6.Salter RB (2004) Continuous passive motion: from origination to research to clinical applications. J Rheumatol 31(11):2104–2105Google Scholar
8.Jarrassé N, Proietti T, Crocher V, Robertson O, Sahbani A, Morel G, Roby-Brami A (2014) Robotic exoskeletons: a perspective for the rehabilitation of arm coordination in stroke patients. Front Hum Neurosc 8. doi:10.3389/fnhum.2014.00947
14.Borboni A, Mor M, Faglia R (2016) Gloreha-hand robotic rehabilitation: design, mechanical model, and experiments. J Dyn Syst Meas Control Trans ASME 138(11). doi:10.1115/1.4033831
17.Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS (1999) Stroke: neurologic and functional recovery the Copenhagen Stroke Study. Phys Med Rehabil Clin N Am 10(4):887–906Google Scholar
Posts Tagged Telemedicine
Stroke patients are often affected by hemiparesis. In the rehabilitation of these patients the function of the hand is often neglected. Thus in this work we propose a robotic approach to the rehabilitation of the hand of a stroke patient in hospital and also at home. Some experimental results can be presented here especially for inpatients. Further experimental results on home-patients must be acquired through a telemedicine platform, designed for this application.
Background: Telemedicine applications have been increasing due to the development of new computer science technologies and of more advanced telemedical devices. Various types of telerehabilitation treatments and their relative intensities and duration have been reported.
Objective: The objective of this review is to provide a detailed overview of the rehabilitation techniques for remote sites (telerehabilitation) and their fields of application, with analysis of the benefits and the drawbacks related to use. We discuss future applications of telerehabilitation techniques with an emphasis on the development of high-tech devices, and on which new tools and applications can be used in the future.
Methods: We retrieved relevant information and data on telerehabilitation from books, articles and online materials using the Medical Subject Headings (MeSH) “telerehabilitation,” “telemedicine,” and “rehabilitation,” as well as “disabling pathologies.”
Results: Telerehabilitation can be considered as a branch of telemedicine. Although this field is considerably new, its use has rapidly grown in developed countries. In general, telerehabilitation reduces the costs of both health care providers and patients compared with traditional inpatient or person-to-person rehabilitation. Furthermore, patients who live in remote places, where traditional rehabilitation services may not be easily accessible, can benefit from this technology. However, certain disadvantages of telerehabilitation, including skepticism on the part of patients due to remote interaction with their physicians or rehabilitators, should not be underestimated.
Conclusions: This review evaluated different application fields of telerehabilitation, highlighting its benefits and drawbacks. This study may be a starting point for improving approaches and devices for telerehabilitation. In this context, patients’ feedback may be important to adapt rehabilitation techniques and approaches to their needs, which would subsequently help to improve the quality of rehabilitation in the future. The need for proper training and education of people involved in this new and emerging form of intervention for more effective treatment can’t be overstated.
In the last few years, telemedicine applications have been increasing due to the development of new computer science technologies and of more advanced telemedical devices. Long-distance communication can be easily achieved by videoconferencing, email, and texting, to name a few. Today there is the possibility of controlling robots, robotic arms, or drones at a distance. Thanks to these advancements, the course of human action has been considerably transformed . During the last 20 years, demographic changes and increased budget allocation in public health have improved new rehabilitative practices [ ]. Rehabilitation is an old branch of medicine, but in the last few years, new telecommunication-based practices have been developed all over the world. These particular approaches in the field of rehabilitation are commonly defined as telerehabilitation, which should be considered as a telemedicine subfield consisting of a system to control rehabilitation at a distance [ ].
Telerehabilitation has been developed to take care of inpatients, transferring them home after the acute phase of a disease to reduce patient hospitalization times and costs to both patients and health care providers. Telerehabilitation allows for treatment of the acute phase of diseases by substituting the traditional face-to-face approach in the patient-rehabilitator interaction . Finally, it can cover situations in which it is complicated for patients to reach traditional rehabilitation infrastructures located far away from where they live.
Controlled studies on rehabilitation have demonstrated that quick management of an injury or a disease is critical to achieve satisfactory results in terms of increasing a patient’s self-efficacy. Hence, a rehabilitation program should start as soon as possible, be as intensive as possible, be prolonged, and continue during the recovery phase. A major factor is the initiation time, which, in general, should begin as soon as possible. In most cases, the initial stages of rehabilitation, after the occurrence of a disease or injury, could be performed by patients at home even if they need accurate and intensive treatment. For these reasons, telerehabilitation was developed to achieve the same results as would be achieved by the normal rehabilitation process at a hospital or face to face with a physiotherapist. Various types of telerehabilitation treatments and their relative intensities and duration have been reported .
The first scientific publication on telerehabilitation is dated 1998 and, in the last few years, the number of articles on the topic has increased, probably because of the emerging needs of people and due to the development of exciting new communication and computer technologies.shows the number of patients treated through telerehabilitation from 1998 to 2008 according to studies published in the international literature [ ].
A remarkable increase in the number of patients treated by telerehabilitation is noticeable from 2002 to 2004. After a subsequent decrease, the number of patients assisted by telerehabilitation increased starting from 2007, probably due to the support of new technologies and the overcoming of the initial skepticism to which every new technology is subjected.
Telerehabilitation is primarily applied to physiotherapy [, ], and neural rehabilitation is used for monitoring the rehabilitative progress of stroke patients [ ]. Telerehabilitation techniques mimic virtual reality [ – ] and rehabilitation for neurological conditions by using robotics and gaming techniques [ ]. Quite often, telerehabilitation has been associated with other nonrehabilitative technologies such as remote monitoring of cardiovascular parameters, including electrocardiogram (ECG), blood pressure, and oxygen saturation in patients with chronic diseases [ ]. These technologies belong to another telemedicine branch called telemonitoring, which has been widely developed and used in recent years. A few studies were also centered on the economic aspects of the use of telerehabilitation to reduce the costs of hospitalization [ ]. We reviewed the status and future perspectives of telerehabilitation by analyzing their impact on patients’ everyday life. The main topics taken into account were (1) the status of telerehabilitation and analysis of the main medical specialties where it is being applied, (2) quality-of-life improvement due to telerehabilitation, and (3) the future of telerehabilitation.
SINGAPORE: Patients from two healthcare institutions across Singapore will be able to carry out physiotherapy exercises in the comfort of their own homes, after a national tele-rehabilitation pilot was launched on Friday (May 5) by Integrated Health Information Systems (IHiS).
IHiS, Singapore’s healthcare technology agency, developed the system together with T-Rehab, a start-up founded by researchers from the National University of Singapore (NUS).
To use the service, patients open an app on an iPad – called Smart Health TeleRehab – and put on neck and limb sensors, depending on which part of the body they are exercising. The instructions are available in five languages: English, Mandarin, Bahasa Melayu, Tamil and Tagalog.
Video demonstrations of the exercises prescribed by the therapists will then be played via the app. The therapist is able to customise the level of difficulty of each exercise, from the number of repetitions to the angle of each limb movement.
The patient’s movements are also recorded for the therapist to review, and to motivate the patient to complete his or her exercises, the system designed to have gaming elements. For instance, there are coloured bars to indicate if the patient has achieved the desired exercise angle, and a counter for the number of repetitions completed.
After the patient completes the exercises, a record of the patient’s performance is sent to the therapist.
The service is available to those deemed suitable to perform physiotherapy exercises without the physical supervision of a physiotherapist. This includes those recovering from strokes, lower limb joint replacements and amputations, falls and fractures.
It is currently offered by NTUC Health and TOUCH Home Care. Twelve other institutions including Ang Mo Kio-Thye Hua Kwan Hospital, Khoo Teck Puat Hospital, and the National University Hospital will provide the service by end-2017.
There are 200 sets of tele-rehabilitation equipment available, which is rented out to the healthcare institutions for a fee. IHiS hopes to get 1,000 patients on the programme by the end of the two-year pilot and currently has around 11 patients on the service since February this year, said Mr Chua Chee Yong, director of IHiS’ planning group.
OVERCOMING INCONVENIENCE, HIGH COSTS
This service comes two-and-a-half years after clinical trials were conducted by the researchers from T-Rehab.
A total of 100 stroke patients were recruited from Ang Mo Kio-Thye Hua Kwan Hospital and the Singapore General Hospital since January 2014, said Dr Gerald Koh, an associate professor and the director of medical undergraduate education at Saw Swee Hock School of Public Health at NUS. He is one of the founders of T-Rehab.
They chose to develop a tele-rehab system after an earlier study he conducted found that only two out of five patients wanted to continue with rehabilitation after discharge, he said. This is despite close to four out of five of them stating that rehabilitation was useful.
According to Dr Koh, many of them cited inconvenience, high costs and difficulty getting to the rehab centre without a caregiver as the main reasons why they stopped going for rehabilitation.
“The very reason why I need rehabilitation is the very reason why I can’t get to the day rehab centre three times a week,” Dr Koh said of the issue of immobility faced by patients.
His study found that those who got therapy through tele-rehabilitation recovered as well as those who did their exercises with a therapist present.
This new service, Dr Koh added, will help to boost rehabilitation participation rate and remove the barriers to carrying out physiotherapy and this will prevent their conditions from deteriorating further.
One of the early adopters of the system, TOUCH Home Care, found that the service benefits both patients and its healthcare workers since it implemented the system in March 2017.
For TOUCH Home Care, the price per session is still the same as a home visit at S$18. However, as the patient is able to carry out the exercises more frequently and at their own time, the hope is that he or she will recover faster and overall, fewer therapy sessions are required, said a physiotherapist at TOUCH Home Care Vivian Lim.
The operator’s therapists have also been more productive.
So far, they spend about 50 minutes on each tele-rehabilitation session, which include prescribing the exercise via the system, reviewing the elderly client’s exercise records and conducting video consultations or calling the patients to provide feedback. A home visit will typically take about 100 minutes, including time to travel from one home to another.
The sessions are not meant to substitute home visits entirely, said Ms Lim, but can replace some of the weekly sessions.
However, not all clients are able to benefit from the new service, as those with conditions such as chronic giddiness and seizures will not be able to perform their exercises without direct supervision, said Ms Rachel Lim, a senior occupational therapist from TOUCH Home Care.
Some of the seniors also “lack confidence” in using technology, while others may not have the right caregivers at home. “There are some caregivers are also elderly who are frail (themselves), with sensory deficits…they can’t help put on the sensors,” said the occupational therapist.
TOUCH Home Care hopes to get 90 of its 300 clients using the remote rehabilitation tool by the end of this year. It now has seven on board.
MEETING SINGAPORE’S HEALTHCARE NEEDS
The tele-rehabilitation service was developed in light of Singapore’s healthcare landscape, said IHiS’ Mr Chua.
“Our growing ageing population (means) we have more aged elderly in the community… more healthcare workers, including our therapists, are also getting older,” he said. This means that there will be greater demand for rehabilitation services, while there will be a growing need to “stretch our manpower resources”.
The service is one of three telemedicine initiatives that will begin this year. A remote vital signs monitoring system will launch later this year, while a national videoconferencing platform for healthcare services was launched in April.
[Abstract] A Telehealth Approach to Caregiver Self-Management Following Traumatic Brain Injury: A Randomized Controlled Trial
Design: Parallel group, randomized controlled trial with blinded outcome assessment.
Setting: General community.
Participants: A total of 153 caregivers (mean age = 49.7 years; 82% female; 54% spouses/partners, 35% parents) of persons with moderate to severe TBI who received acute and/or rehabilitation care at a level I trauma center. Eighty-two percent of participants were evaluated at 6-month follow-up.
Intervention: Individualized education and mentored problem-solving intervention focused on caregivers’ primary concerns delivered via up to 10 telephone calls at 2-week intervals.
Main Outcome Measures: Composite of Bakas Caregiving Outcomes Scale (BCOS) and Brief Symptom Inventory (BSI-18) at 6 months post-TBI survivor discharge. Secondary measures included the Brief COPE.
Results: Caregivers in the treatment arm scored higher on the BCOS-BSI composite (P = .032), with more active coping (P = .020) and less emotional venting (P = .028) as measured by the Brief COPE.
Conclusions: An individualized education and mentored problem-solving approach delivered via telephone in the first few months following community discharge of the TBI survivor resulted in better caregiver outcomes than usual care. Consideration should be given to using this approach to augment the limited support typically offered to caregivers.
[Abstract] H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for individuals post stroke
Implications for Rehabilitation
A repetitive, task-oriented home exercise program that utilizes telephone supervision may be an effective method for the treatment of the upper limb following stroke
This program is best suited for individuals with mild to moderate level impairment and experience a sufficient level of challenge from the exercises
An exercise program that includes behavioural strategies may promote transfer of exercise gains into greater use of the affected upper limb during daily activities
Source: Taylor & Francis Online
[ARTICLE] Multimedia and Gaming Technologies for Telerehabilitation of Motor Disabilities- IEEE Xplore, Full-Text PDF
Rehabilitation for chronic conditions resulting from acute or progressive disease might be delivered in an outpatient facility as in the case of telerehabilitation, selfrehabilitation and, more generally, in the context of home-based rehabilitation to improve the patients’ quality of life.
Here we present the emerging field of home-based applications for continuous digital health, focusing in particular on low-cost rehabilitation systems for motor disabilities based on multimedia and gaming technologies. Innovative technologies for telerehabilitation are illustrated. We also present recent advances in telerehabilitation, considering the most relevant projects that best represent new trends for research and development of new technologies and applications in this context. Telerehabilitation (TRH) is the provision of rehabilitation services at a distance using information and communication technologies (ICT) . TRH services might be needed for diagnosis, assessment, consultations, and monitoring, as well as to supervise therapies or therapeutic settings or to propose interactive therapies. Rather than being described as a super specialization of rehabilitation, therefore, TRH should be viewed as an alternative way to deliver rehabilitation services, particularly suited for chronic conditions that might benefit from home-based care. It has been demonstrated, in fact, that improving motor function, a major goal of any rehabilitative treatment, should be pursued even in the chronic stages of disabling condition, like stroke, Parkinson’s disease, and multiple sclerosis, for which telemedicine could be seen as a great opportunity to allow remote diagnosis and clinical monitoring.
The aim of this article is to present the emerging field of homebased applications for continuous digital health, focusing in particular on low-cost TRH systems for motor disabilities that adopt diffused ICT for gaming and multimedia as well as the networking connection…
Background: After discharge from in-hospital rehabilitation, post-stroke patients should have the opportunity to continue the rehabilitation through structured programs to maintain the benefits acquired during intensive rehabilitation treatment.
Objective: The primary objective was to evaluate the feasibility of implementing an home-based telesurveillance and rehabilitation (HBTR) program to optimize the patient’s recovery by reducing dependency degree.
Method: Post-stroke patients were consecutively screened. Data were expressed as mean ± standard deviation (SD). 26 patients enrolled: 15 were sub-acute (time since stroke: 112 ± 39 days) and 11 were chronic (time since stroke: 470 ± 145 days). For 3 months patients were followed at home by a nurse-tutor, who provided structured phone support and vital signs telemonitoring, and by a physiotherapist (PT) who monitored rehabilitation sessions by videoconferencing.
Results: 23 patients completed the program; 16.7 ± 5.2 phone contacts/patient were initiated by the nurse and 0.9 ± 1.8 by the patients. Eight episodes of atrial fibrillation that required a change in therapy were recorded in two patients. Physiotherapists performed 1.2 ± 0.4 home visits, 1.6 ± 0.9 phone calls and 4.5 ± 2.8 videoconference-sessions per patient. At least three sessions/week of home exercises were performed by 31% of patients, two sessions by 54%. At the end of the program, global functional capacity improved significantly (P < 0.001), in particular, static (P < 0.001) and dynamic (P = 0.0004) postural balance, upper limb dexterity of the paretic side (P = 0.01), and physical performance (P = 0.002). Symptoms of depression and caregiver strain also improved.
Conclusion: The home-based program was feasible and effective in both sub-acute and chronic post-stroke patients, improving their recovery, and maintaining the benefits reached during inpatient rehabilitation
Source: Taylor & Francis Online
[ARTICLE] Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke – Full Text HTML/PDF
Background: Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke.
Methods: A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up.
Results: Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log.
Conclusions: Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings.
By Jordana Bieze Foster, Editor
My former company launched a publication called Telehealth in 1998. Nearly two decades later, that magazine no longer exists, and telemedicine hasn’t revolutionized healthcare the way some thought it would. But advances are being made, and researchers are demonstrating that the potential applications for remote healthcare include disciplines that have always been considered “hands on.”
The publishing group that launched Telehealth had its roots in the world of radiology—a specialty for which working remotely makes all kinds of sense. With the right transmission and viewing equipment, most diagnostic images can be interpreted from anywhere in the world, and few patients are expecting to have face time with their radiologist. So, it’s not surprising that radiology remains a telemedicine trailblazer today, with some radiology practices now based entirely on remote image interpretations.
It’s not a huge leap from the remote assessment of radiographs, magnetic resonance images, and computed tomography scans to the remote assessment of diabetic wounds (see “Telemedicine: Bringing diabetic foot care to the small screen,” January 2015, page 14). Not only can telehealth technology minimize the need for patients with diabetic ulcers—who shouldn’t be ambulating more than necessary and definitely shouldn’t be driving—to make an in-person clinic visit just to check the status of a wound, clinicians can provide informational and motivational consultations via cellphone, Skype, or other cyber-modalities.
Physical therapy and telemedicine, however, would seem to be mutually exclusive. Few clinicians have historically been more hands-on than physical therapists. How effective could a virtual physical therapist possibly be? Surprisingly effective, as it turns out.
In a recent Canadian study, two-month functional outcomes were similar for total knee replacement surgery patients who received either remote physical therapy or in-person therapy sessions (see “Telerehabilitation after TKA,” page 15). But the two experiences differed in significant ways. Unable to perform hands-on adjustments or manipulations on patients, the remote therapists had to be able to effectively explain how to do exercises correctly and how patients could perform basic versions of therapies like massage on themselves. The remote therapists also had to master the technical aspects of the video system, including panning, tilting, zooming, and using an on-screen goniometer.
It’s a somewhat different skill set than that required for conventional physical therapy. Not every clinician will excel at both versions of their job, and not every patient will respond equally to both types of treatment. It will take a lot more research to determine which conditions and which patients are the best candidates for telerehabilitation. And then, of course, there are reimbursement issues to be hammered out.
But the possibilities are exciting. Not only does telerehabilitation have the potential to make therapy more accessible to patients, it also has the potential to make careers in physical therapy and rehabilitation medicine more accessible to individuals with disabilities who aren’t physically able to provide hands-on treatment.
Lower extremity clinicians won’t be as quick to embrace telemedicine as radiologists have been, and for good reasons. But now that the telehealth trail has been blazed, smart practitioners will be thinking about where that path might ultimately lead them.
Telemedicine has become one of the hot trends in healthcare, with more and more patients and doctors using smartphones and tablets to exchange medical information. The convenience of not having to travel to the doctor’s office or clinic is a big part of the appeal—as is the relief of not wasting valuable time thumbing through outdated waiting-room magazines when an appointment runs late. And for patients living in isolated or underserved areas, telemedicine offers care that might otherwise be unattainable. Despite these advantages, telemedicine can be coldly impersonal, lacking the comfort of interacting with another human being.
Silicon Valley-based Sense.ly is working to bring a human face to telemedicine. The company’s Kinect-powered “nurse avatar” provides personalized patient monitoring and follow-up care—not to mention a friendly, smiling face that converses with patients in an incredibly lifelike manner. The nurse avatar, affectionately nicknamed Molly, has access to a patient’s records and asks appropriate questions related directly to the patient’s past history or present complaints. She has a pleasant, caring demeanor that puts patients at ease. Interacting with her seems surprisingly natural, which, of course, is the goal.
By using Kinect for Windows technology, Sense.ly enables Molly to recognize and respond to her patient’s visual and spoken inputs. The patient stands or sits in from of a Kinect sensor, which captures his or her image and sends it to Molly. Does the patient have knee pain? She can show Molly exactly where it hurts. Is the patient undergoing treatment for bursitis that limits his range of motion? He can raise his affected arm and show Molly whether his therapy is achieving results. In fact, the Kinect sensor’s skeletal tracking capabilities allow Sense.ly to measure the patient’s range of motion and to calculate how it has changed from his last session. What’s more, with Kinect providing a clear view of the patient, Molly can help guide him or her through therapeutic exercises.
A growing number doctors and hospitals are recognizing the value of applications such as Sense.ly. In fact, the San Mateo Medical Center is one of several major hospitals that have recently added Molly to their staff, so to speak. The value of such solutions is particularly striking in handling patients who suffer from long-term conditions that require frequent monitoring, such high blood pressure or diabetes.
Solutions like Sense.ly also provide a clear cost benefit for providers and insurers, as treating a patient remotely is less costly and generally more efficient than onsite care. In a recent pilot program, the use of Sense.ly reduced patient calls by 28 percent and freed up nearly a fifth of their day for the clinicians involved in the program.
Most importantly, Sense.ly’s Kinect-powered nurse avatar offers the promise of better health outcomes, the result of more frequent medical monitoring and of patients’ increased involvement in their own care. Something to think about the next time you’re stuck in the doctor’s waiting room.