Posts Tagged telerehabilitation

[WEB SITE] Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke – JAMA Neurology

It’s probably not news to physical therapists (PTs) when research backs up the idea that patients who experience arm impairments poststroke will tend to make greater functional improvements with larger and longer doses of rehabilitation. Unfortunately, PTs are also familiar with the fact that what’s optimal isn’t necessarily what’s typical, with challenges such as payment systems, logistics, and clinic access making it difficult to achieve the best possible results. That’s where telerehabilitation could make a big difference, say authors of a new study that found an entirely remotely delivered rehab program to be as effective as an equal amount of clinic-based sessions.

The findings lend further support to the ideas behind APTA’s efforts to increase telehealth opportunities for PTs and their patients—a significant component of the association’s current public policy priorities. In addition, APTA provides multiple telehealth resources on a webpage devoted to the topic, and has created the Frontiers in Research, Science, and Technology Council that provides interested members and other stakeholders with an online community to discuss technology’s role in physical therapy.

The study, published in JAMA Neurology (abstract only available for free), involved 124 participants who experienced arm motor deficits poststroke. All participants were enrolled in a rehabilitation therapy program that included 36 70-minute treatment sessions, half of which were supervised, over a 6- to 8-week period. The only major difference: one group’s supervised sessions were face-to-face with a physical therapist (PT) or occupational therapist (OT), while the other group received telerehab from a PT or OT via a computer with video capabilities, accompanied by the use of a gaming system.

Researchers were interested in finding out how patients fared in each approach, using scores from the Fugl Meyer (FM) assessment of motor recovery poststroke as their primary measure. Authors of the study also measured patient adherence with therapy as well as levels of patient motivation related to how well they liked the therapy they were receiving and their degree of dedication to treatment goals.

Using a treatment approach “based on an upper-extremity task-specific training manual and Accelerated Skill Acquisition Program,” researchers set up matched programs that included at least 15 minutes per session of arm exercises from a common set of 88 possible exercises, at least 15 minutes of functional training, and 5 minutes of stroke education. The clinic-based participants received in-person instruction on the exercises and used “standard exercise hardware”; the telerehab patients received instructions via video link and engaged in functional exercise via a videogame interface. Here’s what the researchers found:

  • Both groups improved at about the same rate, with the telerehab participants averaging a 7.86 FM gain, compared with an average gain of 8.36 points for the clinic-based group.
  • Improvements were also about the same for the subgroup of participants who entered rehabilitation more than 90 days poststroke, with these “late” participants averaging a 6.6-point gain for the telerehab group and a 7.4-point increase for the clinic-based group.
  • While both groups reported high levels of dedication to treatment goals, the clinic-based group tended to report better levels of motivation and satisfaction. Adherence was also high for both groups, with a 93.4% adherence rate for the clinic-based group and a rate of 98.3% for the telerehab group.
  • Both groups increased their knowledge of stroke at similar rates.

As for the technical details of the telerehab sessions, the system included a computer linked to the internet, a table, a chair, and 12 “gaming input devices.” Keyboards were not necessary. The supervised sessions began with a 30-minute videoconference between the patient and therapist, and the functional training games used were designed to match the functional task work being done with the clinic-based participants. Unsupervised sessions adhered to the same content but didn’t include contact with the therapist.

“In an era when prescribed doses of poststroke rehabilitation therapy are declining, adversely affecting patient outcomes, these and prior findings suggest that outcomes could be improved for many patients…if larger doses of rehabilitation therapy were prescribed,” authors write. “Our study found that a 6-week course of daily home-based [telerehab] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic.”

Authors acknowledged that patient satisfaction with telerehab might be improved by increasing the amount of time spent with the therapist—providing that therapist is properly trained. “Current results underscore the importance of maintaining a licensed therapist’s involvement during [telerehab],” they write.

Ultimately, it’s still too early to determine just how generalizable the findings are to other populations and conditions, the researchers say, but all indicators seem to point to the need for increasing the availability of telerehab and its inclusion in health plans.

“The US Bipartisan Budget Act of 2018 expanded telehealth benefits,” authors write. “Eventually, home-based [telerehab] may plan an ascendant role for improving patient outcomes.”

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.

via JAMA Neurology: Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke

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[ARTICLE] Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial – Full Text

Abstract

Background

Virtual reality training (VRT) uses computer software to track a user’s movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery.

Methods

Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated.

Discussion

The results of this study will be used to support the creation of a definitive randomized controlled trial on the efficacy of home-based VRT for rehabilitation post stroke.

Introduction and objectives

Stroke causes approximately 17,600 hospital admissions per year in Ontario and 50% of individuals who have had a stroke are left with moderate to severe impairment [12]. Most patients who are discharged from inpatient stroke rehabilitation are only 8–10 weeks post stroke and have not completely recovered. Their central nervous systems are still in a period of enhanced neuroplasticity, during which great functional change can be made [34]. Therapy outcomes are dose-dependent; intensive, high-repetition, task-oriented and task-specific therapies are most effective [56]. Therefore, for the greatest recovery possible, these patients require ongoing, intensive therapy. Most are offered this on an outpatient basis. However, for many reasons (transportation difficulties, distance from the rehabilitation center, weather etc.), not all eligible patients are able to attend outpatient therapy. Also, there is a waiting list and a limited number of outpatient therapy sessions are offered to each patient. Home-based therapy may fill an important role towards increasing the availability of rehabilitation, enabling patients to enhance or prolong their therapy and potentially improving outcomes.

Non-immersive virtual reality training (VRT) uses computer software to track the user’s movements and allow him or her to interact with a game or activity presented on a TV screen. It is convenient, timely, enjoyable and may be used for an unlimited period post stroke [78]. VRT has been shown to benefit upper extremity function, standing balance, gait and overall function in the sub-acute and chronic phases post stroke, at least as much as or more than conventional therapy [7910111213].

Home-based VRT offers a promising addition or alternative to existing rehabilitation programs that could make a significant difference in the lives of stroke survivors. A few preliminary studies have investigated the use of home-based VRT for standing balance and upper extremity recovery after stroke and shown potential feasibility of these systems for ongoing rehabilitation in the home [1415161718]. Some VRT platforms allow the user to interface via tactile devices (for example, a dynamic standing frame [14] or robotic glove [18]) while others use motion-tracking via a camera [16]. Some platforms use asynchronous monitoring to allow the therapist to monitor VRT usage and performance after the actual event [16] while others use synchronous monitoring to enable the therapist to watch in while the participant exercises; some even require constant real-time patient/therapist interaction [1719] throughout the therapy session. Users report high satisfaction with home-based VRT [1617], although actual usage can vary greatly [18]. Barriers to the use of home-based VRT include technical issues and lack of previous technical experience [18]. While some previous experience with computers is helpful, those who play video games regularly can become bored with VRT. Facilitators include the flexibility of home-based exercise, support from family and motivation from the VRT itself. Early results, available from a single randomized controlled trial (RCT) with 30 participants, suggest that home-based VRT improves standing balance and gait equally to in-clinic VRT, but that the costs are 44% lower [16].

We wish to add to these early studies of home-based VRT using a virtual reality system (Jintronix Inc.) that was initially developed for stroke rehabilitation and has also been used extensively with healthy and frail elderly individuals. The Jintronix system is marketed for institutional and home use and has a simple-to-use interface, but its home use has not yet been fully evaluated. The games are designed to incorporate motor learning principles such as multiple forms of feedback and task-specific practice that can be progressed to maintain an appropriate level of challenge. Unlike systems used in previous research, the Jintronix system includes a wide selection of games and exercises designed for the rehabilitation of sitting and standing balance, gait and upper extremity use. The system is simple to use and relatively inexpensive; a motion-tracking camera and software eliminates the need for gloves/controllers etc. It is straightforward enough for the patient to use independently; asynchronous monitoring is used to track usage and the therapist can change games and parameters remotely. The purpose of this study is to investigate the feasibility, acceptance and safety of this new, simple-to-use VRT system for use in the home, combined with asynchronous, remote support for the user. The results of this trial will support a definitive RCT in the future.

The primary objective is to assess the feasibility of using VRT in the home with patients post stroke, using quantitative and qualitative methods. Specific objectives are:

  1. 1.

    To estimate the recruitment rate of participants into the study;

  2. 2.

    To assess the ability and compliance of the participants with respect to the components of the research protocol (ability to learn VRT through the training program; ability to comply with the exercise protocol; participant retention);

  3. 3.

    To determine the safety of home-based VRT (presence of minor and major adverse events);

  4. 4.

    To assess the ability of stroke survivors and their study partners to use VRT technology in the home (i.e. technical difficulties, difficulty learning the games);

  5. 5.

    To assess the acceptability of the VRT intervention (enjoyment; perceived efficacy);

  6. 6.

    To estimate the cost for a future definitive RCT on in-home VRT.

The secondary objective is to assess the feasibility of the outcome measures, using quantitative and qualitative methods. Specific objectives are:

  1. 1.

    To assess the feasibility and acceptance of a battery of outcome measures, including physical assessments, questionnaires, an interview and a log book;

  2. 2.

    To assess the potential that home-based VRT might maintain or improve physical outcomes of standing balance, gait and general function and community integration after discharge from hospital-based stroke rehabilitation, compared to those who perform a program of iPad apps designed for fine hand motor skills and cognitive training;

  3. 3.

    To determine the sample size required for a future definitive RCT on in-home VRT.

This study is a prospective, single-site, single-blinded, parallel-group (1:1 ratio) randomized, superiority feasibility trial on the use of VRT for ongoing stroke rehabilitation after discharge from inpatient or outpatient stroke rehabilitation. A feasibility RCT was chosen in order to provide the most useful results to prepare for a future definitive RCT on the efficacy of home-based VRT. iPad apps were chosen as a comparator to VRT because they provide a control group that has equal contact with the researchers and equal time spent in an engaging activity. The use of an active control group (rather than providing control group participants with nothing) was also chosen to facilitate recruitment. The iPad apps chosen to work on hand fine motor control and cognition were not deemed to have any influence on the physical outcome measures of standing balance, gait and gross motor function. The Standard Protocol Items: Recommendation for Interventional Trials (SPIRIT) checklist is available as Additional file 1: Figure S1.[…]

 

Continue —>  Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial | Trials | Full Text

Fig. 1a  Experimental intervention – home-based virtual reality training targeting standing balance, stepping, reaching, strengthening and aerobic exercise. b Control intervention – iPad apps targeting cognition and hand fine motor control

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[WEB SITE] In-home therapy effective for stroke rehabilitation, study shows — ScienceDaily

A multisite US clinical trial compared home-based telerehabilitation program with traditional in-clinic rehabilitation therapy

Summary:
Stroke remains a leading cause of human disability and rehabilitation therapy can help. Supervised in-home rehabilitation therapy delivered via telemedicine can be as effective as in-clinic rehabilitation program as an alternative for stroke survivors who can’t sustain in-person visits for reasons that may include high cost, difficulty traveling to a provider or few regionally available care providers.     
FULL STORY

In-home rehabilitation, using a telehealth system and supervised by licensed occupational/physical therapists, is an effective means of improving arm motor status in stroke survivors, according to findings presented by University of California, Irvine neurologist Steven C. Cramer, MD, at the recent 2018 European Stroke Organisation Conference in Gothenburg, Sweden.

“Motor deficits are a major contributor to post-stroke disability, and we know that occupational and physical therapy improve patient outcomes in a supervised rehabilitation program,” said Cramer, a professor of neurology in the UCI School of Medicine. “Since many patients receive suboptimal therapy doses for reasons that include cost, availability, and difficulty with travel, we wanted to determine whether a comprehensive in-home telehealth therapy program could be as effective as in-clinic rehabilitation.”

In a study conducted at 11 U.S. sites, 124 stroke survivors underwent six weeks of intensive arm motor therapy, with half receiving traditional supervised in-clinic therapy and half undergoing an in-home rehabilitation program supervised via a videoconferenced telemedicine system.

Subjects were on average 61 years old, 4.5 months post-stroke, and had moderate arm motor deficits at study entry. When examined 30 days after the end of therapy, subjects in the in-clinic group improved by 8.4 points on the Fugl-Meyer scale, which measures arm motor status and ranges from 0 to 66, with higher numbers being better. Subjects in the telerehab group improved by 7.9 points, a difference that was not statistically significant.

“The current findings support the utility of a computer-based system in the home, used under the supervision of a licensed therapist, to provide clinically meaningful rehab therapy,” Cramer said. “Future applications might examine longer-term treatment, pair home-based telerehab with long-term dosing of a restorative drug, treat other neurological domains affected by stroke (such as language, memory, or gait), or expand the home treatment system to build out a smart home for stroke recovery.”

He said that the demand for rehabilitation services will likely increase, due to an aging population and increased stroke survival as a result of better access to advanced acute care. Telehealth, defined as the delivery of health-related services and information via telecommunication technologies, can potentially address this growing unmet need.

“We reasoned that telerehabilitation is ideally suited to efficiently provide a large dose of useful rehab therapy after stroke,” said Cramer, whose research team is part of the NIH StrokeNet consortium.

This research builds on the findings of a pilot study of 12 patients with late subacute stroke and arm-motor deficits who were provided 28 days of home-based telerehab program. The results, published in November 2017 in the journal Neurorehabilitation and Neural Repair, found that patient compliance was excellent (97.9%) and participants experienced significant arm-motor gains (Fugl-Meyer scale increase of 4.8 points). The study also found that patients did not need any additional computer skills training due to the design of the telerehab system.

“Getting patients to remain engaged and comply with therapy is a key measure of success of any rehabilitation program,” Cramer said. “Greater gains are associated with therapy that is challenging, motivating, accompanied by appropriate feedback, interesting and relevant. Telerehab achieves this because therapy is provided through games, provides user feedback, can be adjusted based on individual needs, is easy to use — and is fun.”

This study was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development as well as the National Institute of Neurological Disorders and Stroke (grant U01 NS091951), the NIH StrokeNet Clinical Trials Network, the 11 US enrollment sites, the research team at the primary study site at the University of California, Irvine, and the patients and families who participated.

 

via In-home therapy effective for stroke rehabilitation, study shows: A multisite US clinical trial compared home-based telerehabilitation program with traditional in-clinic rehabilitation therapy — ScienceDaily

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[ARTICLE] Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study – Full Text

Abstract

Background

Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs.

Methods

Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures.

Results

Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation.

Conclusions

tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation.

Background

Post-stroke motor function deficits stem not only from neurons killed by the stroke, but also from down-regulated excitability in surviving neurons remote from the infarct [1]. This down-regulation results from deafferentation [2], exaggerated interhemispheric inhibition [3], and learned non-use [4]. Current evidence suggests that post-stroke motor rehabilitation therapies should encourage upregulating neurons and should target neuroplasticity through intensive repetitive motor practice [56]. Previously, our group has examined the feasibility and efficacy of a custom finger tracking training program as a way of providing people with stroke with an engaging repetitive motor practice [789]. In this program, the impaired index finger is attached to an electro-goniometer, and participants repeatedly move the finger up and down to follow a target line that is drawn on the display screen. In successive runs, the shape, frequency and amplitude of target line is varied, which forces the participant to focus on the tracking task. In one study, we demonstrated a 23% improvement in hand function (as measured by the Box and Block test; minimal detectable change is 18% [10]) after participants with stroke completed the tracking training program [9]. While our study did not evaluate changes in activity in daily life (ADL) or quality of life (because efficacy of the treatment was not the study objective), the Box and Block test is moderately correlated (r = 0.52) to activities in daily life and quality of life (r = 0.59) [11]. In addition, using fMRI, we showed that training resulted in an activation transition from ipsilateral to contralateral cortical activation in the supplementary motor area, primary motor and sensory areas, and the premotor cortex [9].

Recently, others have shown that anodal transcranial direct current stimulation (tDCS) can boost the beneficial effects of motor rehabilitation, with the boost lasting for at least 3 months post-training [12]. Also, bihemispheric tDCS stimulation (anodal stimulation to excite the ipsilateral side and cathodal stimulation to downregulate the contralateral side) in combination with physical or occupational therapy has been shown to provide a significant improvement in motor function (as measured by Fugl-Meyer and Wolf Motor Function) compared to a sham group [13]. Further, a recent meta-analysis of randomized-controlled trials comparing different forms of tDCS shows that cathodal tDCS is a promising treatment option to improve ADL capacity in people with stroke [14]. Compared to transcutaneous magnetic stimulation (TMS), tDCS devices are inexpensive and easier to operate. Improvement in upper limb motor function can appear after only five tDCS sessions [15], and there are no reports of serious adverse events when tDCS has been used in human trials for periods of less than 40 min at amplitudes of less than 4 mA [16].

Moreover, tDCS stimulation task also seems beneficial for other impairments commonly seen in people post-stroke. Stimulation with tDCS applied for 20 sessions of 30 min over a 4-week period has been shown to decrease depression and improve quality of life in people after a stroke [1718]. Four tDCS sessions for 10 min applied over the primary and sensory cortex in eight patients with sensory impairments more than 10 months post-stroke enhanced tactile discriminative performance [19]. Breathing exercises with tDCS stimulation seems to be more effective than without stimulation in patient with chronic stroke [20], and tDCS has shown promise in treating central post-stroke pain [21]. Finally, preliminary research on the effect of tDCS combined with training on resting-state functional connectivity shows promise to better understand the mechanisms behind inter-subject variability regarding tDCS stimulation [22].

Motor functional outcomes in stroke have declined at discharge from inpatient rehabilitation facilities [2324], likely a result of the pressures to reduce the length of stay at inpatient rehabilitation facilities as part of a changing and increasingly complex health care climate [2526]. Researchers, clinicians, and administrators continue to search for solutions to facilitate and post-stroke rehabilitation after discharge. Specifically, there has been considerable interest in low-cost stroke therapies than can be administered in the home with only a modest level of supervision by clinical professionals.

Home telerehabilitation is a strategy in which rehabilitation in the patient’s home is guided remotely by the therapist using telecommunication technology. If patients can safely apply tDCS to themselves at home, combining telerehabilitation with tDCS would be an easy way to boost therapy without costly therapeutic face-to-face supervision. For people with multiple sclerosis, the study of Charvet et al. (2017) provided tDCS combined with cognitive training, delivered through home telerehabilitation, and demonstrated greater improvement on cognitive measures compared to those who received just the cognitive training [27]. The authors demonstrated the feasibility of remotely supervised, at-home tDCS and established a protocol for safe and reliable delivery of tDCS for clinical studies [28]. Some evidence shows that telerehabilitation approaches are comparable to conventional rehabilitation in improving activities of daily living and motor function for stroke survivors [2930], and that telemedicine for stroke is cost-effective [3132]. A study in 99 people with stroke receiving training using telerehabilitation (either with home exercise program or robot assisted therapy with home program) demonstrated significant improvements in quality of life and depression [33].

A recent search of the literature suggests that to date, no studies combine tDCS with repetitive tracking training in a home telerehabilitation setting to determine whether the combination leads to improved motor rehabilitation in people with stroke. Therefore, the aim of this pilot project was to explore the safety, usability and feasibility of the combined system. For the tDCS treatment, we used a bihemispheric montage with cathodal tDCS stimulation to suppress the unaffected hemisphere in order to promote stroke recovery [34353637]. For the repetitive tracking training therapy, we used a finger tracking task that targets dexterity because 70% of people post-stroke are unable to use their hand with full effectiveness after stroke [38]. Safety was assessed by noting any decline of 2 points or more in the cognitive testing that persists over more than 3 days. We expect day to day variations of 1 digit. Motor decline is defined by a decline of 6 blocks on the Box and Block test due to muscle weakness. This is based on the minimal detectable change (5.5 blocks/min) [10]. The standard error of measurement is at least 2 blocks for the paretic and stronger side. We expect possible variations in muscle tone that could influence the scoring of the test. Usability was assessed through a questionnaire and by observing whether the participant, under remote supervision, could don the apparatus and complete the therapy sessions. Our intent was to set the stage for a future clinical trial to determine the efficacy of this approach.

Methods

Participants

Participants were recruited from a database of people with chronic stroke who had volunteered for previous post-stroke motor therapy research studies at the University of Minnesota. Inclusion criteria were: at least 6 months post-stroke; at least 10 degrees of active flexion and extension motion at the index finger; awareness of tactile sensation on the scalp; and a score of greater than or equal to 24 (normal cognition) on the Mini-Mental State Examination (MMSE) to be cognitively able to understand instructions to don and use the devices [39]. We excluded those who had a seizure within past 2 years, carried implanted medical devices incompatible with tDCS, were pregnant, had non-dental metal in the head or were not able to understand instructions on how to don and use the devices. The study was approved by the University of Minnesota IRB and all enrolled participants consented to be in the study.

Apparatus

tDCS was applied using the StarStim Home Research Kit (NeuroElectrics, Barcelona, Spain). The StarStim system consists of a Neoprene head cap with marked positions for electrode placement, a wireless cap-mounted stimulator and a laptop control computer. Saline-soaked, 5 cm diameter sponge electrodes were used. For electrode placement, we followed a bihemispheric montage [14] involving cathodal stimulation on the unaffected hemisphere with the anode positioned at C3 and the cathode at C4 for participants with left hemisphere stroke, and vice versa for participants with right hemisphere stroke. Stimulation protocols were set by the investigator on a web-based application that communicated with the tDCS control computer. A remote access application (TeamViewer) was also installed on the control computer, as was a video conferencing application (Skype).

The repetitive finger tracking training system was a copy of what we used in our previous stroke studies [789]. The apparatus included an angle sensor mounted to a lightweight brace and aligned with the metacarpophalangeal (MCP) joint of the index finger, a sensor signal conditioning circuit, and a target tracking application loaded on a table computer. Figure 1 shows a participant using the apparatus during a treatment session.

Fig. 1

Fig. 1 Participant with right hemiparesis receiving transcranial direct current magnetic stimulation (tDCS) in their home simultaneous while performing the finger movement tracking task on the tracking computer (left). The tDCS computer (right) shows the supervising investigator, located off-site, who communicated with the participant through the video conferencing application, controlled the tDCS stimulator through web-based software, and controlled the tracking protocols. (Permission was obtained from the participant for the publication of this picture)

[…]

Continue —> Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study | Journal of NeuroEngineering and Rehabilitation | Full Text

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[Abstract] Understanding User Requirements for the Design of a Home-Based Stroke Rehabilitation System

Limitations following stroke make it one of the leading causes of disability. The current medical pathway provides intensive care in the acute stages, but rehabilitation services are commonly discontinued after one year. While written home exercise programs are regularly prescribed at the time of discharge, compliancy is an issue. The goal of this study was to inform the design of a home-based portable rehabilitation system based on feedback from individuals with stroke and clinicians. A main component under consideration is the type and format of information feedback provided to the user, as this is hypothesized to support compliance with the rehabilitation program. From a series of focus groups and usability testing, a set of design requirements for the hardware and software were constructed. Essential features mentioned for the feedback interface included: task completion time, quality of movement, a selection of exercises, goal tracking, and a display of historical data.

 

via Understanding User Requirements for the Design of a Home-Based Stroke Rehabilitation System – Lora A. Cavuoto, Heamchand Subryan, Matthew Stafford, Zhuolin Yang, Sutanuka Bhattacharjya, Wenyao Xu, Jeanne Langan, 2018

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[Abstract] Wearable Movement Sensors for Rehabilitation: A Focused Review of Technological and Clinical Advances – PM&R

Abstract

Recent technologic advancements have enabled the creation of portable, low-cost, and unobtrusive sensors with tremendous potential to alter the clinical practice of rehabilitation. The application of wearable sensors to track movement has emerged as a promising paradigm to enhance the care provided to patients with neurologic or musculoskeletal conditions. These sensors enable quantification of motor behavior across disparate patient populations and emerging research shows their potential for identifying motor biomarkers, differentiating between restitution and compensation motor recovery mechanisms, remote monitoring, telerehabilitation, and robotics. Moreover, the big data recorded across these applications serve as a pathway to personalized and precision medicine. This article presents state-of-the-art and next-generation wearable movement sensors, ranging from inertial measurement units to soft sensors. An overview of clinical applications is presented across a wide spectrum of conditions that have potential to benefit from wearable sensors, including stroke, movement disorders, knee osteoarthritis, and running injuries. Complementary applications enabled by next-generation sensors that will enable point-of-care monitoring of neural activity and muscle dynamics during movement also are discussed.

 

via Wearable Movement Sensors for Rehabilitation: A Focused Review of Technological and Clinical Advances – PM&R

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[ARTICLE] Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study – Full Text

Abstract

Background

Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs.

Methods

Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures.

Results

Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation.

Conclusions

tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation.

Background

Post-stroke motor function deficits stem not only from neurons killed by the stroke, but also from down-regulated excitability in surviving neurons remote from the infarct [1]. This down-regulation results from deafferentation [2], exaggerated interhemispheric inhibition [3], and learned non-use [4]. Current evidence suggests that post-stroke motor rehabilitation therapies should encourage upregulating neurons and should target neuroplasticity through intensive repetitive motor practice [56]. Previously, our group has examined the feasibility and efficacy of a custom finger tracking training program as a way of providing people with stroke with an engaging repetitive motor practice [789]. In this program, the impaired index finger is attached to an electro-goniometer, and participants repeatedly move the finger up and down to follow a target line that is drawn on the display screen. In successive runs, the shape, frequency and amplitude of target line is varied, which forces the participant to focus on the tracking task. In one study, we demonstrated a 23% improvement in hand function (as measured by the Box and Block test; minimal detectable change is 18% [10]) after participants with stroke completed the tracking training program [9]. While our study did not evaluate changes in activity in daily life (ADL) or quality of life (because efficacy of the treatment was not the study objective), the Box and Block test is moderately correlated (r = 0.52) to activities in daily life and quality of life (r = 0.59) [11]. In addition, using fMRI, we showed that training resulted in an activation transition from ipsilateral to contralateral cortical activation in the supplementary motor area, primary motor and sensory areas, and the premotor cortex [9].

Recently, others have shown that anodal transcranial direct current stimulation (tDCS) can boost the beneficial effects of motor rehabilitation, with the boost lasting for at least 3 months post-training [12]. Also, bihemispheric tDCS stimulation (anodal stimulation to excite the ipsilateral side and cathodal stimulation to downregulate the contralateral side) in combination with physical or occupational therapy has been shown to provide a significant improvement in motor function (as measured by Fugl-Meyer and Wolf Motor Function) compared to a sham group [13]. Further, a recent meta-analysis of randomized-controlled trials comparing different forms of tDCS shows that cathodal tDCS is a promising treatment option to improve ADL capacity in people with stroke [14]. Compared to transcutaneous magnetic stimulation (TMS), tDCS devices are inexpensive and easier to operate. Improvement in upper limb motor function can appear after only five tDCS sessions [15], and there are no reports of serious adverse events when tDCS has been used in human trials for periods of less than 40 min at amplitudes of less than 4 mA [16].

Moreover, tDCS stimulation task also seems beneficial for other impairments commonly seen in people post-stroke. Stimulation with tDCS applied for 20 sessions of 30 min over a 4-week period has been shown to decrease depression and improve quality of life in people after a stroke [1718]. Four tDCS sessions for 10 min applied over the primary and sensory cortex in eight patients with sensory impairments more than 10 months post-stroke enhanced tactile discriminative performance [19]. Breathing exercises with tDCS stimulation seems to be more effective than without stimulation in patient with chronic stroke [20], and tDCS has shown promise in treating central post-stroke pain [21]. Finally, preliminary research on the effect of tDCS combined with training on resting-state functional connectivity shows promise to better understand the mechanisms behind inter-subject variability regarding tDCS stimulation [22].

Motor functional outcomes in stroke have declined at discharge from inpatient rehabilitation facilities [2324], likely a result of the pressures to reduce the length of stay at inpatient rehabilitation facilities as part of a changing and increasingly complex health care climate [2526]. Researchers, clinicians, and administrators continue to search for solutions to facilitate and post-stroke rehabilitation after discharge. Specifically, there has been considerable interest in low-cost stroke therapies than can be administered in the home with only a modest level of supervision by clinical professionals.

Home telerehabilitation is a strategy in which rehabilitation in the patient’s home is guided remotely by the therapist using telecommunication technology. If patients can safely apply tDCS to themselves at home, combining telerehabilitation with tDCS would be an easy way to boost therapy without costly therapeutic face-to-face supervision. For people with multiple sclerosis, the study of Charvet et al. (2017) provided tDCS combined with cognitive training, delivered through home telerehabilitation, and demonstrated greater improvement on cognitive measures compared to those who received just the cognitive training [27]. The authors demonstrated the feasibility of remotely supervised, at-home tDCS and established a protocol for safe and reliable delivery of tDCS for clinical studies [28]. Some evidence shows that telerehabilitation approaches are comparable to conventional rehabilitation in improving activities of daily living and motor function for stroke survivors [2930], and that telemedicine for stroke is cost-effective [3132]. A study in 99 people with stroke receiving training using telerehabilitation (either with home exercise program or robot assisted therapy with home program) demonstrated significant improvements in quality of life and depression [33].

A recent search of the literature suggests that to date, no studies combine tDCS with repetitive tracking training in a home telerehabilitation setting to determine whether the combination leads to improved motor rehabilitation in people with stroke. Therefore, the aim of this pilot project was to explore the safety, usability and feasibility of the combined system. For the tDCS treatment, we used a bihemispheric montage with cathodal tDCS stimulation to suppress the unaffected hemisphere in order to promote stroke recovery [34353637]. For the repetitive tracking training therapy, we used a finger tracking task that targets dexterity because 70% of people post-stroke are unable to use their hand with full effectiveness after stroke [38]. Safety was assessed by noting any decline of 2 points or more in the cognitive testing that persists over more than 3 days. We expect day to day variations of 1 digit. Motor decline is defined by a decline of 6 blocks on the Box and Block test due to muscle weakness. This is based on the minimal detectable change (5.5 blocks/min) [10]. The standard error of measurement is at least 2 blocks for the paretic and stronger side. We expect possible variations in muscle tone that could influence the scoring of the test. Usability was assessed through a questionnaire and by observing whether the participant, under remote supervision, could don the apparatus and complete the therapy sessions. Our intent was to set the stage for a future clinical trial to determine the efficacy of this approach.

Methods

Participants

Participants were recruited from a database of people with chronic stroke who had volunteered for previous post-stroke motor therapy research studies at the University of Minnesota. Inclusion criteria were: at least 6 months post-stroke; at least 10 degrees of active flexion and extension motion at the index finger; awareness of tactile sensation on the scalp; and a score of greater than or equal to 24 (normal cognition) on the Mini-Mental State Examination (MMSE) to be cognitively able to understand instructions to don and use the devices [39]. We excluded those who had a seizure within past 2 years, carried implanted medical devices incompatible with tDCS, were pregnant, had non-dental metal in the head or were not able to understand instructions on how to don and use the devices. The study was approved by the University of Minnesota IRB and all enrolled participants consented to be in the study.

Apparatus

tDCS was applied using the StarStim Home Research Kit (NeuroElectrics, Barcelona, Spain). The StarStim system consists of a Neoprene head cap with marked positions for electrode placement, a wireless cap-mounted stimulator and a laptop control computer. Saline-soaked, 5 cm diameter sponge electrodes were used. For electrode placement, we followed a bihemispheric montage [14] involving cathodal stimulation on the unaffected hemisphere with the anode positioned at C3 and the cathode at C4 for participants with left hemisphere stroke, and vice versa for participants with right hemisphere stroke. Stimulation protocols were set by the investigator on a web-based application that communicated with the tDCS control computer. A remote access application (TeamViewer) was also installed on the control computer, as was a video conferencing application (Skype).

The repetitive finger tracking training system was a copy of what we used in our previous stroke studies [789]. The apparatus included an angle sensor mounted to a lightweight brace and aligned with the metacarpophalangeal (MCP) joint of the index finger, a sensor signal conditioning circuit, and a target tracking application loaded on a table computer. Figure 1 shows a participant using the apparatus during a treatment session.

Fig. 1

Fig. 1Participant with right hemiparesis receiving transcranial direct current magnetic stimulation (tDCS) in their home simultaneous while performing the finger movement tracking task on the tracking computer (left). The tDCS computer (right) shows the supervising investigator, located off-site, who communicated with the participant through the video conferencing application, controlled the tDCS stimulator through web-based software, and controlled the tracking protocols. (Permission was obtained from the participant for the publication of this picture)

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[Abstract + References] Virtual Reality for Neurorehabilitation: Insights From 3 European Clinics

Abstract

Virtual reality for the treatment of motor impairment is a burgeoning application of digital technology in neurorehabilitation. Virtual reality systems pose an opportunity for health care providers to augment the dose of task-oriented exercises delivered both in the clinic, and via telerehabilitation models in the home. The technology is almost exclusively applied as an adjunct to traditional approaches and is typically characterized by the use of gamified exergames which feature task-oriented physiotherapy exercises. At present, evidence for the efficacy of this technology is sparse, with some reviews suggesting it is the same or no better than conventional approaches. The purpose of this article is to provide real-world insights on the adoption of a virtual reality by 3 European clinics in 3 different service delivery models. These include an inpatient setting for Parkinson disease, a kiosk model for pediatric neurorehabilitation, and a home-based telerehabilitation model for neurologic patients. Motivations, settings, requirements for the pathology, outcomes, and challenges encountered during this process are reported with the objective of priming clinicians on what to expect when implementing virtual reality in neurorehabilitation.

References

  1. Laver, K.E., Lange, B., George, S. et al, Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev2017;11:CD008349.
  2. Barry, G., Galna, B., Rochester, L. The role of exergaming in Parkinson’s disease rehabilitation: A systematic review of the evidence. J Neuroeng Rehabil2014;11:33.
  3. Rosly, M.M., Rosly, H.M., Davis, G.M. et al, Exergaming for individuals with neurological disability: A systematic review. Disabil Rehabil2016;39:727–735.
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  5. Johnson, D., Deterding, S., Kuhn, K.A. et al, Gamification for health and wellbeing: A systematic review of the literature. Internet Interventions 2016, 89-106. (Available at)

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  6. Dockx, K., Bekkers, E.M., Van den Bergh Vet et al, Virtual reality for rehabilitation in Parkinson‘s disease. Cochrane Database Syst Rev2016;21:12.
  7. Massetti, T., Trevizan, I.L., Arab, C. et al, Virtual reality in multiple sclerosis—A systematic review.Mult Scler Relat Disord2016;8:107–112.
  8. Ebersbach, G., Ebersbach, A., Edler, D. et al, Comparing exercise in Parkinson’s disease—The Berlin LSVT®BIG study. Mov Disord2010;25:1902–1908.
  9. Goetz, C.G., Poewe, W., Rascol, O. et al, Movement Disorder Society Task Force report on the Hoehn and Yahr staging scale: Status and recommendations. Mov Disord2004;19:1020–1028.
  10. Keus, S.H., Munneke, M., Graziano, M. et al, European Physiotherapy Guideline for Parkinson’s Disease. Information for people with Parkinson’s disease 2014. (Available at)

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  11. Godi, M., Franchignoni, F., Caligari, M. et al, Comparison of reliability, validity, and responsiveness of the Mini-BESTest and Berg Balance Scale in Patients with Balance Disorders. Phys Ther2013;93:158–167.
  12. Palacios-Navarro, G., García-Magariño, I., Ramos-Lorente, P. A Kinect-based system for lower limb rehabilitation in Parkinson’s disease patients: A pilot study. JMed Syst2015;39:103.
  13. Yang, W.C., Wang, H.K., Wu, R.M., Lo, C.S., Lin, K.H. Home-based virtual reality balance training and conventional balance training in Parkinson’s disease: A randomized controlled trial. J Formos Med Assoc2016;115:734–743.
  14. Ghai, S., Ghai, I., Schmitz, G., Effenberg, A.O. Effect of rhythmic auditory cueing on parkinsonian gait: A systematic review and meta-analysis. Sci Rep2018;8:506.
  15. Chen, Y., Chen, H., Fanchiang, D. et al, Effectiveness of virtual reality in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. Phys Ther2018;98:63–77.
  16. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet2017;390:1211–1259.
  17. Renzo, A., Da Dalt, R., Giust, R. et al, The DAT project: Smart home environment for people with disabilities. in: International Conference on Computers for Handicapped PersonsSpringerBerlin2006.
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via Virtual Reality for Neurorehabilitation: Insights From 3 European Clinics – PM&R

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[Abstract] Efficacy of Telerehabilitation for Adults With Traumatic Brain Injury: A Systematic Review

Abstract

Objective: To identify and appraise studies evaluating the efficacy of telerehabilitation for adults with traumatic brain injury (TBI).

Methods: A systematic search of Cochrane Library, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO databases was conducted from January 1980 to April 23, 2017, for studies evaluating the efficacy of telerehabilitation for adults with TBI. Two reviewers independently assessed articles for eligibility and rated methodological quality using 16 criteria related to internal validity, descriptive, and statistical characteristics.

Results: The review yielded 13 eligible studies, including 10 randomized controlled trials and 3 pre-/postgroup studies (n ≥ 10). These evaluated the feasibility and/or efficacy of telephone-based (10 studies) and Internet-based (3 studies) interventions. Overall, the evidence of efficacy was somewhat mixed. The most common study design evaluated the efficacy of telephone-based interventions relative to usual care, for which 4 of 5 randomized controlled trials reported positive effects at postintervention (d = 0.28-0.51). For these studies, improvements in global functioning, posttraumatic symptoms and sleep quality, and depressive symptoms were reported. The feasibility of Internet-based interventions was generally supported; however, the efficacy could not be determined because of insufficient studies.

Conclusions: Structured telephone interventions were found to be effective for improving particular outcomes following TBI. Controlled studies of Internet-based therapy and comparisons of the clinical and cost-effectiveness of in-person and telerehabilitation formats are recommended for future research.

via Efficacy of Telerehabilitation for Adults With Traumatic Bra… : The Journal of Head Trauma Rehabilitation

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[Abstract] Home-based tele-rehabilitation presents comparable and positive impact on self-reported functional outcomes as center-based rehabilitation: Singapore tele-technology aided rehabilitation in stroke (STARS) trial

Introduction/Background
Stroke is a leading cause of disability worldwide. Functional, financial and social barriers commonly prevent individuals with acute stroke and disabilities from receiving rehabilitation following their hospital discharge. Home-based rehabilitation is an alternative to center-based rehabilitation but it is often costlier. Tele-rehabilitation is a promising solution for optimizing rehabilitation utilization, as it can enable clinicians to supervise patients and conversely, patients to receive the recommended care remotely. Our team therefore developed a novel tele-rehabilitation, with the primary aim to estimate the extent to which the proposed tele-rehabilitation resulted in an improvement in function during the first three-months after stroke in comparison to usual rehabilitation.

Material and method
This was a randomized controlled trial. We used the Late-Life Function and Disability Instrument (FDI) to assess our primary outcome (with adjustment made for baseline covariate).

Results
We recruited 124 participants and randomized them to receive either 12-week home-based tele-rehabilitation or usual rehabilitation.

Rehabilitation
Over the 12-week rehabilitation period, the intervention group spent 2246-minutes on their rehabilitation whereas the control group spent 2565-minutes. The median difference between the two groups was not statistically significant (P = 0.649).

Primary Outcome (FDI)
The mean FDI frequency score post-rehabilitation for the intervention and control groups were 39.7 (SD 11.7) and 43.0 (SD 10.6) respectively. The mean FDI limitation score post-rehabilitation for the intervention group was 78.5 (SD 20.6) and that for the control group was 85.4 (SD 19.6). The unadjusted and adjusted differences in both FDI scores between the two groups were not statistically significant (Models 1 and 2).

Conclusion
Both groups reported comparable amount of time spent on rehabilitation and similarly positive impact on the primary outcome. Home-based tele-rehabilitation can be an effective strategy for minimizing or eliminating rehabilitation utilization barriers while achieving the same functional outcome as center-based rehabilitation.

via Home-based tele-rehabilitation presents comparable and positive impact on self-reported functional outcomes as center-based rehabilitation: Singapore tele-technology aided rehabilitation in stroke (STARS) trial – ScienceDirect

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