Archive for category Tele/Home Rehabilitation
[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.[…]
[ARTICLE] Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial – Full Text
After discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to “maintenance” rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.
One hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician’s prescription.
The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.
This study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.
The most common motor deficit following stroke is spastic hemiparesis . More than 90% of patients with hemiparesis recover some lower limb function after a stroke, but rarely with a level of ease or speed that would allow for independent and comfortable ambulation in everyday life, outdoors in particular [1, 2, 3]. In the upper limb, the proportion of patients that recover daily use of the arm is estimated between 10 and 30% [4, 5, 6, 7, 8]. Consequently, around half of stroke survivors do not resume professional activities, and two thirds remain chronically disabled .
In parallel, most patients in chronic stages have their rehabilitation discontinued or converted into “maintenance” therapy, as professionals often estimate that they might no longer progress [7, 10, 11, 12, 13, 14, 15]. Others benefit from reinduction periods, prescribed according to subjective or ill-defined criteria. It has not been demonstrated that this conventional rehabilitation system now fits current knowledge on behavior-induced brain plasticity and on the potential for motor recovery in chronic spastic paresis [16, 17, 18]. Indeed, a significant body of evidence demonstrates that high intensity of rehabilitation (the opposite of “maintenance therapy”) correlates with motor function improvement in chronic stages [16, 19, 20]. One way to achieve sufficient amounts of physical treatment might be to adequately guide and motivate the patient into practicing self-rehabilitation [18, 20]. It has been confirmed that programs of exercises given by the therapist to be performed at home are appreciated by patients not only for the structure they give to everyday life, but also as they represent in themselves a source of motivation and hope, particularly when these programs are associated with ongoing professional support [21, 22].
We hypothesize that there is confusion between the lesion-induced plasticity of the central nervous system – essentially during the first 6 months post-lesion – and the behavior-induced plasticity, which lasts indefinitely [16, 17, 23, 24, 25, 26, 27]. The latter justifies initiatives to organize chronic and intense physical rehabilitation work [17, 18, 23, 24, 25, 26, 27, 28]. Even though previous, short-term open studies evaluating self-rehabilitation programs in spastic hemiparesis suggested the possibility of functional improvement, to our knowledge there are no large-scale prospective randomized controlled protocols that test the effectiveness of long term self-rehabilitation programs in spastic hemiparesis as against conventional rehabilitation systems, especially in chronic stages [29, 30, 31, 32, 33, 34, 35, 36].
Technically, which home rehabilitation exercises might be recommended? From a neurophysiological point of view, muscle overactivity chronologically emerges as the third fundamental feature of motor impairment that begins in the subacute phase in hemiparesis, following paresis and soft tissue contracture that appear in the acute phase [37, 38, 39]. One recognizable form of muscle overactivity is spasticity (hyper-reflectivity to phasic stretch), which is potentiated by muscle shortening [37, 38]. Hypersensitivity to stretch in an antagonist muscle also impedes voluntary motoneurone recruitment for the agonist muscle, a phenomenon called “stretch-sensitive paresis” . As none of the three fundamental mechanisms of motor impairment (paresis, muscle shortening, and muscle overactivity) is distributed symmetrically between agonists and antagonists, there are force imbalances around joints, hindering active movements and deforming body postures . Each of these three mechanisms of impairment, particularly the two most important, which are muscle shortening and muscle overactivity, can be specifically targeted with local treatment, muscle by muscle, aiming to rebalance forces, joint by joint . For the less overactive muscles around each joint, an intensive motor training will aim to break the vicious cycle Paresis-Disuse-Paresis . For their shortened and more overactive antagonists most importantly, a daily program of self-stretch postures at high load combined with a program of maximal amplitude rapid alternating movements, potentially associated with botulinum toxin injections, will aim to increase muscle extensibility and reduce cocontraction, breaking the vicious cycle: Muscle shortening-Overactivity-Muscle shortening [28, 42, 43] (www.i-gsc.com). Significant preliminary results obtained using prescription and teaching of self-rehabilitation programs within a Guided Self-rehabilitation Contract (GSC) led us to hypothesize that this method practiced over the long term might enhance active motor function in chronic hemiparesis beyond 1 year following stroke [18, 44, 45, 46, 47, 48].
From a social point of view, stroke is the leading cause of acquired disability in Western countries. For the Steering Committee on Stroke Prevention and Management in France, the yearly cost of stroke is €5.9 billions, the cost of care in medical and social facilities is €2.4 billions and the cost of daily allowances and disability pensions is €125.8 millions . Additionally, several studies have shown that indirect costs were proportional to direct costs . Stroke thus accounts for a large share of health expenditures. In that regard as well, devising a feasible and effective guided self-rehabilitation program might offer financial advantages for our health systems.[…]
A large scale retrospective study of post-stroke rehabilitation practices compares outcomes among patients using tablet-based therapy at home and those who complete the same therapy in a clinic.
The study, published in Frontiers in Neurology, analyzed data from 3,686 Constant Therapy users—patients with post-stroke aphasia—over a 4-year period (2013-2017).
In the study, home users and clinic users completed cognitive and language tasks such as Functional Math, Name Pictures, Map Reading, and Auditory Commands that are featured in the Constant Therapy app. Home users worked independently while clinic users worked under the guidance of a clinician. The study compared improvement rates for both groups, who were initially struggling with a task (less than 60% accuracy) but eventually mastered it (more than 90% accuracy), explains a media release from The Learning Corp.
Key findings include:
- Home users took less time to master tasks than users who only practiced in the clinic. While both home and clinic users required roughly the same amount of practice to master cognitive and language tasks, users who had on-demand access to therapy on their tablet mastered tasks in a median of six days, while those with only in-clinic access mastered tasks in a median of 12 days.
- Home users practiced therapy more frequently than clinic users. Users who had access to digital therapy on their own terms took advantage of practicing at home at least every two days, while clinic users practiced in the clinic just once every five days.
- Improvements are possible long after a stroke has occurred. Thousands of people in the study, regardless of where they practiced, showed significant gains in language and cognitive skills even though their stroke occurred long ago (on average two years ago for home users and average of 1.6 years ago for clinic users).
- Improvements aren’t just for the young. While the average age of home users was 60 years old and the average age of clinic users was 64 years old, nearly one third (29%) of users were 71 years old or more, and the oldest user was 97 years old.
Veera Anantha, president and CTO of The Learning Corp, suggests that the study’s findings show that home users who practice often can also progress quickly, which may mean they are ready to work on more challenging tasks in their next home or clinic session.
“These insights from real world patient experience could help update existing guidelines and highlight areas for future study to uncover how improvements in specific tasks can help people living post-stroke regain the skills they cherish, such as reading a newspaper, having a complete conversation, or ordering from a menu at a restaurant,” Anantha states.
A previous study published in Frontiers in Human Neuroscience examined the effectiveness of Constant Therapy among a group of 51 patients. It provided preliminary evidence for the usefulness of a tablet-based platform to deliver tailored language and cognitive therapy to individuals with aphasia, per the release.
[Source(s): The Learning Corp, Business Wire]
[Abstract] Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial
We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke.
A single-blinded, 2-sequence, 2-period, crossover-designed study.
Rehabilitation clinics and participant’s home environment.
Individuals with disabilities poststroke.
During each intervention period, each participant received 12 training sessions, with a 4-week washout phase between the 2 periods. Participants were randomly allocated to home-based rehabilitation first or clinic-based rehabilitation first. Intervention protocols included mirror therapy and task-specific training.
MAIN OUTCOME MEASURES:
Outcome measures were selected based on the International Classification of Functioning, Disability and Health. Outcomes of impairment level were the Fugl-Meyer Assessment, Box and Block Test, and Revised Nottingham Sensory Assessment. Outcomes of activity and participation levels included the Motor Activity Log, 10-meter walk test, sit-to-stand test, Canadian Occupational Performance Measure, and EuroQoL-5D Questionnaire.
Pretest analyses showed no significant evidence of carryover effect. Home-based rehabilitation resulted in significantly greater improvements on the Motor Activity Log amount of use subscale (P=.01) and the sit-to-stand test (P=.03) than clinic-based rehabilitation. The clinic-based rehabilitation group had better benefits on the health index measured by the EuroQoL-5D Questionnaire (P=.02) than the home-based rehabilitation group. Differences between the 2 groups on the other outcomes were not statistically significant.
The home-based and clinic-based rehabilitation groups had comparable benefits in the outcomes of impairment level but showed differential effects in the outcomes of activity and participation levels.
Post-stroke arm motor function recovery progressed just as well, whether the exercises were performed via home-based telemedicine or in an office environment, according to a randomized trial discussed recently at the International Stroke Conference.
Improvement in arm motor function on the Fugl-Meyer scale was 7.86 points with telerehab versus 8.36 points at day 30, which met noninferiority criteria, Steven Cramer, MD, of the University of California Irvine, reports, in a media release from Medpage Today.
Arm recovery exceeded the minimal clinically important difference in both groups and didn’t differ between rehab strategies by aphasia status.
“What we’re trying to do with home-based telehealth does not compete with or replace traditional rehab medicine. It is expanding tools,” Cramer adds.
ISC session moderator Louise McCullough, MD, PhD, of the University of Texas Health Science Center at Houston, agreed but noted some advantages to rehab from home.
“If we can optimize it… there could be huge cost savings,” she comments, “and especially for people in rural areas, like lots of Texas does not have access to rehab. It might be 2 hours away. This gives more options for people.”
The NIH StrokeNet trial included 124 adults who were 4 to 36 weeks post-ischemic or hemorrhagic stroke and had a baseline arm motor Fugl-Meyer score of 22 to 56 on the 66-point scale.
Treatment consisted of 36 sessions (18 supervised) of 70 minutes each, over 6 to 8 weeks. Intensity, duration, and frequency of therapy were matched between groups. Participants were randomized to therapy at home via telemedicine or in a traditional clinic setting with the same Accelerated Skill Acquisition program (impairment focused, task specific, and with intensive engagement), the release explains.
Telerehab patients started their supervised sessions with a video conference where they worked with the therapist.
For the 15 minutes of the session that was functional training, the in-clinic group got functional tasks whereas the home-based group got functional games. “This is not your father’s Wii game,” Cramer notes, in the release.
The games could be set to emphasize targets in specific parts of the visual field and could vary in speed, range of motion, target size, and cognitive demand. Input devices to play the games ranged from a squeezing device to a “whack-a-mole” mallet and a gun.
Patients’ preference to go to clinic appears to be because of that live social interaction. McCullough continues. “We now know social isolation is very common. But if you have low vision or you live alone, it’s really difficult to get to clinic. So now we have to get it so the preference is to do it at home.”
“I think that social interaction is going to be really important to fold into our telemedicine and telehealth platforms for whatever disease,” she adds.
[Source: Medpage Today]
[Abstract] Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials
To study the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning in stroke.
A systematic literature search was conducted in 6 databases from January 2000 to May 2018.
Inclusion criteria applied the patient, intervention, comparison, outcome, study design framework as follows: (P) stroke; (I) technology-based distance physical rehabilitation interventions; (C) any comparison without the use of technology; (O) physical functioning; (S) randomized controlled trials (RCTs). The search identified in total 693 studies, and the screening of 162 full-text studies revealed 13 eligible studies.
The studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and assessed for methodological quality and quality of evidence. Meta-analysis was performed if applicable.
A total of 13 studies were included, and online video monitoring was the most used technology. Seven outcomes of physical functioning were identified-activities of daily living (ADL), upper extremity functioning, lower extremity functioning, balance, walking, physical activity, and participation. A meta-analysis of 6 RCTs indicated that technology-based distance physical rehabilitation had a similar effect on ADL (standard mean difference 0.06; 95% confidence interval: -0.22 to 0.35, P=.67) compared to the combination of traditional treatments (usual care, similar and other treatment). Similar results were obtained for other outcomes, except inconsistent findings were noted for walking. Methodological quality of the studies and quality of evidence were considered low.
The findings suggest that the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning might be similar compared to traditional treatments in stroke. Further research should be performed to confirm the effectiveness of technology-based distance physical rehabilitation interventions for improving physical functioning of persons with stroke.