August 23, 2010
Efficacy of Stroke Rehabilitation Devices
Here’s an interesting article about the Myomo, a robotic device developed at MIT and sold by Myomo Inc. Part of the article addresses the lack of scientific evidence demonstrating efficacy of the device. Here’s an excerpt:
But there is no rigorous scientific evidence demonstrating how well it works. And the $7,000 device casts a spotlight on the hard-to-navigate world of rehabilitation devices — in which patients who are often desperate face a growing number of products whose effectiveness is still being determined.
“While there’s some suggestive, tiny studies — that are really pilot studies — that it might be useful, there’s no proof of efficacy using the usual criteria,’’ said Dr. Joel Stein, chairman of the rehabilitation and regenerative medicine department at Columbia University. He is also on Myomo’s scientific advisory board.
“I’ve worked with many stroke patients through the years, and I’m careful to not be too paternalistic deciding for them. . . . They feel like the medical system has given up on them, and there’s a fine line between not over-promising and saying we have nothing shown to be helpful, therefore you should just give up.’’
July 13, 2010
Technology in Rehabilitation
I posted a link to this seminar series a few months ago. Since then, the seminar has been posted on YouTube. You can watch the video here:
This is part of a seminar series put on by the Cleveland FES Center. The next series of lectures is scheduled to begin in September 2010.
July 12, 2010
Online Hemianopic Alexia (Word Blindness) Rehabilitation
A new online service has emerged that hopes to help people suffering partial word blindness (Hemianopic Alexia). The online rehabilitation service Read-Right is a therapy and research application developed by University College London and funded by the UK Stroke Association. It’s functions are twofold:
- to provide web-based therapy for patients with hemianopic alexia (HA)
- to find out if the therapy works over the internet
You can find Read-Right here.
June 11, 2010
The Cost of Stroke Treatment (Study)
A recent Canadian study found that the average financial cost of a stroke during the first 6 months is approximately $50,000. The study found that health-care covered around 80% of the costs, leaving the families to cover the additional 20%.
Most of the health-care costs related to hospitalization, whereas the remaining 20% related to lost time from jobs and expenses for the families.
Every year, 50,000 Canadians suffer a stroke and require treatment, which works out to an cost of more than $2.5 Billion each year.
The study examined 12 hospitals across the country, from Halifax to Vancouver, and tracked 232 patients during their stay in the hospital and after they returned home. Tracked costs included:
- appointments
- medications
- purchase of assistive devices like canes or wheelchairs
- home accessibility modifications such as ramps
- caregiver time away from a job
You can read more about the study here.
May 7, 2010
Rehabilitation of Arm Function After Stroke - Literature Review, Review
Here’s a great scientific literature review of Arm Function Rehabilitation After Stroke. Unfortunately, it isn’t hugely accessible to non-technical readers (not many people know what “ipsilesional corticospinal excitability” means). Here’s my review of the main points of the article, in plain terms:
- This study examined 66 other studies published between 2004 and 2008 from Medline using the keywords “stroke”, “upper limb”, and “rehabilitation”.
- Only randomized control studies were included in the review.
- High intensity rehabilitation training programs during subacute stroke rehabilitaiton (less than 6-months post-stroke) resulted in significant improvements in arm function.
- Learned non-use (gradually giving up trying to use a partially paralyzed arm) is the result of brain re-organization that starts within hours of a stroke.
- Rehabilitation that concentrates on compensation using the healthy limb can accelerate and perpetuate learned non-use. Some of the studies examined inhibition of the healthy part of the brain’s motor cortex using TMS.
- Natural plasticity of the brain after stroke, which is associated with a re-allocation of brain networks from one function to another, leads to a certain amount of natural upper extremity neurological recovery
- Training by repeating tasks directly linked to daily life activities promotes recovery. An “enriched” sensory environment (proprioceptive, visual, etc.) while performing these tasks is beneficial.
- Residual voluntary motor ability at 1-month post stroke is the best predictor of how much hand dexterity will be regained.
- In people whose stroke occurred 6 months or more previously (referred to as ”chronic”), 2 hours of transcutaneous neurostimulation (with an FES stimulator, for example) delivered just prior to rehabilitation training sessions, improves function of the weak hand
- The impact of acupuncture on upper limb motor recovery is not conclusive.
- Thermal stimulation, where patients are encouraged to take their paretic arm away when they feel an uncomfortable sensation, could promote recovery.
- Constraint-induced movement therapy is effective in reversing learned non-use of a paretic arm. It is believed that CIMT encourages the brain re-allocation referred to above.
- For higher-functioning chronic stroke survivors, mental imagery: imagining moving the paretic limb, or imagining movements performed by another person, are beneficial to recovery of motor function. No benefit has been demonstrated in lower-functioning stroke survivors and those with cognitive impairments. Mental imagery hasn’t been the subject of many randomly controlled studies.
- Unilateral task practice using the paretic limb yields improvements superior to those of bimanual task practice.
- Both transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES) have been shown to facilitate some motor recovery, but the cost/benefit and risk/benfit ratios have yet to be evaluated.
- TMS inhibition of the healthy part of the motor cortex can temporarily improve dexterity of the paretic limb, but at this stage this is not a clinically relevant treatment. In some cases, the inhibition procedure may actually be harmful.
- Constraint of the healthy limb in CIMT doesn’t yield more functional improvements than intensive movement therapy without a constraint.
- More intensive training very soon after a stroke doesn’t yield functional improvement beyond that of standard treatment.
- One year after a stroke, 9 hours of movement therapy isn’t sufficient to yield clinically significant results, whereas 57 hours of rehabilitation training does yield results for people with moderate motor impairment.
- EMG-triggered electrical stimulation eliciting hand opening, (i.e. bursts of electrical stimulation of a muscle initiated by weak voluntary activation of the muscle), has been claimed to be more efficacious than electrical stimulation triggered by other means, but there is insufficient evidence to fully validate this conclusion.
- Electrical stimulation to open the hand during repetitive grasp and release tasks is an integral part of a functional strategy, and promotes motor relearning.
- Several studies have concluded that CIMT is better than conventional therapy, including one study of 43 patients at less than 16 weeks poststroke.
- In a very broad study of 222 patients, CIMT improved pinch grip and several fine motor tasks, but failed to show significant improvement in a patient’s ability to open his or her hand.
- The following details results for various robotics systems:
- NeReBot: A group of acute poststroke subjects (some as early as 7-days poststroke) had better voluntary hand control compared to a group who received no therapy. The results were still evident 8 months later.
- InMotion2: “The motor improvements observed after 18 hours of therapy are not clinically significant and do not spread to distal motor capacities.”
- Bi-Manu-Track: Bimanual and uni-manual rehabilitation yielded similar improvements with the use of this robot.
- MIME and BACTRAC: “The functional improvements on manual dexterous ability are limited to the execution speed of tasks that the patient had already mastered before treatment.” - Author’s therapy recommendations:
| Moderate Motor Impairment | Severe Motor Impairment | |
| Early stroke rehabilitation (< 6 months) |
Functional rehabilitation training (25 hours) including: Distal EMG-stimulation + distal bimanual movements (6 hours) | Bimanual distal robot (10 hours) or Distal EMG-stimulation + distal bilateral movements (20 hours) Then if possible: functional rehabilitation training (15 hours) |
| Chronic stroke rehabilitation (> 6 months) |
Constraint-Induced movement therapy (CI therapy) (30 hours) or Functional rehabilitation training (30 hours) (in a virtual environment setting or with verbal feedback on the performance) + Mental Imagery |
If the neurophysiological criteria are favorable: classic rehabilitation training (50 hours) with trunk restraint including distal EMG-stimulation + distal bilateral movements (20 hours) |
April 22, 2010
Technology in Rehabilitation Seminar May 14 Online
FEScenter.org is hosting an online seminar entitled “Technology in Rehabilitation” on May 14. The event starts at 8:30am EDT (12:30pm in the UK, and between 8:30-10:30pm in Australia).
You can view the presentation Here.
Here’s a quick abstract of the speech:
Speaker:
Paolo Bonato Ph.D.
Assistant Professor, Department of Physical Medicine and Rehabilitation
Harvard Medical School
Title: “Technology in Rehabilitation”
Recent advances in sensing technology, robotics, and interactive gaming platforms have provided researchers and clinicians in the field of physical medicine and rehabilitation with new tools. These tools are aimed to improve the management of patients with impairments associated with the inability to perform certain activities of daily living such as walking on level ground, climbing a stairway, reaching for objects with the upper extremities, and manipulating small objects with the hands. Different clinical scenarios require the use of different technologies and the development of different systems and methodologies. In the older adults otherwise healthy, clinicians are interested in tracking activity profiles and detecting the worsening of motor function (e.g. balance control) so that adequate interventions can be set in place when needed. In individuals with severe mobility limitations such as those often associated with a stroke and traumatic brain injury, technology could be used to facilitate the recovery of motor functions. When individuals no longer respond in a clinically significant way to interventions, technology could be used to augment or replace function. This presentation aims at providing examples of clinical applications in which wearable sensors, robotics, and interactive gaming are relied upon in order to provide clinical personnel with ways to facilitate the recovery of motor function in patients with neurological conditions. Issues related to monitoring mobility in older adults and to detecting falls in the home environment will be presented in a clinical context and the technical characteristics of desirable systems for subjects’ monitoring will be discussed. Robotic systems designed for implementing exercise routines suitable to restore motor abilities in patients post stroke will be presented. The need for motivating patients using interactive gaming will be discussed together with the need for tracking the quality of the subject’s performance. This is a key point to guarantee that patients benefit from the exercise routines prescribed by clinicians. The need for tracking improvements in motor abilities in response to rehabilitation protocols will be emphasized. In conclusion, future scenarios depicting how we anticipate that technology will change physical medicine and rehabilitation in the next decade will be discussed.
– Source
Here’s a video from a February 2009 lecture by Kevin L. Kilgore about upper extremity devices for people with C5/C6 Spinal Cord Injuries. He focuses on the Freehand System, and implantable system for hand control:
And, finally, a link to all the lectures in the series.
April 21, 2010
Web-Based Hand, Arm, Shoulder Rehabilitation - Literature Review
A new study was published recently in the American Journal of Occupational Therapy detailing the results of a very small study involving a single post-stroke subject for one week of telerehabilitation. You can find more information here.
One may argue that such a study is anecdotal at best, and that a broader study is required to substantiate its claims.
Fortunately, there’s a long history of much more convincing scientific studies involving at-home rehabilitation of people with stroke and other neurological injuries like SCI. Such studies have generally shown positive results, which is why the results of the above study are not too surprising. I’ve provided links to abstracts and quick summaries of a few highlights below:
Efficacy of telemedicine in occupational therapy: a pilot study (2001) - The authors conclude that select occupational therapy evaluation data can be accurately transmitted and properly scored using low-bandwidth telemedicine systems.
Web-based telerehabilitation for the upper extremity after stroke (2002) - A description of a telerehabilitation system for stroke rehabilitation.
An Evaluation Framework for a Rural Home-Based Telerehabilitation Network (2005) - A survey of 43 professionals agreed that there are unmet needs among elderly people who are discharged from hospital settings.
Development of a teletechnology protocol for in-home rehabilitation (2006) - The authors’ results showed promise that both the telerehabilitation technology and intervention procedures were feasible in an elderly population.
A telerehabilitation approach to delivery of constraint-induced movement therapy (2006) - The authors reported large improvements in hand and arm function of post-stroke subjects. The gains were the same under both direct and remote supervision of a therapist.
Telerehabilitation using the Rutgers Master II glove following carpal tunnel release surgery: proof-of-concept (2007) - Dramatic improvements were achieved using the Rutgers Masters II haptic glove. All patients would either very strongly, or strongly recommend similar at-home therapy to others.
Telerehabilitation Using a Virtual Environment Improves Upper Extremity Function in Patients With Stroke (2007) -Home-based rehabilitation of 11 stroke subjects resulted in improvements of hand and arm function that were maintained at the time of a four month post-intervention evaluation.
Telerehabilitation is an exciting new field that holds the promise of providing cost-effective, high quality care to people facing a wide range of medical issues. For information about our telerehabilitation services, visit our stroke and SCI home rehabilitation page.
April 20, 2010
Stroke Rehabilitation with Robots
Researchers in the United States have found that robotic therapy can help stroke victims regain arm movement even years after their brain injuries. The study will be published in the online edition of the New England Journal of Medicine on Friday, April 23, 2010.
The study, a three-year randomized control trial (RCT) of 127 veterans in the U.S, found that stroke victims who had 12 weeks of robot-assisted therapy for their affected arm had an improved quality of life compared with those who had no additional therapy beyond the initial post-injury rehabilitation period. These findings go against conventional thinking that rehabilitation beyond the initial period had little benefit for stroke survivors.
Patients with moderate to severe disability in arm function resulting from stroke at least 6 months to five years earlier were included. After 6 months of therapy, the 49 patients in the robotic treatment group demonstrated clinically significant upper-arm function compared with the 28 patients who did not receive specific therapy for their upper limb.
Importantly, another 50 patients in the study did similar high-intensity exercises with the assistance of a therapist rather than a robot and demonstrated similar improvements.
Dr. Howard Kirshner, a professor and vice-chair in neurology at Vanderbilt Medical Center North in Nashville, commented to CBC:
“The most important take-away message for stroke survivors is that therapy, whether using new-fangled technologies, or using intensive standard therapy by trained therapists, is essential for optimal recovery of function after a stroke.”
CBC News
The study used the MIT Manus rehabilitation robot, developed at MIT, and commercialized by Interactive-Motion Technologies.
The findings are similar to those of another recent publication concerning the same device.
Here’s a video of the robot:
April 19, 2010
Glenrose Hospital - Virtual Reality Rehabiltation
Edmonton’s Glenrose Rehabilitation Hospital has acquired a new virtual reality system for rehabilitation. The CAREN (Computer-Assisted Rehabilitation Environment) will be installed over the next near, and will be ready for use in early 2011.
The product of Dutch company Motek Medical, CAREN consists of a large cylindrical screen and sophisticated projector system that creates a virtual environment. The user stands on a moving platform facing the screens that simulates motion in the virtual environment.
The Department of National Defence will cover $1.5 million of the $1.75 million price tag, with the Government of Alberta covering the additional $250,000.
Here’s a video of the CAREN in action:
April 16, 2010
Stroke Rehab Toronto
Researchers at the Toronto Rehabilitation Institute have joined forces with game designers at Algoma University in Sault Ste. Marie (700 km away, also in Ontario) to create video games to assist in speech therapy.
Dwayne Hammond, a strategic advisor at Algoma, suggests:
“All games teach, they’re all puzzles of some sort, and so if you develop a game specifically for rehabilitation purposes … it has potential to cause patients to follow their therapy much more than otherwise.”
When asked about the Nintendo Wii, and its use as a clinical modality for movement rehabilitation, Hammond says:
“The Wii is great but certainly I think the expectation is when you start to develop any product for an actual purpose, targeting something, you will be much more effective at that.”
The idea, which turned into the product the team is working on today, involves a therapist using paper cards to help patients exercise their brains. The cards contain illustrations of objects that patients must identify.
The team intends to move the identification program into software that can be used both in a clinical setting, as well as at home in a telerehabilitation capacity.
The team hopes to have created a commercially available product within a year.
Source: CTV, April 16, 2010
