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.
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 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
Stroke Rehabilitation in BC
The following table from a 2005 report from the BC Stroke Strategy shows patient wait times for post-stroke rehabilitation in British Columbia.
| Physiotherapy | Occupational Therapy | Speech Therapy | |
| Number of Locations Reporting Service | 57 (66%) | 41 (48%) | 21 (24%) |
| Range of wait time: In-Patient | 4 hours - 2 weeks | 24 hours - 7 days | 24 hours - 7 days |
| Range of wait time: Out-Patient | 2 days - 4 weeks | 7 days - 4 weeks | 1 week - indefinite |
This post will be updated with the latest numbers as soon as they are published.
Reporting hospitals’ level of knowledge regarding stroke programs offered as outpatient services or community services was limited in many cases. The most commonly reported hospital programs for stroke patients were general rehabilitation clinics and speech therapy. Community programs varied widely. Several sites reported support for patients and families offered by the Stroke Recovery Association. In fact, this is the most widely offered program of its type in Canada, with 38 groups located in: Cranbrook, Grand Forks, Kamloops, Kelowna, Prince George, Salmon Arm, Trail and District, Vanderhoof, Vernon, Burnaby, North Vancouver, Richmond, Vancouver, Abbotsford, Coquitlam, Langley, Maple Ridge / Pitt Meadows, Mission, Port Coquitlam, Powell River, Sechelt, South Delta, Surrey, White Rock, Alert Bay, Campbell River, Comox Valley, Nanaimo, Parksville, Saanich Peninsula, and Victoria.
March 30, 2010
Improved Hand Function in Cerebral Palsy
A Rutgers-based study, recently published in the IEEE Transactions on Information Technology in Biomedicine journal, has shown that an at-home treatment regimen involving video games can improve hand function in teenagers with cerebral palsy.
The pilot study, involving only three teenage participants, combined a Sony Playstation 3 console and a commercial gaming glove with their custom-made games. Rutgers engineers created custom game and exercise software aimed at improving hand speed and range of motion.
The system enhanced the participants’ abilities to perform a range of daily personal and household activities.
After three months of therapy, two study participants were able to lift heavy objects, a task they were unable to accomplish before the trial. Participants showed varying improvement in activities of daily living including brushing teeth, shampooing, dressing and opening heavy doors.
The study was the result of a collaboration between engineers at Rutgers University’s Tele-Rehabilitation Institute and clinicians at the Indiana University School of Medicine.
In addition to game and exercise software, the apparatus features an online telerehabilitation platform that allowed researchers to oversee participants’ routines and evaluate their recovery of motor function.
Here’s a link to the full article (requires a subscription to the journal).
Here’s a video from the Rutgers website:
October 16, 2009
Modified Constraint Induced Movement Therapy Discussion
In early 2008, an online discussion took place between two researchers regarding the implementation details of Constraint Induced Movement Therapy (CIMT). Dr. Steven Wolf, the principle investigator of the 2006 EXCITE study makes some interesting comments about Dr. Steven Page’s mCIT trial (Modified Constraint Induced Therapy).The following compares a few of the main components of Dr. Wolf’s CIMT and Dr. Page’s mCIT:
| CIMT | mCIT | |
| Location | clinic | home |
| Hours of Daily Therapy | 6 hours* | 0.5 hours |
| Duration of Therapy | 3-6 weeks | 10 weeks |
| Daily Arm Restraint** | 9 hours/day for 2 weeks | 5 hours/day for 5 days/week for 10 weeks |
| Benefit to Patient | Statistically Significant: refer to article |
Statistically Significant: refer to article |
* patients experiencing fatigue are not be required to complete 6 hours/day
** CIMT and mCIT require that patients restrain their less affected limb for periods of time during the day.
October 14, 2009
Constraint Induced Therapy at Home
What is Constraint Induced Therapy (CIT)?
Initially called “forced use therapy,” constraint induced (movement) therapy (CIT) is the principle of immobilizing one hand so that the participant uses only the other hand during therapy. During hand rehabilitation in stroke, for example, participants wear a mitten on their less affected hand and perform exercise tasks with only their weak hand.
For many years researchers had known that intensive exercise therapy (IET) accelerated recovery in the central nervous system. The related term “neuroplasticity” was introduced to describe the ability of the nervous system to reorganize itself after injury.
In a 2006 randomized controlled trial, stroke rehabilitation researchers found that CIT resulted in larger improvements than conventional therapy. So, it appears that CIT can be an important component of a successful recovery after a neurological injury such as stroke or spinal cord injury.
Here’s a video of Constraint Induced Movement Therapy:
What are the limitations of CIT?
In most cases, CIT providers require subjects to have a minimum level of functional movement in their affected limb. This excludes many people with moderate levels of disability. Perhaps the major limitation of CIT in its original form is the requirement that participants spend up to 3 weeks in a clinic. This can be prohibitively expensive, sometimes costing more than $20,000 for therapy, accommodation, and travel.
Only a few rehabilitation clinics offer the “authorized” version of CIT, so you may need to relocate for a period of time to participate. In most cases, this is very expensive, so it is worth contacting your insurance company before you embark on this option. Less intensive protocols have been suggested, e.g. modified CIT (mCIT) in which a therapist supervises CIT for 30 minutes/day, 3 times/week for 10 weeks and in addition the participant performs self-directed exercise tasks 5 hours/day, 5 days/week with a mitt on the less affected hand. The supervised portions can occur at home if the therapist uses a telerehabilitation link.
Finally, you can conduct a program on your own. You will set up a regimen of training exercises for yourself and wear a mitt on your less affected hand. Do a Google search for mCIT (or Modified Constraint Induced Therapy) before beginning so that you understand what’s involved. Be sure to ask your doctor or physical or occupational therapist whether they recommend self-directed mCIT BEFORE you begin
New ways of delivering Intensive Exercise Therapy (IET)
The latest approach to upper extremity rehabilitation is to use devices that provide task-specific IET of the shoulder, arm and hand. The tasks include “range-of-motion” of the shoulder and arm as well as grasp and release tasks of the hand. The latest devices, like the ReJoyce system for example, use computers to track these movements and control highly-motivating computer games.
Telerehabilitation providers are beginning to emerge online. In this case, a provider will run through an assessment with you online. Provided you fit their criteria and have physician approval, they will ship you the necessary equipment. Your caregiver will set up the equipment and the provider will schedule rehabilitation sessions with you. During these sessions, a therapist will supervise you directly using a web cam. Often, the therapist can configure the equipment in your home to match your exercise requirements. You will likely need to have your caregiver present for these sessions for safety reasons. Telerehabilitation is usually much less expensive than in-clinic rehabilitation.
