Posts Tagged Occupational therapy

[Abstract] Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of Constraint Induced Movement Therapy and Robot Assisted Therapy in NHS Scotland

The routine use of evidence-based upper limb rehabilitation interventions after stroke has the potential to improve function and increase independence. Two such interventions are Constraint Induced Movement Therapy and Robot Assisted Therapy. Despite evidence to support both interventions, their use within the National Health Service appears, anecdotally, to be low. We sought to understand user perceptions in order to explain low uptake in clinical practice.

A combination of a cross-sectional online survey with therapists and semi-structured interviews with stroke patients was used to explore uptake and user opinions on the benefits, enablers and barriers to each intervention.

The therapists surveyed reported low use of Constraint Induced Movement Therapy and Robot Assisted Therapy in clinical practice within the Scottish National Health Service. Barriers identified by therapists were inadequate staffing, and a lack of training and resources. Interviews with stroke patients identified themes that may help us to understand the acceptability of each intervention, such as the impact of motivation.

Barriers to the uptake of Constraint Induced Movement Therapy and Robot Assisted Therapy within the clinical setting were found to be similar. Further qualitative research should be completed in order to help us understand the role patient motivation plays in uptake.

via Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of Constraint Induced Movement Therapy and Robot Assisted Therapy in NHS Scotland – Gillian Sweeney, Mark Barber, Andrew Kerr,

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[Dissertation] Advancing Rehabilitation Research Through Characterization of Conventional Occupational Therapy for Adult Stroke Survivors with Upper Extremity Hemiparesis


Stroke remains a leading cause of long-term disability in the United States. While significant medical advances have led to decreased stroke mortality rates, incidence of stroke has remained roughly the same. This has resulted in an increased number of stroke survivors living with upper extremity (UE) hemiparesis requiring occupational therapy (OT). Despite a significant increase in the number of stroke rehabilitation trials over the past decade, a recent systematic review and meta-analysis found insufficient evidence that any experimental interventions were superior to conventional rehabilitation for improving UE motor function post-stroke. While it may be true that novel interventions are no more effective than conventional rehabilitation, an equally probable reason is the large disparities in dosage, frequency, and interventions used across control groups in clinical trials.
In the stroke rehabilitation literature, control interventions are often referred to as standard care or conventional rehabilitation. Concerningly, the majority of stroke rehabilitation trials lack an empirically based rationale for how control interventions are comparable to standard care rehabilitation. Inadequate descriptions of, and rationales for, control interventions across stroke rehabilitation trials are significant barriers to the advancement of evidence-based practice. Without a true understanding of `standard care’ in real-world practice, there is no way to know if the control intervention is truly comparable. There is an urgent need to characterize `standard care’ rehabilitation to inform control intervention development and improve interpretability of clinical trial results. The purpose of this study was to investigate current practices of occupational therapy practitioners in outpatient rehabilitation settings to address upper extremity hemiparesis in adult stroke survivors.
In Chapter 2, a cross-sectional e-mail survey was sent to OT practitioners across the United States to determine current practice patterns of therapists working in outpatient stroke rehabilitation nationwide. The results of this study (n=269) revealed that stretching, bilateral upper extremity training, strength training, weightbearing, manual therapy and task-oriented training were used by more than 85% of OT practitioners in our sample. Poor patient compliance (84%), medical complexity (64%), and spasticity (63%) were the most commonly reported barriers to patients meeting their OT goals in outpatient rehabilitation.
Chapters 3 and 4 present the results of a video-based observational study of outpatient OT sessions at an academic medical center. The Rehabilitation Treatment Specification System (RTSS) was used to analyze 30 OT treatment sessions. The average total session time was 52 ± 4.7 minutes with 36.2 ± 7.4 minutes of active time and 15.8 ± 7.1 minutes of inactive time per session. Interventions in the RTSS categories of `Skills and Habits’ (e.g., task-oriented activities) and `Organ Function’ (e.g., stretching, weightbearing) were used in the majority of OT sessions with `Skills and Habits’ activities accounting for 59% of active time and `Organ Function’ activities accounting for 35% of active time. After removing outliers, an average of 150.2 ± 85.2 UE repetitions occurred per session. Functional electrical stimulation (FES) was commonly used as an adjuvant to task-oriented activities and knowledge of performance was provided often during treatment.
Taken together, these results suggest that task-oriented training is commonly used by OT practitioners to address UE hemiparesis and musculoskeletal interventions are often used to mitigate spasticity in preparation for task-oriented activities. Future research will include video observation and analysis of OT practice sessions across multiple practice settings, as well as analyzing our remaining survey data across multiple practice settings (e.g., inpatient rehabilitation, skilled nursing facilities) to describe similarities and differences with the current findings.
Full Text: Wengerd_Dissertation_11.26.19.pdf (3.16 MB) View|Download

via OhioLINK ETD: Wengerd, Lauren Rachel

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[Abstract] Psychiatric disorders following traumatic brain injury: a nationwide population-based cohort study and the effects of rehabilitation therapies



To investigate the risk of psychiatric disorders following TBI, and to clarify whether the post-TBI rehabilitation was associated with a lower risk of developing psychiatric disorders.


A register-based, retrospective cohort design


Using data from the National Health Insurance Research Database (NHIRD) of Taiwan, we established an exposed cohort with TBI and a nonexposed group without TBI matched by age and year of diagnosis between 2000 and 2015.


This study included 231,894 patients with TBI and 695,682 controls.


Rehabilitation therapies in TBI patients.

Main Outcome Measures

A multivariable Cox proportional hazards regression model was used to compare the risk of developing psychiatric disorders.


The incidence rate of psychiatric disorders was higher in the TBI group when compared with the control group. Compared with the control group, the risk of psychiatric disorders in the TBI group was twofold (HR=2.056, 95% CI:1.940- 2.172, p < 0.001). Among the TBI subjects, 49,270 (21.25%) had received rehabilitation therapy and had a lower risk of psychiatric disorders (HR=0.691, 95% CI: 0.679-0.703, p < 0.001). In the subgroup analysis, the medium- to high-level intensity rehabilitation therapy was associated with lower risks of psychiatric disorder (HR=0.712 and 0.568, respectively), but there was no significant finding in the low-intensity group.


We found that TBI was associated with a high risk for developing psychiatric disorders, and that the post-TBI rehabilitation significantly reduced the risk of psychiatric disorders in a dose-dependent manner.

via Psychiatric disorders following traumatic brain injury: a nationwide population-based cohort study and the effects of rehabilitation therapies – Archives of Physical Medicine and Rehabilitation

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[ARTICLE] Upper Extremity Function Assessment Using a Glove Orthosis and Virtual Reality System – Full Text


Hand motor control deficits following stroke can diminish the ability of patients to participate in daily activities. This study investigated the criterion validity of upper extremity (UE) performance measures automatically derived from sensor data during manual practice of simulated instrumental activities of daily living (IADLs) within a virtual environment. A commercial glove orthosis was specially instrumented with motion tracking sensors to enable patients to interact, through functional UE movements, with a computer-generated virtual world using the SaeboVR software system. Fifteen stroke patients completed four virtual IADL practice sessions, as well as a battery of gold-standard assessments of UE motor and hand function. Statistical analysis using the nonparametric Spearman rank correlation reveals high and significant correlation between virtual world-derived measures and the gold-standard assessments. The results provide evidence that performance measures generated during manual interactions with a virtual environment can provide a valid indicator of UE motor status.


Virtual world-based games, when combined with human motion sensing, can enable a neurorehabilitation patient to engage in realistic occupations that involve repetitive practice of functional tasks (). An important component of such a system is the ability to automatically track patient movements and use those data to produce indices related to movement quality (). Before these technology-derived measures can be considered relevant to clinical outcomes, criterion validity must be established. If validated, measures of virtual task performance may reasonably be interpreted as reflective of real-world functional status.

The objective of the study described in this article was to investigate the criterion validity of upper extremity (UE) performance measures automatically derived from sensor data collected during practice of simulated instrumental activities of daily living (IADLs) in a virtual environment. A commercially available SaeboGlove orthosis () was specially instrumented to enable tracking of finger and thumb movements. This instrumented glove was employed with an enhanced version of the Kinect sensor-based SaeboVR software system () to enable employment of the hand, elbow, and shoulder in functional interactions with a virtual world. Performance measures were automatically generated during patient use through a combination of arm tracking data from the Kinect and the glove’s finger and thumb sensors. The primary investigational objective was to determine whether performance indices produced by this system for practice of virtual IADLs are valid indicators of a stroke patient’s UE motor status.

Previous investigations into combining hand tracking with video games to animate UE therapy have produced evidence for the efficacy of such interventions. A recent study compared a 15-session hand therapy intervention using a smart glove system and video games with a usual care regimen (). Stroke patients using the smart glove system realized greater gains in Wolf Motor Function Test (WMFT) score compared with dosage-balanced conventional therapy. Another study investigating a similar glove-based device found significantly greater improvements in Fugl-Meyer and Box and Blocks test results for stroke patients who performed 15 sessions that included the technology-aided therapy compared with subjects receiving traditional therapy only (). An instrumented glove has also been used to support video game therapy that incorporates gripping-like movements and thumb-finger opposition ().

Past research into the use of human motion tracking (sometimes referred to as motion capture) technologies for assessment of UE function has produced encouraging results. One group of researchers compared naturalistic point-to-point reaching movements with standardized reaching movements embedded in a virtual reality system, and established concurrent validity between the two (). An investigation involving a device that incorporates handgrip strength and pinch force measurement into virtual reality exercises provided support for system use as an objective evaluation of hand function, and for the potential of replacing conventional goniometry and dynamometry (). In another study, researchers employed a Kinect sensor in a software system that attempts to emulate a subset of the Fugl-Meyer Upper Extremity (FMUE) assessment (). Pearson correlation analysis between the Kinect-derived scores and traditionally administered FMUE test results for 41 hemiparetic stroke patients revealed a high correlation. Previous research involving the SaeboVR system established a moderate and statistically significant correlation between virtual IADL performance scores and the WMFT (). Due to limitations of the Kinect optical tracking system, this previous work involving the SaeboVR system did not include tracking of grasp-release manual interactions with virtual objects (). The present research addresses this limitation by fusing data from the Kinect sensor with data from finger- and wrist-mounted sensors on the SaeboGlove orthosis to reconstruct the kinematic pose of the patient’s UE.

The use of an assistive glove orthosis in the present work fills an important clinical need. Inability to bring the hand and wrist into a neutral position due to weakness and/or lack of finger extension can prevent participation in occupation-oriented functional practice (). A common technique to enable stroke patients to achieve a functional hand position (and thus participate in rehabilitation) is a dynamic splint that supports finger and/or wrist extension. When larger forces are necessary (e.g., to overcome abnormal muscle tone), an outrigger-type splint may be employed. For patients with no more than mild hypertonicity, a lower-profile device such as the SaeboGlove orthosis () can be used. Employment of an assistive glove orthosis in the context of virtual IADLs practice thus addresses some of the leading causes of hand motor control deficits following stroke and their adverse impact on ability to participate in daily activities ().



Candidates were recruited from a population of stroke patients receiving in-patient rehabilitation care, outpatient rehabilitation, or who had been previously discharged from rehabilitative care at the UVA Encompass Health Rehabilitation Hospital (Charlottesville, VA, USA). Table 1 includes the study characteristics. Of 17 patients enrolled in the study, 15 completed the protocol. One subject dropped out due to unrelated illness. A second subject was disenrolled due to an inability to adequately express an understanding of consent during re-verification at the beginning of the first post-consent study session.

Table 1.

Patient Characteristics (n = 17).

Age, years, median (range) 67 (25-83)
Time since stroke onset in months, median (range) 12 (1-72)
Sex, M/F, n (%) 10 (59)/7 (41)
Race category, Black/White, n (%) 3 (18)/14 (82)
Ethnic category, Hispanic/non-Hispanic, n (%) 0 (0)/17 (100)
Side of hemiplegia, L/R, n (%) 10 (59)/7 (41)
Affected side dominance, dominant/nondominant, n (%) 9 (53)/8 (47)

All study activities were conducted under the auspices of the University of Virginia Institutional Review Board for Health Sciences Research (IRB-HSR). All study sessions took place in a private room within the UVA Encompass Health outpatient clinic between October 20, 2017, and February 9, 2018. Licensed Occupational Therapists trained in study procedures and registered with the IRB-HSR were responsible for all patient contact, recruitment, consent, and protocol administration.

Verification of inclusion/exclusion criteria was through a three-step process including an initial medical record review prior to recruitment, verbal confirmation prior to administration of consent, and an evaluation screen conducted by a study therapist following consent. Inclusion criteria included history of stroke with hemiplegia, ongoing stroke-related hand impairment, sufficient active finger flexion at the metacarpal phalangeal joint in at least one finger to be detected by visual observation by a study therapist, antigravity strength at the elbow to at least 45° of active flexion, antigravity shoulder strength to at least 30° each in active flexion and abduction/adduction, and 15° in active shoulder rotation from an upright seated position. Participants had visual acuity with corrective lenses of 20/50 or better and were able to understand and follow verbal directions. The study excluded patients with visual field deficit in either eye that would impair ability to view the computer monitor and/or with hemispatial neglect that would impair an individual’s ability to process and perceive visual stimuli. The study also excluded individuals with motor limb apraxia, significant muscle spasticity, or contractures of the muscles, joints, tendons, ligaments, or skin that would restrict normal UE movement.


A commercial SaeboGlove orthosis was fitted with wrist and finger motion sensors to permit tracking of finger joint angles during grasp-release interactions with a virtual environment. The instrumented glove orthosis is shown in Figure 1. The sensors were attached to the existing tensioner band hooks on the dorsal side of each glove finger. An electronics enclosure mounted to the palmar side of the SaeboGlove’s plastic wrist splint processes the sensor data and transmits information to a personal computer (PC) that hosts the modified SaeboVR software. Data from both the SaeboGlove-integrated sensors and from a Kinect sensor were used by a custom motion capture algorithm, which employs a human UE kinematics model to produce real-time estimates of arm, wrist, and finger joint angles.

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Figure 1.
SaeboGlove orthosis with sensors to track grasp interactions.



Continue —->  Upper Extremity Function Assessment Using a Glove Orthosis and Virtual Reality System

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[Abstract] Robotic-assisted therapy with bilateral practice improves task and motor performance in the upper extremities of chronic stroke patients: A randomised controlled trial.



Task-specific repetitive training, a usual care in occupational therapy practice, and robotic-aided rehabilitation with bilateral practice are used to improve upper limb motor and task performance. The difference in effects of two strategies requires exploration. This study compared the impact of robotic-assisted therapy with bilateral practice (RTBP) and usual task-specific training facilitated by therapists on task and motor performance for stroke survivors.


Forty-three community-dwelling stroke survivors (20 males; 23 females; 53.3 ± 13.1 years; post-stroke duration 14.2 ± 10.9 months) were randomised into RTBP and usual care. All participants received a 10-minute per-protocol sensorimotor stimulation session prior to interventions as part of usual care. Primary outcome was different in the amount of use (AOU) and quality of movement (QOM) on the Motor Activity Log (MAL) scale at endpoint. Secondary outcomes were AOU and QOM scores at follow-up, and pre-post and follow-up score differences on the Fugl-Meyer Assessment (FMA) and surface electromyography (sEMG). Friedman and Mann-Whitney U tests were used to calculate difference.


There were no baseline differences between groups. Both conditions demonstrated significant within-group improvements in AOU-MAL and FMA scores following treatment (P < 0.05) and improvements in FMA scores at follow-up (P < 0.05). The training-induced improvement in AOU (30.0%) following treatment was greater than the minimal detectable change (16.8%) in the RTBP group. RTBP demonstrated better outcomes in FMA wrist score (P = 0.003) and sEMG of wrist extensor (P = 0.043) following treatment and in AOU (P < 0.001), FMA total score (P = 0.006), FMA wrist score (P < 0.001) and sEMG of wrist extensor (P = 0.017) at follow-up compared to the control group. Control group boost more beneficial effects on FMA hand score (P = 0.049) following treatment.


RTBP demonstrated superior upper limb motor and task performance outcomes compared to therapists-facilitated task training when both were preceded by a 10-minute sensorimotor stimulation session.


via Robotic-assisted therapy with bilateral practice improves task and motor performance in the upper extremities of chronic stroke patients: A randomi… – PubMed – NCBI

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[ARTICLE] Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis – Full Text


Background. Despite the rise of virtual reality (VR)-based interventions in stroke rehabilitation over the past decade, no consensus has been reached on its efficacy. This ostensibly puzzling outcome might not be that surprising given that VR is intrinsically neutral to its use—that is, an intervention is effective because of its ability to mobilize recovery mechanisms, not its technology. As VR systems specifically built for rehabilitation might capitalize better on the advantages of technology to implement neuroscientifically grounded protocols, they might be more effective than those designed for recreational gaming.

Objective. We evaluate the efficacy of specific VR (SVR) and nonspecific VR (NSVR) systems for rehabilitating upper-limb function and activity after stroke. Methods. We conducted a systematic search for randomized controlled trials with adult stroke patients to analyze the effect of SVR or NSVR systems versus conventional therapy (CT).

Results. We identified 30 studies including 1473 patients. SVR showed a significant impact on body function (standardized mean difference [SMD] = 0.23; 95% CI = 0.10 to 0.36; P = .0007) versus CT, whereas NSVR did not (SMD = 0.16; 95% CI = −0.14 to 0.47; P = .30). This result was replicated in activity measures.

Conclusions. Our results suggest that SVR systems are more beneficial than CT for upper-limb recovery, whereas NSVR systems are not. Additionally, we identified 6 principles of neurorehabilitation that are shared across SVR systems and are possibly responsible for their positive effect. These findings may disambiguate the contradictory results found in the current literature.


Better medical treatments in the acute phase after stroke have increased survival and with that the number of patients needing rehabilitation with an associated increased burden on the health care system. Novel technologies have sought to meet this increased rehabilitation demand and to potentially allow patients to continue rehabilitation at home after they leave the hospital. Also, technology has the potential to gather massive and detailed data (eg, kinematic and performance data) that might be useful in understanding recovery after stroke better, improving the quality of diagnostic tools and developing more successful treatment approaches. Given these promises, several studies and meta-analyses have evaluated the effectiveness of technologies that use virtual reality (VR) in stroke rehabilitation. In a first review, Crosbie et al analyzed 6 studies that used VR to provide upper-limb rehabilitation. Although they found a positive effect, they concluded that the evidence was only weak to moderate given the low quality of the research. A later meta-analysis analyzing 5 randomized controlled trials (RCTs) and 7 observational studies suggested a positive effect on a patient’s upper-limb function after training. Another meta-analysis of 26 studies by Lohse et al, which compared specific VR (SVR) systems with commercial VR games, found a significant benefit for SVR systems as compared with conventional therapy (CT) in both body function and activity but not between the 2 types of systems. This study, however, included a variety of systems that would treat upper-limb, lower-limb, and cognitive deficits. Saywell et al analyzed 30 “play-based” interventions, such as VR systems including commercial gaming consoles, rehabilitation tools, and robot-assisted systems. They found a significant effect of play-based versus control interventions in dose-matched studies in the Fugl-Meyer Assessment of the Upper Extremity (FM-UE). In contrast, a more recent large-scale analysis of a study with Nintendo Wii–based video games, including 121 patients concluded that recreational activities are as effective as VR. A later review evaluated 22 randomized and quasi–randomized controlled studies and concluded that there is no evidence that the use of VR and interactive video gaming is more beneficial in improving arm function than CT. In all, 31% of the included studies tested nonspecific VR (NSVR) systems (Nintendo Wii, Microsoft Xbox Kinect, Sony PlayStation EyeToy). Hence, although VR-based interventions have been in use for almost 2 decades, their benefit for functional recovery, especially for the upper limb, remains unknown. Possibly, these contradictory results indicate that, at present, studies are too few or too small and/or the recruited participants too variable to be conclusive. However, alternative conclusions can be drawn. First, VR is an umbrella term. Studies comparing its impact often include heterogeneous systems or technologies, customized or noncustomized for stroke treatment, addressing a broad range of disabilities. However, effectiveness can only be investigated if similar systems that rehabilitate the same impairment are contrasted. This has been achieved by meta-analyses that investigated VR-based interventions for the lower limb, concluding that VR systems are more effective in improving balance or gait than CT. Second, a clear understanding of the “active ingredients” that should make VR interventions effective in promoting recovery is missing. Therapeutic advantages of VR identified in current meta-analyses are that it might apply principles relevant to neuroplasticity,, such as providing goal-oriented tasks,, increasing repetition and dosage,, providing therapists and patients with additional feedback,,, and allowing to adjust task difficulty. In addition, it has been suggested that the use of VR increases patient motivation, enjoyment,, and engagement; makes intensive task-relevant training more interesting,; and offers enriched environments. Although motivational aspects are important in the rehabilitation process because they possibly increase adherence, their contribution to recovery is difficult to quantify because it relies on patients’ subjective evaluation., Rehabilitation methods, whether VR or not, however, need to be objectively beneficial in increasing the patient’s functional ability. Hence, an enormous effort has been expended to identify principles of neurorehabilitation that enhance motor learning and recovery. Consequently, an effective VR system should besides be motivating, also augment CT by applying these principles in the design. Following this argument, we advance the hypothesis that custom-made VR rehabilitation systems might have incorporated these principles, unlike off-the-shelf VR tools, because they were created for recreational purposes. Combining the effects of both approaches in one analysis might, thus, mask their real impact on recovery. Again, in the rehabilitation of the lower limb, this effect has been observed. Two meta-analyses investigating the effect of using commercial VR systems for gait and balance training did not find a superior effect, which contradicts the conclusions of the other systematic reviews. In upper-limb rehabilitation, this question has not been properly addressed until the most recent review by Aminov et al. However, there are several flaws in the method applied that could invalidate the results they found. Specifically, studies were included regardless of their quality, and it is not clear which outcome measurements were taken for the analysis according to the World Health Organization’s International Classification of Function, Disability, and Health (ICF-WHO). In addition, a specifically designed rehabilitation system (Interactive Rehabilitation Exercise [IREX]) was misclassified as an off-the-shelf VR tool. Because their search concluded in June 2017, the more recent evidence is missing. We decided to address these issues by conducting a well-controlled meta-analysis that focuses only on RCTs that use VR technologies for the recovery of the upper limb after stroke. We analyze the effect of VR systems specifically built for rehabilitation (ie, SVR systems) and off-the-shelf systems (ie, NSVR commercial systems) against CT according to the ICF-WHO categories. Also, we extracted 11 principles of motor learning and recovery from established literature that could act as “active ingredients” in the protocols of effective VR systems. Through a content analysis, we identified which principles are present in the included studies and compared their presence between SVR and NSVR systems. We hypothesized, first, that SVR systems might be more effective than NSVR systems as compared with CT in the recovery of upper-limb movement and, second, that this superior effect might be a result of the specific principles included in SVR systems.[…]


Continue —->  Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis

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[BLOG POST] A Stylish Weighted Blanket – The Gravity Blanket


A study conducted by the Occupational Therapy in Mental Health journal revealed that 63% of subjects using a wieghted blanket reported lower anxiety and 78% preferred the weighted blanket as a calming modality than other options provided.

Weighted blankets have been found to provide comfort for many people, including people with anxiety, autism, ADHD, sensory processing disorder, PTSD, and insomnia. The comfort comes from the power of “deep touch pressure stimulation” that has been shown to increase serotonin and melatonin. These hormones are responsible for the feelings associated with relaxation, while decreasing cortisol, the hormone responsible for stress.

What’s special about The Gravity Blanket?

Although there are many weighted blanket options out there, Gravity makes a point to go beyond functionality and put additional focus on the look and feel of the blanket. Their products look more like luxury lifestyle pieces than therapy items. Their website offers a small selection of items; each with the simple and sleek design that they have come to be known for.

Gravity also has a partnership with the sleep and meditation app, Calm. The two wellness brands teamed up for a limited availability offer known as The Dream Package. The package combines a Calm-branded Gravity Blanket and a year’s subscription to the Calm app.

To learn more about The Gravity Blanket, look at the other products they offer, or compare to the Harkla Blanket that we’ve previously blogged about, you can find their website at

via A Stylish Weighted Blanket – The Gravity Blanket – Assistive Technology Blog

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[ARTICLE] Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review – Full Text


Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians’ eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers.


Virtual reality and active video games (VR/AVG) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice [,]. A steady increase in the number of peer-reviewed articles evaluating the effects of VR/AVG interventions in many rehabilitation populations has been observed over the past 20 years. This increase reflects a growing interest in VR/AVG from the rehabilitation research and development sectors. Ideally, newly developed and empirically evaluated products and interventions that are found to be safe and effective would be quickly integrated into clinical practice. Yet what we are observing in patient care follows a more typical pattern for the adoption of evidence-based treatment techniques or tools: one of slow and variable progress [].

Collaboration between engineers and product end-users can inform the development of useful VR/AVG technologies that meet the needs of clients and therapists. Moving VR/AVG technology into the hands of therapists allows clients to benefit from its therapeutic potential. Systematically examining the factors that impact VR/AVG adoption in rehabilitation, and the effect of knowledge translation (KT) strategies on behaviors related to their use, is critical for guiding the successful implementation of these technologies. A clear understanding of how VR/AVG is being used by clinicians, the limitations clinicians face in integrating the technologies into their daily treatment routines, and the most effective strategies for supporting clinicians in technology adoption are paramount to informing these implementation approaches.

Recent surveys of occupational and physical therapists in Canada [], the United States (Levac et al., in preparation), and Scotland [] on their use of VR/AVG and their learning needs related to future use of these technologies provides a foundational knowledge base about current clinical use. Nearly half of the 1071 respondents in Canada [] and 76% of the 491 U.S. respondents (Levac et al., in preparation) had used VR/AVG clinically. However, only 12% of respondents in Canada [], 31% in the United States (Levac et al., in preparation), and 18% of the 112 respondents in Scotland [] reported current use. This discrepancy indicates the need for additional efforts to identify and to address existing barriers to VR/AVG use. Commercially available AVG systems were the most common systems in use in all 3 countries [,] (Levac et al., in preparation); the use of rehabilitation-specific VR systems by Canadian [] and U.S. therapists (Levac et al., in preparation) was much lower (<3% of respondents for any given system).

Despite low reported daily use, VR/AVG systems were perceived by therapists to be widely relevant to rehabilitation for a number of different client populations, functional recovery goals and practice settings []. Sixty-one percent of respondents in Scotland reported that they would use gaming if it were available to them []. The majority of respondents in both Canada [] (76.3%) and the United States (69.9%) (Levac et al., in preparation) reported low self-efficacy in using VR/AVG clinically, but were interested in learning more. Commonly reported learning needs included knowledge and skills in selecting appropriate systems and games for individual clients, grading activities, evaluating outcomes, and integrating theoretical approaches to treatment [,,]. These findings suggest a strong need for educational resources and knowledge translation (KT) supports to facilitate evidence-based technology adoption [,]. KT is the process of moving evidence into practice []. KT interventions have the potential to support adoption by targeting known barriers to change, including a lack of knowledge and skills [].

Strong insights into the factors influencing therapists’ adoption of VR/AVG have emerged only in the past 5 years. A decomposed Theory of Planned Behavior, which integrates constructs from the Technology Adoption Model and the Diffusion of Innovation theory forms the theoretical basis for the majority of this research [,]. The Theoretical Domains Framework (TDF) is another approach that can be used to conceptualize the evaluation of barriers and facilitators of change, including technology adoption []. The TDF is an implementation framework that integrates 128 theoretical constructs drawn from 33 behavior change theories into 14 barrier/facilitator domains []. Although the framework has not been applied yet to this body of literature, it offers a more comprehensive approach to the identification and classification of barriers and facilitators of change than a single theory or framework alone. Drawn from the KT literature, the framework can be used to structure the assessment of barriers and facilitators of change across a range of contexts, as well as the selection of interventions to target these barriers and facilitators [].

The purpose of this scoping review was to apply the TDF to examine the extent, range, and nature of studies assessing VR/AVG barriers and facilitators and/or recommending or evaluating KT interventions to promote VR/AVG adoption in rehabilitation since 2005. Our objectives were to

  1. present an overview of factors known to limit or support VR/AVG adoption for rehabilitation;

  2. describe the KT strategies that have been recommended or evaluated to address these factors and to report on their effectiveness, where possible; and

  3. provide recommendations for technology development, research, and clinical implementation based on these findings.


Continue —>  Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review

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[BLOG POST] 5 Smartphone Games That Encourage Wrist Rehabilitation

Tired of using dumbbells for rehabilitation following distal radius fractures? Looking for new interventions to increase client engagement? Look no further than your patient’s smartphone! Incorporate it into exercise routines to help your patients regain wrist balance and to provide proprioceptive input.

Evidence Supports Proprioceptive Activities

Emerging evidence supports the use of proprioceptive activities for distal radius fracture rehabilitation.1 A cross-sectional study involving females treated operatively and non-operatively for a distal radius fracture found that participants had significantly less joint position sense in comparison to study controls.2 The proprioceptive limitations correlated highly with functional impairment on the Patient Rated Wrist Evaluation.3

By addressing proprioceptive deficits while encouraging functional wrist range of motion, smartphone applications complement a traditional hand therapy program for individuals requiring skilled therapy following a distal radius fracture.

Some games to consider:

  • Chopper Lite – Action packed side-scrolling helicopter game where a tilt of the screen flies the chopper.
  • Labyrinth – Classic labyrinth game in which you must guide a ball through a labyrinth by moving your device.
  • Tilt Maze Lite – Maze game where a tilt of your device helps a marble through a maze toward the exit. Use different mazes to test wrist balance and timing. The game stores the player’s best time for each maze so patients can track their performance as their wrist heals.
  • Water Slide Extreme – Unique water slide game featuring tight corners and huge loops that you must navigate by twisting or leaning your device.
  • Snail Mail – Kart-style racing game in which the player controls a racing snail on a mission to collect packages and deliver them to the farthest reaches of the universe while dodging obstacles such as laser towers, slugs, asteroids, and salt.

The clinician should consider using smartphones as an intervention following distal radius fractures. Skilled hand therapists can assist with appropriate postural mechanics and provide guidelines for the amount of time a patient should devote to gaming.

Rehabilitation at Your Fingertips

Certain smartphone applications can be used to address client-specific deficits, decrease functional concerns, and achieve client-centered goals. Incorporating smartphone gaming in hand therapy may provide motivation and convenience to your clients.



  1. Algar, L., & Valdes, K. (2014). Using smartphone applications as hand therapy interventions. Journal of Hand Therapy27(3), 254–257. doi:10.1016/j.jht.2013.12.009
  2. Karagiannopoulos, C., Sitler, M., Michlovitz, S., & Tierney, R. (2014a). A Descriptive Study on Wrist and Hand Sensori-Motor Impairment and Function Following Distal Radius Fracture Intervention. Journal of Hand Therapy27(3), e2–e3. doi:10.1016/j.jht.2013.08.006
  3. Karangiannopoulos, et al. (2014)

via 5 Smartphone Games That Encourage Wrist Rehabilitation | MedBridge Blog

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[Abstract] Soymilk ingestion immediately after therapeutic exercise enhances rehabilitation outcomes in chronic stroke patients: A randomized controlled trial. – NeuroRehabilitation


Study investigated the effects of an 8-week rehabilitation exercise program combined with soymilk ingestion immediately after exercise on functional outcomes in chronic stroke patients.

Twenty-two stroke patients were randomly allocated to either the soymilk or the placebo (PLA) group and received identical 8-weeks rehabilitation intervention (3 sessions per week for 120 minutes each session) with corresponding treatment beverages. The physical and functional outcomes were evaluated before, during, and after the intervention. The 8-week rehabilitation program enhanced functional outcomes of participants.

The immediate soymilk ingestion after exercise additionally improved hand grip strength, walking speed over 8 feet, walking performance per unit lean mass, and 6-Minute Walk Test performance compared with PLA after the intervention. However, the improvements in the total score for Short Physical Performance Battery and lean mass did not differ between groups.

This study demonstrated that, compared with rehabilitation alone, the 8-week rehabilitation program combined with immediate soymilk ingestion further improved walking speed, exercise endurance, grip strength, and muscle functionality in chronic stroke patients.

via Articles, Books, Reports, & Multimedia: Search REHABDATA | National Rehabilitation Information Center

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