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 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 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.
April 15, 2010
Telehealth and TeleStroke News
Here’s a quick summary of telehealth news over the last four weeks.
1. CTN and AT&T Telehealth Network Expansion - The University of California’s California Telehealth Network (CTN) has a AT&T a contract to expand telehealth services in the state. Funding for the project comes for the FCC’s Rural Health Care Pilot Program. The project will see the CTN will working with AT&T to construct a statewide network connecting smaller regional hospitals and clinics to larger hospitals, giving rural residents access to more specialists and experts.
2. PricewaterhouseCoopers’s New HealthCast Report - According to a PricewaterhouseCoopers report, health care reform in the United States will results in a widespread effort to keep people well, out of the hospital and more engaged in managing their own health. The report suggests that lesser known provisions of the U.S. Health Reform package put increased emphasis on disease prevention, positive health outcomes and better coordination of care. Additionally, the report suggests the package emphasizes comparative effectiveness research, including more personalized medicine, which paves the way for more individualized care in a more patient-focused health system. According to the report, mass customization of health care services will be enabled by technology including smart phones, EMR databases, home health monitoring, telehealth, as well as wireless communication, social media and other Internet innovations.
3. Review of TeleStroke System in Kearney, Nebraska - The telestroke program in Nebraska uses a high-quality video and audio system to evaluate possible stroke patients in outlying hospitals. Typically, when patients suffer stroke, they have a limited time to receive clot-busting drugs, such as tPA. In this case, a physician only has three hours to make an intervention. Once a stroke patient is brought into an outlying hospital, the on-call neurologist in the system is available to evaluate the patient through telestroke.
March 26, 2010
ReJoyce For Stroke and Spinal Cord Rehab: Video
This video was put together by Alberta Innovates and published in mid-March. It features interviews with ReJoyce inventors Dr. Jan Kowalczewski and Dr. Arthur Prochazka, as well as clinical trial investigators Dr. Mary Galea and Su Ling Chong. Ginny Bockman, a study participant, is also featured.
Here’s the transcript:
Dr. Prochazka - “As far as we know, this is the first large-scale study of in-home telerehabilitation in the world. I think this is the first study where we have learned how to interact with people in their homes, take them right through a training program of many weeks, measure the outcome, and then also, of course, develop the technology that allows all of this to happen.”
Dr. Kowalczewski - “I really hope it reaches as many people as it can. The reason why I’m saying this is because we’re seeing such positive results in our studies. I really hope that anyone that’s had a stroke or spinal cord injury can really benefit from this.”
Su-ling Chong - “In conventional therapy, you go to a place and you just do the functional tasks. We sneak the functions into the game, and patients enjoy it. Most of the time I have to tell the person that their hour is up because, usually, they just want to keep going.”
Dr. Galea - “A device like the ReJoyce is useful for people because it can be installed in their own home very simply, and people can use it in the comfort of their own home without needing to travel. The telerehabilitation enables the therapist to keep in touch with them, monitor their progress, and deal with any difficulties they might be having. That is a very important way to of continuing to enable people to continue improving without tying them to the hospital’s apron strings. It allows them to get on with their own lives.”
Mrs. Bockman - “When I woke up in the hospital, I couldn’t move my arms; I couldn’t move my hands and I thought, “how am I going to live my life?” When I started doing this [ReJoyce telerehabilitation], a lot more things started coming back to me. I’m able to hold my brush, with my hand, brush my own hair, brush my own teeth, feed myself. Senses have also gone back to playing with a Sony Playstation. I can kick my husband’s but on a lot of games, and I’m happy with that.”
March 18, 2010
Report: Stroke Rehabilitation Services In Canada Are Inadequate
Today, a report in the Canadian Medical Association Journal suggested that Canadian stroke rehabilitation services are inadequate. According to the article, Canada’s stroke rehabilitation programs suffer from:
“inadequate facilities, beds and staff to deliver services; inadequate treatment, including outpatient services, and inadequate funding.”
The article cites Christina O’Callaghan, executive director of the Ontario Stroke Network, who says that three out of every four people who have a stroke severe enough to require hospital admission fail to get sent to rehabilitation.
“It has created a situation in which stroke sufferers often have little option but to languish in long-term care facilities or nursing homes, says Dr. Mark Bayley, medical director of the neuro rehabilitation program at the Toronto Rehabilitation Institute in Ontario. “If some people with more severe strokes were provided with the adequate amount of rehabilitation, a certain number of them would be able to go home. This would save our health care system from having to utilize our very limited and expensive long-term care resources as much as we do currently.”
Read the full report here.
