REVIEW] Self-Assisted Upper Limb Rehabilitation Devices, A Comprehensive Review – Full Text PDF

Abstract

For the purpose of Upper Limb rehabilitation, the use of mechanical and robot assisted rehabilitation the rapiesarenota new concept. Such system sallow patients to perform the rapies with minimalorno assistance. The complexity of such systems vary from being as simple as a custom made bars to highly so phisticated roboticexo skeletons. The advancement of robotics and motor control mechanisms has fueled interest in this domain and we see a lot of development in the field of robot assisted rehabilitation with in a comparatively short span of time. This paper presents a review and tabulates the results of a few selected rehabilitation devices. The devices include mechanical as well as intelligent robotics based rehabilitation devices.

INTRODUCTION

Self-assisted rehabilitation devices target those patients who are capable of carrying out upper limb rehabilitation routines themselves by using less impaired limb to control the most impaired one. The main advantage of self-performed rehabilitation exercises is that they allow a patient to vary thetrainingintensityandfrequencyofaparticularroutineasp ertherequirement and capability and hence increasing the effectiveness of that exercise in rehabilitation. The more robust and ergonomic a system is, the more effective will be there habilitation routines which in turn improve the recovery time of the patient. A patient with limited upper arm mobility can easily and efficiently operate a particular rehabilitation system only if it is: …

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[ARTICLE] A Rehabilitation-Internet-of-Things in the Home to Augment Motor Skills and Exercise Training – Full Text

Although motor learning theory has led to evidence-based practices, few trials have revealed the superiority of one theory-based therapy over another after stroke. Nor have improvements in skills been as clinically robust as one might hope. We review some possible explanations, then potential technology-enabled solutions.

Over the Internet, the type, quantity, and quality of practice and exercise in the home and community can be monitored remotely and feedback provided to optimize training frequency, intensity, and progression at home. A theory-driven foundation of synergistic interventions for walking, reaching and grasping, strengthening, and fitness could be provided by a bundle of home-based Rehabilitation Internet-of-Things (RIoT) devices.

A RIoT might include wearable, activity-recognition sensors and instrumented rehabilitation devices with radio transmission to a smartphone or tablet to continuously measure repetitions, speed, accuracy, forces, and temporal spatial features of movement. Using telerehabilitation resources, a therapist would interpret the data and provide behavioral training for self-management via goal setting and instruction to increase compliance and long-term carryover.

On top of this user-friendly, safe, and conceptually sound foundation to support more opportunity for practice, experimental interventions could be tested or additions and replacements made, perhaps drawing from virtual reality and gaming programs or robots. RIoT devices continuously measure the actual amount of quality practice; improvements and plateaus over time in strength, fitness, and skills; and activity and participation in home and community settings. Investigators may gain more control over some of the confounders of their trials and patients will have access to inexpensive therapies.

Neurologic rehabilitation has been testing a motor learning theory for the past quarter century that may be wearing thin in terms of leading to more robust evidence-based practices. The theory has become a mantra for the field that goes like this. Repetitive practice of increasingly challenging task-related activities assisted by a therapist in an adequate dose will lead to gains in motor skills, mostly restricted to what was trained, via mechanisms of activity-dependent induction of molecular, cellular, synaptic, and structural plasticity within spared neural ensembles and networks.

This theory has led to a range of evidence-based therapies, as well as to caricatures of the mantra (eg, a therapist says to patient, “Do those plasticity reps!”). A mantra can become too automatic, no longer apt to be reexamined as a testable theory. A recent Cochrane review of upper extremity stroke rehabilitation found “adequately powered, high-quality randomized clinical trials (RCTs) that confirmed the benefit of constraint-induced therapy paradigms, mental practice, mirror therapy, virtual reality paradigms, and a high dose of repetitive task practice.”1 The review also found positive RCT evidence for other practice protocols. However, they concluded, no one strategy was clearly better than another to improve functional use of the arm and hand. The ICARE trial2 for the upper extremity after stroke found that both a state-of-the-art Accelerated Skill Acquisition Program (motor learning plus motivational and psychological support strategy) compared to motor learning-based occupational therapy for 30 hours over 10 weeks led to a 70% increase in speed on the Wolf Motor Function Test, but so did usual care that averaged only 11 hours of formal but uncharacterized therapy. In this well-designed RCT, the investigators found no apparent effect of either the dose or content of therapy. Did dose and content really differ enough to reveal more than equivalence, or is the motor-learning mantra in need of repair?

Walking trials after stroke and spinal cord injury,38 such as robot-assisted stepping and body weight-supported treadmill training (BWSTT), were conceived as adhering to the task-oriented practice mantra. But they too have not improved outcomes more than conventional over-ground physical therapy. Indeed, the absolute gains in primary outcomes for moderate to severely impaired hemiplegic participants after BWSTT and other therapies have been in the range of only 0.12 to 0.22 m/s for fastest walking speed and 50 to 75 m for 6-minute walking distance after 12 to 36 training sessions over 4 to 12 weeks.3,9 These 15% to 25% increases are just as disappointing when comparing gains in those who start out at a speed of <0.4 m/s compared to >0.4 to 0.8 m/s.3

Has mantra-oriented training reached an unanticipated plateau due to inherent limitations? Clearly, if not enough residual sensorimotor neural substrate is available for training-induced adaptation or for behavioral compensation, more training may only fail. Perhaps, however, investigators need to reconsider the theoretical basis for the mantra, that is, whether they have been offering all of the necessary components of task-related practice, such as enough progressively difficult practice goals, the best context and environment for training, the behavioral training that motivates compliance and carryover of practice beyond the sessions of formal training, and blending in other physical activities such as strengthening and fitness exercise that also augment practice-related neural plasticity? These questions point to new directions for research….

Continue —> A Rehabilitation-Internet-of-Things in the Home to Augment Motor Skills and Exercise Training – Mar 01, 2017

Figure 1. Components of a Rehabilitation-Internet-of-Things: wireless chargers for sensors (1), ankle accelerometers with gyroscopes (2) and Android phone (3) to monitor walking and cycling, and a force sensor (4) in line with a stretch band (5) to monitor resistance exercises.

 

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[ARTICLE] A modular telerehabilitation architecture for upper limb robotic therapy – Full Text

Several factors may prevent post-stroke subjects from participating in rehabilitation protocols, for example, geographical location of rehabilitation centres, socioeconomic status, economic burden and lack of logistics surrounding transportation. Early supported discharge from hospitals with continued rehabilitation at home represents a well-defined regimen of post-stroke treatment. Information-based technologies coupled with robotics have promoted the development of new technologies for telerehabilitation. In this article, the design and development of a modular architecture for delivering upper limb robotic telerehabilitation with the CBM-Motus, a planar unilateral robotic machine that allows performing state-of-the-art rehabilitation tasks, have been presented. The proposed architecture allows a therapist to set a therapy session on his or her side and send it to the patient’s side with a standardized communication protocol; the user interacts with the robot that provides an adaptive assistance during the rehabilitation tasks. Patient’s performance is evaluated by means of performance indicators, which are also used to update robot behaviour during assistance. The implementation of the architecture is described and a set of validation tests on seven healthy subjects are presented. Results show the reliability of the novel architecture and the capability to be easily tailored to the user’s needs with the chosen robotic device.

Figure 10.
Subject 1 performing 80 repetitions of the clock-game in unassisted simulated post-stroke condition: Cartesian position (upper left side), Cartesian velocity (right upper side), x component of hand velocity over time during NW forward/backward movement (lower left side) and y component of hand velocity over time during NW forward/backward movement (lower right side).

Continue —> A modular telerehabilitation architecture for upper limb robotic therapy – Jan 01, 2017

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[Abstract] An observational study of Australian physiotherapy consultations to explore the prescription of strategies.

Abstract

Objective

The aim of the study was to explore the types of self-management strategies prescribed; the number of strategies and the overall length of time allocated to self-management prescription, by consultation type and by injury location, in physiotherapy consultations.

Methods

A cross-sectional, observational study of 113 physiotherapist–patient consultations was undertaken. Regression analyses were used to determine whether consultation type and injury location were associated with the number of strategies prescribed and the length/fraction of time spent on self-management.

Results

A total of 108 patients (96%) were prescribed at least one self-management strategy – commonly exercise and advice. The mean length of time spent on self-management was 5.80 min. Common injury locations were the neck (n = 40) and lower back (n = 39). No statistically significant associations were observed between consultation type or injury location for either outcome (number of strategies and the length/fraction of time allocated to self-management prescription).

Conclusion

Physiotherapists regularly spend time prescribing self-management strategies such as exercise, advice, and the use of heat or ice to patients receiving treatment linked to a range of injury locations. This suggests that self-management is considered to be an important adjunct to in-clinic physiotherapy. The practice implications of this are that clinicians should reflect on how self-management strategies can be used to maximize patient outcomes, and whether the allocation of consultation time to self-management is likely to optimize patient adherence to each strategy.

Source: An observational study of Australian private practice physiotherapy consultations to explore the prescription of self-management strategies – Peek – 2017 – Musculoskeletal Care – Wiley Online Library

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[WEB SITE] Silver Linings: Remote rehab – Telehealth helps seniors recover in rural areas – New Hampshire

Samuel Brown, 86, uses a video game form of telerehabilitation at the New Jewish Home in New York City as Director of Cardiac Rehabiliation Programs Bridgett Zimmermann watches. The home is launching a pilot program that will send these units into patients’ homes. (GRETCHEN GROSKY/Union Leader)

Silver Linings: Remote rehab — Telehealth helps seniors recover in rural areas, By GRETCHEN M. GROSKY, New Hampshire Union Leader

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Melly said the use of Jintronix at the New Jewish Home has resulted in a 60 percent reduction in rehospitalizations of these patients.

“The more engaged the patient is, the better their outcome is,” Melly said.

At the center, Melly said you will see others in the rehabilitation room or patient’s families gather around to cheer on the patient as they go for soccer goals or reach the pinnacle of a rock climb.

“How much fun is that?” she said.

On this day, Brown scored a 6 out of 6 in soccer and 5 out of 6 in skiing. When he leaves the facility, Brown said he plans on buying a Wii videogame console to keep up with his therapy.

“It’s something I can do at home,” he said.

Evin said Jintronix is actually safer than a Wii for people like Brown because the program is tailored to the patient and the patient’s progress is monitored by their health team and tracked.

The future

Bartels said there is “a lot of activity” in the field of telerehabilitation and there are other similar programs in development. He points to the future in sensors.

At Northeastern University, researchers are studying the use of sensors in ceilings to track a person’s movement, their gait, and their level of exercise. He said a person’s gait tells a lot about a person’s health. He said it’s one thing to watch a person walk across the room once for the doctor – it’s another thing to watch a person walk 50 times back and forth a day between the bedroom and the kitchen.

“A slower gait may mean an infection or something with medication and side effects or they’re depressed,” Bartels said.

At the Dartmouth Institute they are using sensors to monitor overweight elders.

Melly said she expects the New Jewish Home to be using more of this type of technology in the future.

“It’s the case of technology finally catching up with the medical needs,” she said.

Silver Linings is a continuing Union Leader/Sunday news report focusing on the issues of New Hampshire’s aging population and seeking out solutions. Union Leader reporter Gretchen Grosky would like to hear from readers about issues related to aging. She can be reached at ggrosky@unionleader.com or (603) 206-7739. See more at www.unionleader.com/aging.

Source: Silver Linings: Remote rehab — Telehealth helps seniors recover in rural areas | New Hampshire

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[ARTICLE] Efficacy of home-based visuomotor feedback training in stroke patients with chronic hemispatial neglect – Full Text

Hemispatial neglect is a severe cognitive condition frequently observed after a stroke, associated with unawareness of one side of space, disability and poor long-term outcome. Visuomotor feedback training (VFT) is a neglect rehabilitation technique that involves a simple, inexpensive and feasible training of grasping-to-lift rods at the centre. We compared the immediate and long-term effects of VFT vs. a control training when delivered in a home-based setting. Twenty participants were randomly allocated to an intervention (who received VFT) or a control group (n = 10 each). Training was delivered for two sessions by an experimenter and then patients self-administered it for 10 sessions over two weeks. Outcome measures included the Behavioural Inattention Test (BIT), line bisection, Balloons Test, Landmark task, room description task, subjective straight-ahead pointing task and the Stroke Impact Scale. The measures were obtained before, immediately after the training sessions and after four-months post-training. Significantly greater short and long-term improvements were obtained after VFT when compared to control training in line bisection, BIT and spatial bias in cancellation. VFT also produced improvements on activities of daily living. We conclude that VFT is a feasible, effective, home-based rehabilitation method for neglect patients that warrants further investigation with well-designed randomised controlled trials on a large sample of patients.

Continue —> Efficacy of home-based visuomotor feedback training in stroke patients with chronic hemispatial neglect: Neuropsychological Rehabilitation: Vol 0, No 0

Figure

Figure 3 of 5 Figure 3. (A) Lesion map for individual patients. B-C) Lesion overlap map summarising the degree of involvement for each voxel in the intervention (B; N = 8) and control (C; N = 5) groups. Lesions were identified by a clinical neurologist (K.M.), who was blind to the design, group assignment and purpose of the study. Lesions were mapped onto 11 axial slices of a T1-weighted template, corresponding to the MNI z coordinates of −24, −16, −8, 0, 8, 16, 24, 32, 40, 50, 60 mm using identical or closest matching transverse slices for each patient using MRIcro software package (Rorden & Brett, 2000 Rorden, C., & Brett, M. (2000). Stereotaxic display of brain lesions. Behavioural Neurology, 12, 191–200. doi: 10.1155/2000/421719 [CrossRef], [PubMed], [Web of Science ®] ). Due to technical difficulties at the clinical facility, we were able to obtain and map digital brain scans for 13 patients only (6 MRIs and 7 CTs) as the remaining digital brain scans were either lost or corrupted. Please note however, that all brain scan reports were available and confirmed the presence of a stroke and its location for all our patients. The range of colour scale derives from the absolute number of patient lesions involved in each voxel.

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