Posts Tagged Occupational therapy

[BLOG POST] Home After a Stroke: Bathing Can Be Exhausting

Bathing Can Be Exhausting

As an OT I did not know how tiring a.m. care is because I never watched a stroke survivor do one task after.  Here is why bathing leaves me feeling refreshed instead of exhausted and frustrated.

Washing.  I do not struggle to soap up a washcloth one-handed or chase a bar of soap after I drop it.  I pour shower gel on a nylon poof and knead it a few times to get it soapy.  To wash my sound arm, I use a gross grasp in my affected hand to hold the nylon poof.  I do not struggle to wring out a washcloth one-handed.  I hang the nylon poof on a suction-cup hook, hose it down, and let it air dry.  I use shampoo suds to wash my face.
I press down on the nylon poof that is resting on my thighs to squeeze out suds so my sound hand can soap up my crotch.  Before I could hold the shower hose with my hemiplegic hand,
I used my forearm to press the shower hose against my stomach to rinse my crotch.  Water runs downhill.  This freed my sound hand to deal with the nooks and crannies.  If my husband was alive I would still want to bathe this private part of my body.

Drying.  My towel rack is next to the shower so I can reach it while sitting on my shower chair.  I drape the towel over one shoulder while I dry my arms and trunk.  When I get out of the shower I stand to dry my crotch with the towel draped over my shoulder.  My shoulder carries the weight of the towel so it is easy for my sound hand to manipulate the free end.  I never hold up my affected leg to dry it.  I don a terrycloth bathrobe which dries my buttocks and thighs and I let my calves air dry while I brush my teeth and comb my hair.

Dressing.  For the 1st year after my stroke, dressing was easier if I rested after bathing.  I laid on the bed in my bathrobe with a towel under my wet hair and listened to music on the radio.  homeafterstroke.blogspot.com

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[WEB SITE] Stroke Rehabilitation from “Head to Toe” – Rehab Managment

Stroke Rehabilitation from “Head to Toe”

An 82-year-old female who suffered a left corona radiata CVA and presented with decreased left-sided neuromuscular control and coordination uses the body weight support device over the treadmill. The therapist assists with advancement and placement of her left lower extremity during functional ambulation.

By Devin Cooney, MOR, OTR/L; Brittany Merkh, PT, DPT; Kelly Tender, MS, CCC-SLP 

According to the American Stroke Association, one in four people worldwide will have a stroke. It is the number five cause of death and a leading cause of long-term disability in the United States. More than 7 million stroke survivors are currently living in the United States.1

Many stroke survivors choose to go to an acute inpatient rehabilitation facility for their specific rehabilitation needs. In 2018, 1,494 individuals and their families selected Kessler Institute for Rehabilitation in Marlton, NJ, for their start of recovery. Thirty percent of those individuals were diagnosed with a stroke. Although their rehabilitation needs were different, they shared a common goal: to gain the skills, strengths, and strategies to rebuild their lives.

Recently, rehabilitation has shifted to include greater use of technology. The integration of technology-based rehabilitation within stroke recovery may empower an individual toward being more engaged in their own care in addition to forcing greater outcomes and providing objective data.2 Technology can be incorporated in stroke recovery from “head to toe,” including rehabilitation of cognitive-communication, recovery of swallow function, improvement of upper and lower extremity use, and restoration of the ability to walk.

Communication and Swallow Function

Depending on the area of the brain in which a stroke occurs, a survivor may experience problems related to speech, reading, writing, and/or understanding words (aphasia). Technology is often incorporated into speech-language pathology treatment for individuals affected by aphasia at Kessler-Marlton. Technology such as smartphones, tablets, text-to-speech or word prediction software, augmentative-alternative communication devices, video telecommunication, and online support communities provide additional avenues for survivors affected by aphasia to communicate.3

Use of technology is also widely incorporated in the management of dysphagia. There are many causes of dysphagia, but a very common cause is stroke. Swallowing problems can lead to poor nutrition, pneumonia, and poorer quality of life. A specialized swallowing test (videofluoroscopic swallow study and/or fiber optic endoscopic evaluation of swallowing) is recommended to better assess the problems and determine a treatment plan. Swallowing exercises may be needed to improve strength and coordination of swallowing muscles. One example of technology utilized at Kessler-Marlton is surface electromyography (sEMG) biofeedback to provide visual monitoring of the sEMG signal to guide performance in swallowing therapy, increase active participation, provide objective data, and track outcomes.4,5 Use of sEMG in conjunction with swallow exercise has been shown to improve functional swallowing outcomes.6 Additional supportive interventions include neuromuscular stimulation, patterned electrical stimulation, pressure biofeedback to measure and target tongue strength, and dysphagia applications to offer education and personalized exercise programs to patients and their families.

Upper Extremity and Vision Restoration

Stroke survivors may have difficulty performing activities of daily living for various reasons. However, for the purpose of this article the focus will be on the recovery of upper extremity use and visual/visuo-spatial impairments. Occupational therapy (OT) is vital in stroke recovery, and the goal is to increase, improve, or restore independence within activities of daily living. While manual therapies are typically used with the majority of patients, therapists at Kessler Marlton incorporate supportive technology and equipment including an integrated therapy system with a touchscreen display that can be used for oculomotor therapy, motor control training, and cognitive learning; a computerized, task-oriented upper extremity workstation; and a hand rehabilitation system that uses a wireless orthosis to deliver electrical stimulation.

The integrated therapy systems is a large technological board with a touch screen. It can be used to target a wide range of impairments including vision-related activities. These activities focus on visuomotor coordination, reaction time, visual processing, and visuospatial perception. This technology engages patients and can be personalized to individual needs.

In addition to vision, OT focuses on the rehabilitation of the upper extremity when indicated. To facilitate this, the computerized upper extremity workstation is often utilized. It is a computerized training system with a full workstation as well as a computer program. It utilizes games and objective data to motivate and engage patients. This system offers the ability to complete both gross and fine motor activities including different grip and pinch patterns. Different planes of movement or positions can also be completed to downgrade or upgrade patient challenge.

When appropriate, the hand rehabilitation system with wireless orthosis may be utilized to target the upper extremity. While neuromuscular electrical stimulation (NMES) can be used on different body parts and muscle groups, this device specifically targets the muscles of the hand. This system’s program settings such as pinching, grasping, and releasing can be utilized individually or while completing functional activities.

Restoration of the Lower Extremity

Many people who are affected by stroke lose function of their lower extremity to some capacity. The goal of the physical therapist (PT) is to facilitate improved functional independence and maximize safety with overall mobility while primarily focusing on lower extremity recovery. Recently, with the use of technology, rehabilitation and mobility can be initiated sooner, which translates into improved overall outcomes.

Within the inpatient rehabilitation setting at Kessler-Marlton, PTs have access to a multitude of technology options, including an adaptive cycling machine. The cycling device is multimodal and allows patients to participate passively, motor-supported, or actively. The passive mode allows for early mobilization of patients diagnosed with stroke, as it is able to assist with reducing muscle tone in those patients with hypertonicity. With patients who are not ready to perform ambulation itself, the passive mode also allows for repetitive motions that mimic the back-and-forth motion of walking. These repetitive, rhythmic movements help to stimulate the brain to reorganize and relearn motor tasks.

As patients improve and regain motor control and neuromuscular strength, the adaptive cycling machine can be used in the motor-supported mode, which allows the motor to assist to stimulate both strength and endurance until the patient is able to participate in active mode. In active mode, the patient is using her or his own strength to pedal.

Partial Weight-Bearing

As early mobilization is an important factor in recovery, another technological device that assists the user with partial weight-bearing is of great importance. This technology is a body weight-supported gait training device in which the patient is supported by an overhead suspension system and harness. This system allows the patient, who might not necessarily be able to stand on his or her own, the opportunity to force weight-bearing through the affected lower extremity to force motor recovery. In the upright position, it not only affords the patient the opportunity to weight-bear, but it also promotes proper upright posturing and provides the patient a safe, fall-free environment in which to practice initiating mobility. This system allows the therapist to provide hands-on assistance at the lower extremity or at the pelvis to achieve proper gait pattern. The device can be used for over-ground training or for training over the treadmill, which challenges a patient’s coordination and timing of the different phases of the gait cycle. As a patient improves, the overhead system can be adjusted to allow increased weight-bearing and increased degrees of freedom.

As the patient moves into a more ambulatory level, he or she still may demonstrate impairments in the amount or quality of movement in their lower extremity. The use of functional electrical stimulation (FES) may be used as a recovery tool. The FES device this facility uses is a wireless foot drop system that helps to stimulate the nerves and muscles of the affected lower extremity, most often at the ankle and in the thigh, to re-educate the brain and restore muscle function during walking. This system comes with a lower leg cuff to stimulate the ankle muscles in patients with difficulty clearing their toes or patients with foot drop. The system also comes with a thigh cuff to stimulate muscles in the upper leg to provide stability while in stance phase.

Although speech, occupational, and/or physical therapy itself has been shown to improve patient outcomes, the integration of technology in therapeutic intervention following stroke can maximize patient motivation and progress. For example, the inclusion of technology in physical therapy has been able to allow patients the opportunity to participate in therapy at earlier phases. This early mobilization is crucial to jump-start a patient’s recovery. The use of technology throughout the patient’s recovery process has been an integral part in demonstrating improved outcomes which allows physical therapists to facilitate recovery by working on the often stated patient-centered goal of returning to walking. RM

Devin Cooney, MOR, OTR/L, has worked at Kessler Institute for Rehabilitation—Marlton for the past 3 years. The majority of her career has been spent in the acute rehabilitation setting focusing on ADLs and IADLs to encourage safe return to home.

Brittany Merkh, PT, DPT, is Co-Chair of the Stroke Program at Kessler Institute for Rehabilitation in Marlton, New Jersey. Most of her career has been spent in acute rehabilitation, treating patients with a variety of diagnoses.

Kelly Tender, MS, CCC-SLP, is senior speech-language pathologist and leader within the SLP department. Her certifications and training include MDTP, VitalStim, PENS, and sEMG. She is a member of the hospital’s stroke committee. For more information, contact RehabEditor@medqor.com.

References

1. About Stroke. www.stroke.orghttps://www.stroke.org/en/about-stroke. Published 2019. Accessed November 21, 2019.

2. Des Roches C, Kiran S. Technology-based rehabilitation to improve communication after acquired brain injury. Front Neurosci. 2017;11. doi:10.3389/fnins.2017.00382. Accessed November 21, 2019.

3. Technology for People with Aphasia. www.stroke.orghttps://www.stroke.org/en/life-after-stroke/recovery/daily-living/technology-for-people-with-aphasia. Published 2019. Accessed October 12, 2019.

4. Steele C. Treating dysphagia with sEMG biofeedback. The ASHA Leader. 2004;9(13):2-23. doi: https://www.doi.org/10.1044/leader.ftr2.09132004.2.

5. Crary M, Carnaby (Mann) G, Groher M, Helseth E. Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia. 2004;19(3). doi: https://www.doi.org/10.1007/s00455-004-0003-8.

6. Bogaardt H, Grolman W, Fokkens W. The use of biofeedback in the treatment of chronic dysphagia in stroke patients. Folia Phoniatrica et Logopaedica. 2009;61(4):200-205. doi: https://www.doi.org/10.1159/000227997

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[WEB SITE] High-Energy Rehab – Rehab Managment

High-Energy Rehab

by Jackie Skirkanich, PTA, Janine Volpe-Clarkson, MS, CCC-SLP, and Alexandra Waller, MS, OTR/L

Headquartered in Wallingford, Conn, Gaylord Specialty Healthcare is a rehabilitation-based healthcare system that operates the only CARF-accredited stroke specialty program in Connecticut for both inpatient and outpatient care. As a means to optimize the functional progress of patients who led very active lives prior to their debilitating stroke, Gaylord established its Young Stroke program with a focus on an aggressive and highly individualized plan of care.

Young Stroke Program ElIgibility

This name, “Young Stroke,” can be deceiving since qualification for the program depends mostly on the patient’s baseline before the stroke, rather than age. A stroke patient of any age may be considered a candidate for Gaylord’s Young Stroke program if that person was significantly and actively employed, or a student or primary caregiver at the time of the stroke. The complexity of the patient’s stroke is also taken into consideration in determining eligibility for the program.

Patients who participated in Gaylord’s Young Stroke program last year spanned from age 17 to 81 years, with an average age of 55 years. The patient population that fits the Young Stroke criteria generally has fewer co-morbidities and a more active baseline than those in Gaylord’s general stroke population. The program’s more aggressive and highly activity-specific therapies take advantage of the greater energy and resilience of these patients.

Aggressive, Customized Therapy

The Young Stroke program is a segment of Gaylord’s inpatient stroke program. If appropriate, Young Stroke patients work on regaining or improving the specific skills they need to achieve their goals of returning to school, work, or caregiving.

When working with students, for example, therapists may focus on helping them find adaptive techniques or equipment to help them take notes and exams and determine what further recommendations can be made to their school to ensure that they have the best chances of success.

A primary caregiver for a very young child may engage in activities related to picking up the child, feeding the child, diapering, bathing, or transferring the child to a car seat or crib. Someone whose career required them to work on a computer might practice typing or work on certain spreadsheets or programs. Their therapists will help determine if they need to have adaptations for workstations or one-handed techniques.

Why Young Stroke?

A 2016 guideline from the American Heart Association (AHA) and American Stroke Association (ASA) states that approximately 20% of strokes occur among individuals of vocational age. Vocational roles, the guideline explained, provide an identity and contribute to increased self-esteem and life satisfaction.

The AHA and ASA also report the number of individuals who were working before their stroke and returned to work after their stroke varies from 20% to 66%. Included in the most frequently found factors associated with return to work are many of the skills emphasized by the Young Stroke program, including independence in activities of daily living (ADLs), good communication skills, and good higher-level cognitive skills and processing speed.1

After a Gaylord physiatrist determines whether a patient meets the Young Stroke program criteria, they—together with a team of interdisciplinary experts from physical therapy, occupational therapy, speech therapy, and recreational therapy—will create a plan of care and potential goals based on the patient’s pre-injury societal roles and baseline activity.

Kevin: A “Young Stroke” Case Study

Patient Kevin came to Gaylord Specialty Healthcare in September of 2019 after suffering a left basal ganglia infarct. The 65-year-old was an avid runner and skier and a career-long executive and chief executive officer of a booming toiletry manufacturing company that sells its product on some of the nation’s largest online retail sites. Kevin manages a small staff and is frequently invited to deliver motivational talks to college business students about overcoming challenges as an entrepreneur.

Kevin spent 2 weeks in an acute care hospital before being transferred to Gaylord Specialty Healthcare. He was unable to move his right arm or leg due to hemiparesis. Additionally, he presented a memory deficit, was affected with dysarthria, and was NPO at the time of his arrival. He made his goals clear from the beginning: He wished to return to his company on a full-time basis, resume his motivational speaking, and be physically active once more. He was deemed to be an excellent candidate for the Young Stroke program.

Throughout his three-and-one-half-week-long inpatient stay at Gaylord’s long-term acute care hospital, Kevin was immersed in an intense, highly customized, interdisciplinary plan of care including physical, occupational, and speech therapy that propelled him well on his way to achieve his goals.

Physical Therapy

The role of the physical therapist in the Young Stroke program is to assess their patient’s mobility, their limitations, and to procure the most recovery possible out of the patient’s deficits. Physical therapy for Young Stroke patients tends to be considerably more aggressive than that of the general stroke program as the population generally has greater endurance and fewer comorbidities.

Kevin’s first few therapy sessions were initially contact-guard assist, but a vigorous land-based therapy regimen quickly helped him become more independent. Aquatic therapy was soon added with focus placed on moving one limb to the contralateral side to promote improved core strength and coordination with weight-bearing functional mobility tasks.

As is often the case for stroke patients who make a sudden transition from an active to a sedentary lifestyle, Kevin experienced considerable stiffness. The 90-degree pool temperature and numerous warm-water jets considerably helped promote soft-tissue extensibility in his lumbar musculature.

As Kevin became increasingly tolerant of the aggressive therapy program, he was able to perform exercises including light plyometric drills and lunges in the hospital’s body-weight support system, to promote lower extremity unilateral stabilization and balance.

On his last inpatient day at Gaylord, Kevin was able to jog in the body-weight support system for the first time since the stroke and independently walk out of Gaylord Specialty Healthcare’s doors.

Occupational Therapy

In occupational therapy, Kevin worked toward independently performing activities of daily living such as showering, self-dressing, and more. But as a Young Stroke patient, much additional emphasis was also placed on regaining some of the highly specific skills that would help him successfully return to his career.

Kevin expressed a great desire to focus on arm control in hopeful preparation for a return to driving. Also, as a corporate CEO who “signed checks all day long,” he expressed specific, considerable interest in being able to legibly sign his own name.

Kevin’s occupational therapist developed a rigorous and customized exercise plan that included weights, resistance bands, and grippers to improve strength. Each day in therapy, Kevin practiced signing his name and writing numbers repeatedly. He often played a popular word-based board game with his therapist that not only required him to think critically, but also write his answers on paper. At first, the 65-year-old patient’s words were nearly illegible. As the weeks progressed, so, too, did his handwriting.

To further improve arm and hand control in preparation for driving, his occupational therapist recommended use of the hospital’s high-tech multidisciplinary therapy touchscreen program to work his coordination, balance, and hand/eye coordination. As he neared discharge, Kevin took, and passed, a pre-driving screen that tests reaction time, cognition, and attention using the same multidisciplinary therapy program.

Speech Therapy

A FEES assessment conducted before Kevin’s transfer to Gaylord revealed a severe pharyngeal stage dysphagia and silent aspiration with pureed foods and thin liquids. Due to this finding, Kevin arrived at Gaylord NPO. Kevin’s speech-language pathologist began an aggressive pharyngeal strengthening exercise routine and incorporated the use of a swallowing biofeedback system every day.

A modified barium swallow study 1 week later revealed that Kevin could transition to a PO diet. An NDD3 diet with thin liquids was recommended with the use of swallowing strategies. Near the end of his three-and-a-half week stay, Kevin underwent another modified barium swallow study and was upgraded to a regular-consistency diet without the need for strategy use.

Kevin was found to have a memory deficit that was addressed with memory recall exercises. Memory strategy use was discussed and implemented. Other assessments revealed that Kevin had significant deficits in oral-motor functioning and deficits in motor speech functioning. His speech-language pathologist aggressively worked to improve his mild-moderate oral motor deficit with electrode stimulation to the facial muscles and introduced oral exercises. Speech intelligibility strategies and tongue twisters were also introduced and practiced to improve motor speech.

Goals Fulfilled

Like many of his peers in Gaylord’s Young Stroke Program, Kevin was discharged to home at the end of his three-and-a-half-week stay at Gaylord Specialty Healthcare and transitioned to Gaylord’s outpatient therapy program for continued improvements. As of January 2020, fewer than 4 months after his stroke, Kevin plans on returning to the helm of his personal products business on a full-time basis. RM

Jaclyn Skirkanich, PTA, received an associate’s degree in Physical Therapy (PTA) from Naugatuck Valley Community College in 2014, a bachelor’s degree from UCONN in 2019, and is currently enrolled in a doctoral physical therapy program at Mercy College. She has been employed at Gaylord Specialty Healthcare since 2017.

Janine Volpe-Clarkson, MS, CCC-SLP, earned a Bachelor of Science from The College of Saint Rose and a Master of Science from Southern Connecticut State University. She is employed by Gaylord Specialty Healthcare as a speech-language pathologist, is the Center Coordinator of Clinical Education for inpatient speech-language pathology, and serves on the neurobehavioral committee.

Alexandra Waller, MS OTR/L, received her bachelor’s degree and master’s degree from Springfield College. She has been employed as an Occupational Therapist at Gaylord Specialty Healthcare for the past four years, is an aquatic therapist and member of the neurological committee. For more information, contact RehabEditor@medqor.com.

Reference

1. AHA/ASA Guideline. Guidelines for Adult Stroke Rehabilitation and Recovery. Available at: https://www.aan.com/Guidelines/Home/GetGuidelineContent/744. Accessed January 30, 2020.

Plateau or Progress? Objective Gait Data Helps Decide

by Frank Long, MS, Editorial Director, Rehab Management

The best stroke rehabilitation outcomes are no accident. They are informed by measures of performance that can help determine whether a patient is continuing to make functional gains or has reached a plateau. This is especially important for recovering the ability to walk, a common rehab goal among post-stroke patients and one that objective temporal-spatial measure of gait can help bring into focus.

A 2017 study spotlights the clinical value of objective gait data in helping determine the effectiveness of modified standardized task-specific training (MSST) on gait recovery post-stroke.1 MSST is a progressive gait training program for outpatients that includes the use of a treadmill to address gait dysfunction.1 The objective gait data gathered for this study helped researchers compare the performance of two study subjects using different gait-recovery programs for the purpose of gauging the effectiveness of MSST as outpatient treatment.

What the Data Measure

A computerized mat was used to gather objective temporal-spatial gait data about each study subject. The temporal-spatial data collected included measures for velocity, cadence, step length, step length differential, double limb support average, single limb support, toe in/out, and base of support average. Study subjects were tested with the computerized mat at 10 weeks, 6 months, and 10 months.1

Both participants in the study demonstrated significant changes in temporal-spatial parameters of gait, a conclusion the authors reached in part by using objective data generated by the computerized mat. Other evaluations used include the 6-Minute Walking Test, Stream, Functional Independence Measure, locomotion/stairs subscale, Stroke Impact Scale, Modified Ashworth Scale, and lower extremity sensation.1

An Open Window

Clinical decision-making evidence is vital to healthcare, and this study demonstrates that objective data about the temporal-spatial measure of gait can help evaluate the effectiveness of therapy. This data may be especially helpful in evaluating progress during the 2-month window after stroke when critical motor learning occurs. It is important to economize the oftentimes limited number of reimbursable visits available during that period, which clinicians can do by using objective temporal-spatial gait data to help set recovery goals and move patients toward them while the window remains open. RM

Reference

1. McCain KJ, Shearin S. The impact of modified standardized task-specific training (MSTT) on gait outcomes in persons with subacute stroke: A case report. Cogent Medicine. 4:1, DOI: https://www.doi.org/10.1080/2331205X.2017.1417669

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[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

Abstract

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

Abstract

Objective

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.

Design

A register-based, retrospective cohort design

Setting

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.

Participants

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

Interventions

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.

Results

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.

Conclusions

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

Abstract

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.

Introduction

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 ().

Method

Participants

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.

Materials

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.

Abstract

BACKGROUND/AIM:

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.

METHODS:

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.

RESULTS:

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.

CONCLUSIONS:

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

Abstract

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.

Introduction

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 gravityblankets.com.

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

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