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Spinal Cord Injury Rehabilitation with ReJoyce

ReJoyce has been the subject of a spinal cord injury rehabilitation research study in Vancouver since late 2009. Here’s a recent video about the study, published by the Rick Hansen Institute.

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Hand/Arm Stimulator Trial in the UK

Dr. Jane Burridge, Professor of restorative neuroscience at Southampton University in the UK, is part of a team building a new hand and arm electrical stimulation system for people who have suffered a stroke. Functional Electrical Stimulation (FES) is commonly used as a rehabilitation tool to help retrain a patient’s nervous system by stimulating nerves that control movement. The Bioness H200 is an example of a commercially available stimulator used for hand rehabilitation. Here’s a video of a stroke patient using the H200:

The new UK stimulation system will help patients with hand and arm movements, providing just enough muscle stimulation to help patients complete a set of movements, like reaching out and grasping a tea cup. The researchers hope that training with such a device will help stroke patients regain use of their arms and hands faster, and more effectively.

The project received £464,231 (approximately $722,000) in funding from the EPSRC (Engineering and Physical Science Research Council), and is designed to complement existing hand arm and shoulder rehabilitation training using virtual reality rehabilitation games.

‘We’re going to be stimulating a number of different muscles to open the hand, as well as to reach the arm forward. And, instead of doing it on a pre-determined, very tightly controlled trajectory, we’re actually going to do it with a free movement, with just minimal support from a sling.’ – Dr. Jane Burridge

The experimental work, starting in March 2011 and scheduled to run for three years, will include an eight-week clinical trial involving up to eight stroke patients.

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Robot-Assisted Therapy in New Jersey

During his presentation at Neuroscience 2010, Dr. Sergei V. Adamovich’s suggested that stroke rehabilitation involving video-gaming in combination with a robotic system could improve a patient’s abilities.

“In virtual environments, individuals with arm and hand impairment practiced tasks such as reaching and touching virtual objects. They took a cup from a shelf and put it on a table, hammered a nail, and even played a virtual piano.” – Dr. Adamovich, New Jersey Institute of Technology

The study’s 24 subjects, who had suffered a stroke at least six months prior to therapy, played with the video game system for about 22 hours over a two-week period. The subjects were helped by a robotic arm, and were challenged to perform increasingly difficult tasks.

“Our preliminary data suggest that, indeed, robot-assisted training in virtual reality may be beneficial for functional recovery after chronic stroke. Furthermore, our data imply that this recovery may be particularly due to increased functional connections between different brain regions.” – Dr. Adamovich

The following is a video of Dr. Adamovich’s robotic system.

Sources: Science Daily, RAVR Lab

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New EMG-Controlled Hand Rehabilitation Robot

Tommy Chan at Deltason, a Hong Kong medical devices distributor with an impressive array of rehabilitation products, has recently added the “Hand Of Hope” to his company’s line.

Hand Of Hope

Hand Of Hope

Developed at the Hong Kong Polytechnic University, the Hand Of Hope combines non-invasive EMG sensors with a robotic exo-skeleton to help the patients perform tasks related to rehabilitation. The device is controlled by non-invasive EMG pickup electrodes that detect patients’ attempts to move their hands. Once an attempted movement is detected, linear actuators are used to drive each finger. The system is used to increase performance of hand grasp (palmar grasp and pinch) and hand opening. The range of motion of each finger actuator can be customized for each patient.

Hand Of Hope

Hand Of Hope - Prototype

Hand Of Hope

Hand Of Hope - Prototype

Here are some pictures of the device:

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Large Portion of Post-Stroke Therapy Not Based On Clinical Studies

An alarming study published in Implementation Science in October 2010 suggests that the rate of reliance on the research literature in clinical decision making among physical therapists is low. Simply put, a large portion (more than 50%) of physical therapists surveyed in the study rarely base their post-stroke treatment programs on evidence-based research studies.

The study identified organizational, research, and practitioner characteristics associated with research use among physical therapists involved in post-stroke rehabilitation services. Of 263 physical therapists surveyed, more than a third hardly used evidence-based research at all (no more than once per month), with more than 50% only referring to evidence-based research 2-5 times per month.

The author summarizes the need important of evidence-based medicine in the following paragraph:

Evidence-based medicine has been described as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Numerous perceived benefits of evidence-based practice (EBP), including improvement to the work environment, increased professional accountability, ensuring the future of the profession, improved efficiency of service delivery, and compliance with regulatory agencies or quality assurance initiatives in the workplace, may lead healthcare professionals to incorporate research evidence into clinical practice. A patient-centered motivation for appropriately applying findings from rigorously conducted research in clinical decision making is to improve the quality of healthcare services and patient outcomes. There is empirical evidence to support these latter benefits in post-acute stroke rehabilitation, wherein the degree of compliance with a clinical practice guideline has been associated with not only physical recovery but also patient satisfaction.

The authors’ study was primarily based on data collected in Canada, but cited the following statistics gathered from similar studies conducted in other parts of the world:

Location PTs Surveyed 0-1 times/month 2-5 times/month
USA 488 25% 49%
Australia 124 43.9% unknown
Canada (this study) 263 33.8% 52.9%
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Brain Plasticity After Stroke

A University of South Carolina study using neuroimaging of stroke patients struggling to regain their communication skills has found that brain cells outside the damaged area can take on new roles.

Julius Fridriksson, a researcher at the USC’s Arnold School of Public Health, said the findings offer hope to patients of “chronic stroke,” characterized by the death of cells in a specific area of the brain. The damage results in long-term or permanent disability.

“For years, we heard little about stroke recovery because it was believed that very little could be done,” Fridriksson said. “But this study shows that the adult brain is quite capable of changing, and we are able to see those images now. This will substantially change the treatment for chronic-stroke patients.”

The study, reported in the Sept. 15 issue of the Journal of Neuroscience, involved 26 patients with aphasia, a communication disorder caused by damage to the language regions in the brain’s left hemisphere. Aphasia impairs a person’s ability to process language and formulate speech.

About 35% of stroke patients have speech and/or communication problems. While many patients with aphasia regain some language function in the days and weeks after a stroke, scientists have long thought that recovery is limited after this initial phase.

Fridriksson’s study shows that the brain can recover and that a patient’s ability to communicate can improve.

Stroke patients underwent a functional magnetic resonance imaging test. They also received multiple MRI sessions before and after undergoing 30 hours of traditional speech therapy used to improve communication function in patients with aphasia.

By using fMRI — an imaging technique more improved and widely used in the past decade — Fridriksson was able to see the healthy areas of the brain that “take over” the functions of the areas damaged as a result of a stroke.

“The areas that are immediately around the section of the brain that was damaged become more ‘plastic,’” Fridriksson said. “This ‘plasticity,’ so to speak, increases around the brain lesions and supports recovery. In patients who responded well with the treatment for anomia [difficulty in recalling words and names], their fMRI showed evidence that areas of the brain took over the function of the damaged cells.”

The study found that patients who did not experience these changes did not recover as much, he said.

Source: Charleston Regional Business Journal

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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.’’

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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:

  1. to provide web-based therapy for patients with hemianopic alexia (HA)
  2. to find out if the therapy works over the internet

You can find Read-Right here.

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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)
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)
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)
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Technology in Rehabilitation Seminar May 14 Online 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:

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.

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.

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