Advances in Brain Recovery and Rehabilitation 2010

In the January edition of Stroke http://bit.ly/f6wALm Dr. Zorowitz and his team at the Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine and the Department of Neurology Danube University and Danube Clinic Austria discuss Advances in Brain Recovery and Rehabilitation 2010. This review details how the discoveries in the past year have impacted on our understanding of brain recovery and how various approaches to neurorehabilitation, and brain imaging have been used to demonstrate reorganization in the human brain during stroke rehabilitation.

health-related quality of life (HRQOL) of people with Parkinson’s disease (PD)

In the January edition Parkinsonism and related disorders http://bit.ly/dMq5LB Dr. Soh and her team at The University of Melbourne Australiaand Orthopaedics and Gait Analysis Research, Murdoch Childrens Research Institute, Royal Children’s Hospital, Australia look at demographic and clinical factors that predict the health-related quality of life (HRQOL) of people with Parkinson’s disease (PD). The motor symptoms that contributed most often to overall life quality were gait impairments.
The LegTutor system has been developed to intensively practice gait virtual functional tasks. The LegTutor can work on both isolated and coordinated exercise practice of the knee and hip. Intensive practice will improve the patients physiological movement ability that will allow them to practice functional walking and decrease the rate of functional movement decline.

Bimanual Upper Limb Training in stroke

In the January edition BMC neurology http://bit.ly/eEXL5d Dr. Sleimen-Malkoun and her team from Institut des Sciences du Mouvement CNRS & Université de
la Méditerranée, Marseille, France and Laveran, Service de Réhabilitation Fonctionnelle, 13 Marseille, France discuss bimanual training strategies to help clinicians to adapt therapy in order
to maximize rehabilitation benefits.

The HandTutor and ArmTutor systems incorporates virtual functional task practice that includes bilateral training techniques that allow for intensive practice using both upper limbs.
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Exercise for multiple sclerosis: a single-blind randomized trial comparing three exercise intensities

n the January edition of Multiple Sclerosis Journal, http://bit.ly/hnKOSe Dr. Johnny Collett and his group from Movement Science Group, School of Life Sciences, Oxford Brookes University, UK and Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford, UK and Nuffield Orthopaedic Centre, Oxford UK report on Exercise for multiple sclerosis: a single-blind randomized trial comparing three groups that did cycling exercises of different intensities. Each group exercised for 20 min twice a week for 12 weeks. The continuous group worked for 20 mins at 45% peak power, the intermittent group worked for 20 mins according to 30 sec on, 30 sec off at 90% peak power and the combined group worked 10 mins continuous and 10 mins intermittent. The group concluded that a greater benefited was associated with higher-intensity exercise, but this may be less well tolerated.

The HandTutor and LegTutor system encourages intensive massed and motivating exercise practice of the upper and lower extremities.

Motor learning and training of co-ordinated joint movements with the HandTutor and LegTutor systems

In the January edition of Journal of NeuroEngineering and Rehabilitation http://bit.ly/gYcxHf Dr. Sun Jong Choi and his team from the Department of Orthopedic Surgery, Synergy Hospital and Seoul National University report on the validity of gait parameters for hip flexor contracture in patients with cerebral palsy.
Hi group compared the kinematic data during the gait analysis of twenty-four patients with cerebral palsy (mean age 6.9 years) and 28 normal children (mean age 7.6 years). They found that the maximum pelvic tilt, maximum psoas length, hip flexor index, and minimum hip flexion in stance were found to be clinically relevant parameters in evaluating hip flexor contracture.
As we know children with CP and other patients with other neurological injury and disease will exhibit a central neurological problem that will lead to a flexor pattern either or both upper and lower extremities. The main problem that causes this problem is the lack of interjoint co-ordination. Normal physiological movement and the ability to do functional movement e.g. walking needs not only the joint range of motion but chief in importance is interjoint co-ordination.
The HandTutor, ArmTutor and LegTutor systems incorporate the concept of virtual functional tasks. These tasks allow the patient to be given intensive active exercise practice and targeted movement feedback on the position of one, two or more joints and instructions on how to move the joint in association with another joint. Therefore the LegTutor system works on isolated and combined movements of the hip and knee and the HandTutor system works on isolated and combined movements of the shoulder, elbow, wrist and fingers. This allows the patient to do intensive task practice that will teach them how to do coordinated movements of two or more joints. Motor learning that teaches the patient how to move more than two joints in a coordinated pattern will improve functional movement ability and the performance of the everyday tasks e.g. walking.

Interventions being developed to manipulate neuroplasticity

In the January edition of Nature reviews Neurology http://bit.ly/gxRTKA Dr Dimyan and his group from the Human Cortical Physiology and Stroke Neurorehabilitation Section, National Institute of Neurological Disorders and Stroke USA discuss neuroplasticity in the context of motor rehabilitation after stroke

Approximately one-third of patients post stroke exhibit persistent disability after the initial cerebrovascular episode. This disability can be a combination of speech cognitive and movement impairments with motor impairments accounting for most post stroke disability. Intensive exercise practice is the key tool for improving movement ability and the primary goals of post stroke rehabilitation is to increase the patients independent functional activity capability to improve quality of life needs of individual patient.

In this article, Dimyan and Cohen provide a review of neuroplasticity associated with poststroke motor impairment and highlight the latest experimental interventions being developed to manipulate neuroplasticity to enhance motor rehabilitation. As the methods for providing motor rehabilitation change,

The HandTutor, ArmTutor and LegTutor systems incorporate the concept of virtual functional tasks to give the patient a motivating platform, regardless of their movement ability, in which to perform intensive active exercise practice.

Exercise therapy and recovery after SCI: evidence that shows early intervention improves recovery of function

In the January edition of Spinal Cord Dr. Brown and his colleagues from Texas A&M University, College Station, TX, USA discuss exercise therapy and recovery after SCI. Locomotor training is one of the most effective strategies currently available for facilitating recovery of function after an incomplete spinal cord injury (SCI). However, there is still controversy regarding the timing of treatment initiation for maximal recovery benefits evidence that shows early intervention improves recovery of function. There paper concludes that implementing an exercise regimen in the acute phase of SCI maximizes the potential for recovery of function.

The HandTutor system can is used early in the physical rehabilitation of incomplete spinal cord injury patients as the virtual functional exercise tasks can be tailored to the movement ability of the patient. Therefore the patient can start to do intensive repetitive exercises even if they have limited upper extremity arm and hand movement ability.

Tele-rehabilitation as successful as out patient physiotherapy post Total Knee Replacement

Trevor Russell of the School of Health and Rehabilitation Science, University of Queensland, Brisbane, Australia show that internet-based rehab is a viable treatment option following knee surgery. The results was published in the January edition of the Journal of Bone and Joint Surgery (JBJS) http://bit.ly/fXwmxD

Study Details:

* The researchers enrolled 65 patients who underwent TKA and randomized them to receive six weeks of either traditional outpatient rehab services or Internet-based outpatient rehab.
* For the purposes of this study, patients in the telerehab group performed their therapy in a hospital room designed and furnished to replicate a typical home environment.
* Patients in the tele-rehabilitation group received rehab through real-time (live video and audio) interaction with a physical therapist via an Internet-based system. Therapy sessions were limited to 45 minutes

The study showed that participants in the Internet-rehab group achieved outcomes comparable to those of the conventional rehabilitation group. The paper concludes that this study offers measurable evidence that such technology can be used to provide effective rehabilitation services for knee replacement patients.

The LegTutor uses a dedicated rehabilitation software that uses motivating games that can be customized to the stage of rehabilitation and the patients movement ability post TKR. The LegTutor encourages both open and closed kinetic loop active exercises.

What is the Traumatic Brain Injury (TBI) Model Systems

The TBI Model Systems (TBIMS) were established in 1987 through a grant from the United States Department of Education, National Institute on Disability Rehabilitation and Research (NIDRR). Establishment of the Burn Care Model Systems followed in1994. All TBI Model Systems are housed in or linked to well-established medical centers that provide high quality trauma care from onset of injury through the post-acute phase. Each of these facilities treats large numbers of persons with traumatic brain injury, necessary for supporting research projects and data collection. There are currently sixteen TBIMS projects located throughout the United States.

The Institute for Rehabilitation and Research Houston
Craig Hospital Englewood, Colorado
Kessler Medical Rehabilitation Research & Education Center
Albert Einstein Healthcare Network, Moss Rehabilitation Research Institute
Ohio Regional TBI Model System The Ohio State University Research Foundation
Mayo Clinic College of Medicine Rochester, Minnesota
Mount Sinai School of Medicine, New York,
Carolinas Rehabilitation Charlotte
UT Southwestern Medical Center Dallas,
Santa Clara Valley Medical Center- Medical Staff Corporation San Jose, CA
University of Alabama at Birmingham Birmingham
Virginia Commonwealth University Department of Physical Medicine and Rehabilitation Richmond, VA
JFK-Johnson Rehabilitation Institute NJ
University of Washington Seattle, WA

Information on over 6000 individuals with traumatic brain injury during the acute hospital stay and in the community after discharge and the aim of the project is to

* What diagnostic and treatment innovations can improve rehabilitation outcomes for persons with traumatic brain injury.
* Which methods of service delivery interventions after inpatient rehabilitation discharge are most effective?
* Which interventions improve vocational outcomes and community integration?
* Can we predict long-term outcomes at hospital discharge and at long-term follow-up? What are the key predictors?
* What is the relationship between cost of care and outcomes? If we spend more money, do we obtain better results?

A video showing the use of the HandTutor system with a TBI patient can be found at: http://www.meditouch.co.il/index.aspx?id=2358&videoid=1

Using HandTutor on Orthopedic hand injury patients

An upcoming clinical trial by Meir Medical Centre Israel led by Dr. Ronen http://bit.ly/fMhAem will focus on using the HandTutor system on a hand injury population.

The study aims to characterize the HandTutor system and the focused objectives are:

1. To examine the test-retest reliability when measuring the range of movement (ROM) of the wrist and the fingers with the system.
2. To examine the correlation between the ROM when measured by the HandTutor, and the ROM when measured by a conventional tools (goniometer).
3. To examine the correlation between the performance in the HandTutor (in the games part), and the performance in functional activities.
4. To examine the difference between healthy people and hand injured people when using the HandTutor.
5. To examine the participants feedback for using the HandTutor (Level of enjoyment, etc).
6. To examine the level of pain that participants with hand injury experience when using the HandTutor.

American Heart Association (AHA) American Stroke Association (ASA) suggest new stroke care assessment metrics to improve stroke care

The AHA and ASA suggest that higher quality and faster stroke care with a more precise, data-driven basis can be achieved if hospitals adopt new metrics for comparing stroke centre performance. This will lead the way to improvement in the quality of stroke care and possibly for the development of national standards of stroke care.

One of these metrics is the time frame from admission to assessment for post-stroke rehabilitation and indicates that intensive early physical rehabilitation treatment based on intensive massed repetitive practice improves functional outcome post stroke. These standards will lead the way to establishing a certification program for comprehensive stroke centers http://bit.ly/hTopPH

New HandTutor system video

http://bit.ly/fDS44h

The video explains the concept of using virtual functional tasks to give the patient both instructions on how to perform the correct movement to complete the tasks and augmented feedback on their movement performance.

Instructions and feedback are the key factors that contribute to motor learning and contribute to the ability of the HandTutor system in teaching the patient how to move their arm and hand.

Evidence for neuroplasticity

Neurological damage and stroke in particular, is the leading cause of long term disability worldwide. In just the last two decades, science has begun to appreciate the central nervous system's attempts to repair itself through a process termed neuroplasticity. Recent advances in non-invasive functional neuroimaging techniques, such as positron emission tomography (PET), functional MRI (fMRI) and near-infrared spectroscopy (NIRS), have enabled the study of brain activity in humans after stroke. Presented in brief are landmark papers that describe how adaptive changes occur in the human brain after focal neurological damage. These changes are thought to be due to re-organisation of neural networks following the brain injury and are thought to play a role in recovery of function following stroke.

Cross-sectional studies at chronic stages of stroke have demonstrated that the pattern of brain activation is different between paretic and normal hand movements, and suggested that long-term recovery is facilitated by compensation, recruitment and reorganization of cortical motor function in both damaged and non-damaged hemispheres (Chollet et al., 1991; Weiller et al., 1992; Cramer et al., 1997; Cao et al., 1998; Ward et al., 2003a).
http://bit.ly/f5AMYg
Subsequent longitudinal studies from subacute to chronic stages (before and after rehabilitation following intensive physical and occupational therapy) have revealed a dynamic, bihemispheric reorganization of motor network. (Marshall et al., 2000; Calautti et al., 2001; Feydy et al., 2002; Ward et al, 2003b).
http://bit.ly/eE1ZfZ

Recovery of function after stroke: principles of rehabilitation

In the January 2010 edition of J Rehabil Med neurologist Dr. Hummelsheim H from Rehabilitationszentrum Leipzig, University of Leipzig Germany discusses repetitive training of complex hand and arm movements with shaping is beneficial for motor improvement in patients after stroke http://bit.ly/hlWAnJ The group compared usual therapy to usual therapy plus intensive isolated exercises based on repetitive execution of a sawing and grasping and transport movement.

The group used isolated exercises based in repetitive execution of a sawing and grasping and transport movement.

The group present their finding in a powerpoint document http://bit.ly/f64W58 and other land mark papers that indicate that functional recovery outcome is improved if the rehabilitation physical and occupational therapy program adheres to the following concepts:
Repetitive active movement execution (massed motor practice)
Shaping: Difficulty of the motor tasks is increased in small increments.
Training close to the individual limits of performance
Training of simple movement parameters (strength, velocity etc.)

The HandTutor and ArmTutor system intensively trains simple movement parameters uses virtual functional tasks. The tasks can be set according to the individual patients limits of movement ability and the difficulty of the tasks can be shaped. The feedback gives the patient information on their performance of the tasks and instructions on how to improve their movement. Instruction and feedback is part of the learning cycle and the HandTutor and ArmTutor system teaches the patient how to move their arm and hand and improves functional movement ability.

Number of hours of inpatient physcial and occupational therapy in SCI pateints in Australia, Norway and the Netherlands

The January edition of the Journal of American Physiotherapy presents a report by Dr. Langeveld of the Revalidatiecentrum De Hoogstraat in Holland http://bit.ly/i6G7IS on the number of hours per week of inpatient physical and occupational therapy of spinal cord injury (SCI) patients over four week time span. The report found that the number of hours was Holland 28 compared to Australia 43 hours and Norway 39 hours.
The report does not comment on the quality of the rehabilitation outcome or the uptake in the use of new neuro rehabilitation devices such as the HandTutor system that encourage active exercise practice and increase the amount of intensive repetitive exercises performed by the SCI patients in the inpatient environment.

Neuroplasticity and its applications for rehabilitation

In the January edition of the American Journal of Therapeutics Symposium: Stroke Management, Dr. Young and Dr. Tolentino of Rush University report on neuroplasticity and its applications for rehabilitation http://bit.ly/gN0oUW . The report describes the various studies on neuro plasticity and the variety of interventions now available.
The HandTutor system uses the proven concept of active intensive exercise practice. However the power of the dedicated rehabilitation software is the fact the exercise task provides the patient with real time instructions on how to move their arm and fingers. The tasks can be customized so that the difficulty level will exercise the patients exact movement dysfunction. In addition augmented feedback is provided on the result of the patient’s movement and on the patients movement performance this motivates and stimulate patients to continue task practice.

HandTutor system exercises pinch, opposition and grip

In the January edition of Archives of Physical Medicine and Rehabilitation Dr. Heidi Fischer of the Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, IL and Dr. Rymer of the Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL report on Use of Visual Force Feedback to Improve Digit Force Direction During Pinch Grip in Persons With Stroke http://bit.ly/hIiTQW .
The paper notes that Following stroke, the paretic fingers generate digit forces with a higher than normal proportion of shear force to compression force during grip. This misdirected digit force may lead to finger-object slip and failure to stably grasp an object.
The HandTutor system can be used to intensively exercise isolated individual finger movements that enable practice of grip, pinch and opposition movements of the fingers. The dedicated rehabilitation software uses virtual functional tasks that provide the patient with instructions on how to move their fingers. In this way the patient exercises both extensors and flexors to properly co-ordinate during these movements. Virtual functional tasks employ augmented feedback so that the patient can understand whether they have done the movement correctly. Augmented feedback is a critical element in motor learning and therapists use augmented feedback when the patient has very limited finger motor sensory ability and control of finger movements. Augmented feedback is employed as the patients finger range of motion can not be sensed by the patients own intrinsic proprioception or seen using other extrinsic feedback methods e.g. mirror feedback.

The difference between traditional therapeutic task practice and virtual functional task practice

What is the difference between traditional therapeutic task practice and virtual functional task practice of the arm and hand with the HandTutor system?

Intensive and massed exercise practice has been proven to improve patient movement ability and the ability to do everyday living tasks. The HandTutor system employs virtual functional tasks. These are computer generated tasks or games that have been formulated to allow the therapist to customize which joint or combination of joint and which movement parameter will be exercised during the practice. In other words virtual functional tasks can be customized according to the patients movement ability. Therefore patients with very limited or no active movement ability can, through active assisted exercises, undertake intensive and massed movement practice. Similarly if the patient has better movement ability but still needs to work on pushing this ability to its limit the virtual tasks can be customized so that the patient needs to employ for example his maximum range of movement and or his maximum speed of opening of the fingers in order to succeed in the repetitive task. While the patient is performing the task they continue to receive instructions on how to do the task, how to correct compensatory movement patterns as well as feedback on their success in completing the task or adhering to the task requirements. This feedback is known as augmented motion feedback and teaches the patient how to move their arm and hands again.
Traditional task practice relies on the patient performing modified everyday living tasks or ADL tasks e.g. picking up a cup. The drawback to this approach is that ADL tasks can not be modified for patients that have limited or need to further improve their movement ability beyond just performing the task.

No access to Physiotherapy and occupational therapy following stroke in the UK

A major review from the Care Quality Commission (CQC) the independent regulator of health and social care in England today stated that stroke patients in the UK “face a postcode lottery” which determines their access to rehabilitation services with some areas having little or no access to stroke specialist community-based rehabilitation http://bit.ly/fHx9x0 .
The report further states that only two thirds of primary care trusts (the NHS bodies responsible for buying services from healthcare providers) commissioned specialist stroke physiotherapy and occupational therapy.
This has recently been confirmed by the mother of the many Cerebral Palsy patients using the HandTutor system. Her son has been waiting for over two years for an appointment to see an NHS occupational therapist. In the end she was forced to engage a private occupational therapist at a cost of £150 per session.
The HandTutor is a motivating dedicated arm and hand biofeedback rehabilitation system. The HandTutor enables patients to undertake intensive exercise practice which is proven to improve functional movement ability and is the mainstay of physical rehabilitation. The HandTutor system is used by rehabilitation clinic, private community physical and occupational therapists as well as home care patients. Home care patients have the option of remote motivating tele-rehabilitation support.

Rewards points entitles you to HandTutor systems for your clinic

Call out to all OTs, PTs, Physio therapists: Start using the HandTutor system through our rewards points program:

MediTouch Ltd has launched our rewards program for all trained OT/ PT’s, etc. The program will allow OT's and PT's to start to give their patients intensive exercise practice using the HandTutor System, glove and dedicated rehabilitation software.

Members of the rewards program will receive in depth HandTutor therapy training so that they can offer independent therapy sessions using the HandTutor. These sessions will be provided via the Internet remotely in real time - as distance learning. We will continue to track the progress & education online towards advanced use of the HandTutor system.

Following training the clinic/ PT/ OT will be credited for every patient referral of the HandTutor System to our clinic which results in a home care sale. Credits earned will entitle the PT/ OT and or clinic to receive additional ArmTutor, LegTutor and 3DtTutor for arm and leg rehabilitation using virtual functional task practice.

For More Info: alan@meditouch.co.il, www.meditouch.co.il

Cautious about Gabrielle Giffords receovery from tbi

At a press conference yesterday Dr. Peter Rhee, MD, MPH, medical director of trauma and critical care at University Medical Center who has assessed Gifford said "When you get shot in the head, and the bullet goes through your brain, the chances of you living is very small, and the chances of you waking up and actually following commands is even much smaller than that.”

Treatment during the acute phase of post traumatic brain injury is critical with doctors preventing and treating infection, bleeding and swelling. We are in this stage now and at this stage in Gifford’s recovery clinicians are cautiously optimistic that she could make a good recovery. However, it is still too early to confirm that she will have a complete recovery with no deficits or impairments in vision, speech, memory and upper and lower limb movement function.

Why can’t the doctors tell us the probability of a full recovery. Why is there just caution in their prognosis? The answer is that therapists and doctors focus on signs and symptoms rather than initial diagnosis as an outcome prediction. Patients, who have suffered brain injury e.g. stroke, traumatic brain injury, as well as other neurological or orthopedic injury, often have severe upper or lower extremity movement impairments. In short they have difficulty in doing the everyday living tasks that others take for granted. Therefore in the post acute and chronic stage of rehabilitation, doctors and therapists will look at a patient’s movement ability after brain trauma, detailed neurocognitive tests and scales based on functional movement ability will be used to determine the patients sensory movement impairment and help the therapist plan rehabilitation treatment.

Physical and occupational therapy is based on the proven efficacy of high intensity training undertaken as early as possible following brain injury which has been shown to improve both lower and upper extremity movement ability. The HandTutor and ArmTutor systems are a glove for finger movement practice and an elbow brace respectively. The system uses dedicated rehabilitation software that provides customized virtual functional arm hand and shoulder exercise tasks regardless of the patients arm movement ability. Through intensive exercise practice the patient learns how to move their arm and fingers again. HandTutor and ArmTutor teach the patient how to move their arm again as the program incorporates all the acceptable principles of neuromuscular rehabilitation:



1. The exercise tasks adopt a virtual functional approach.

2. The exercises are customized to train deficits in motor abilities or motor impairments including speed, range and co-ordination of movement.

3. Exercise training customized to these movement impairments improve functional ability.

4. The HandTutor is suitable for a wide range of neuromuscular hand movement dysfunction.

5. Dedicated rehabilitation software uses motion feedback to train proprioception which plays an important role in movement control and is often affected by musculoskeletal and central nervous system damage.

6. Adaptation is avoided as the virtual functional exercise tasks can be varied.

7. Intensive repetitive exercise training with motion feedback allows the brain to compensate for the lost function through neuromuscular plasticity.



The HandTutor and ArmTutor systems are used by all patients that have hand and arm movement dysfunction regardless of diagnosis. The system focuses on the sign and symptoms which are the amount and quality of patient’s active movement ability. This information provides the therapist and patient with real time feedback on movement ability and improvement. We all wish Gifford a full and complete recovery www.HandTutor.com.

Prozac May Speed Physical Rehabilitation After Stroke Why?

Dr. Francois Chollet and his team from University Hospital of Toulouse and INSERM report on their research to assess the effect of a daily treatment with Prozac (fluoxetin 20 mg) on motor performance in patients with mild to severe motor deficit after ischemic stroke http://bit.ly/iaFmIw .
The team found that after three months of follow-up, patients taking generic Prozac had improved their Fugl-Meyer Motor Scale score compared to controls.
Is the reason for this the effect of Prozac on neurotransmitters in the brain, with a possible mechanism of action being that Prozac increases neuronal excitability and this increase in excitability is linked to increased plasticity? Alternatively is the explanation more obvious!!! Patients given anti depressants undertake more intensive early physiotherapy and occupational therapy because they are less depressed. It has been proven in controlled clinical trials that intensive and early intervention with physical therapy is associated with better recovery outcomes. Therefore the effect that was seen may be due not to a central biochemistry mechanism of action but instead due to the antidepressant effect with the Prozac treated group being in a better condition to practice physical and occupational therapy in a more intensive and early fashion after stroke onset.

Stroke: Removing restraints on recovery

In the January 2011 edition of Nature Reviews Drug Discovery Dr. Clarkson in her paper Stroke: Removing restraints on recovery discusses that GABA acts as an inhibitor of neural excitability and therefore removing this inhibitor post stroke may result in an improvement in locomotor function.

Recovery after stroke involves remapping of the neuronal circuitry in the regions adjacent to the site of injury — the peri-infarct zone — (neural plasticity) but so far there are no pharmacological therapies that can promote this. Now, Clarkson et al. show that inhibiting tonic GABA (gamma-aminobutyric acid)-ergic signalling days after a stroke can improve locomotor function.

Combining intensive task practice with conceptual advances in neuro rehabilitation

In a study that appears in the November edition of Neurology Today Dr. Lindenberg of Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA report on their research that Bihemispheric brain stimulation facilitates motor recovery in chronic stroke patients http://bit.ly/gOoFb7 . The group showed that a combination of bihemispheric transcranial direct current stimulation tDCS and peripheral sensorimotor activities (traditional OT and PT) improved motor functions in chronic stroke patients. This research shows how conceptual advances in the neuroscience of recovery can be translated into clinical practice as established rehabilitation technique e.g. the “usual treatment” of functional exercise practice was combined with the tDCS. The HandTutor system provides patients with virtual functional task practice even if they do not have the movement ability to do traditional task practice exercise.

Combining active intensive exercise practice with augmented feedback

In the January edition of Archives of Physical Medicine and Rehabilitation Prof Fung and his group from the Physiotherapy Faculty at the Hong Kong Polytechnic University discuss the Effects of sensory cueing on voluntary arm use for patients with chronic stroke: a preliminary study http://bit.ly/edgC6x .

The group studied 16 community residents with chronic unilateral stroke and mild to moderate upper-extremity impairment. The patients engaged in repetitive upper-extremity task practice for 2 weeks while wearing an ambulatory sensory cueing device on their affected hand for 3 hours a day.

The group found that the patients arm function measured with Action Research Arm Test (ARAT), the Box and Block Test, the Fugl-Meyer Assessment (FMA) improved. However the group did not do a controlled clinical trial with the control group receiving usual care compared to the trial group receiving UC and sensory cueing. They therefore did not differentiate the rehabilitation effect of intensive active practice to the “additional” effect of sensory cueing.

The HandTutor system uses the proven concept of active intensive exercise practice and combines this with augmented feedback to motivate and stimulate patients to continue task practice.

Book review: Spinal Spinal Cord Injury Rehabilitation Dr. EDELLE C. FIELD-FOTE

In her book Spinal Spinal Cord Injury Rehabilitation (Contemporary Perspectives in Rehabilitation) Dr. EDELLE C. FIELD-FOTE, PH.D., P.T. Associate Professor, Departments of Physical Therapy and Neurological Surgery University of Miami Leonard M. Miller School of Medicine presents an evidenced-based guide to the state-of-the-art in spinal cord rehabilitation. In the book, an expert team of clinicians address new scientific knowledge and technological advances proven to maximize restoration of function in individuals with SCI.

Dr Field Forte describes Neurologic Physical Therapy at the Nexus of Recovery, Restoration, and Regeneration proven by the growing recognition in both clinical practice and research that movement experience is a necessary component of optimal neural recovery.

The book offers therapists

* Guidance to interpret the ever-changing research literature and to assess clinical trials.
* Discusses how neural circuitry changes as a consequence of SCI, how neural activity may be used to predict prognosis, and what interventions might aid in restoration of appropriate neural organization.
* Identifies individuals who might benefit from implanted systems for electrical stimulation to assist with a wide variety of functions, as well as the limitations of these devices.
* Provide a stepwise guide for assessing motor, sensory, and functional status.
* Describes the skills and techniques that facilitate the use of available motor capacity for maximum function.
* Outlines the role of intensive, task-specific training to improve arm and hand function and techniques to promote locomotor function.

The HandTutor system enables therapists to customize the exercise practice to a level slightly above the patient’s movement ability. This allows the augmented feedback in the virtual rehabilaition tasks to motivate the patients improve their hand movement ability during intensive practice.

The power of retrospective compared to prospective clinical trial results

In a Retrospective study published in Circulation and the Journal of the American Heart Association Dr. Kurth from INSERM in Paris France show that migraines are associated with increased risk of ischemic stroke however these strokes are typically associated with good functional outcomes. See more details: http://bit.ly/eYu0KI

Passing thought: Is a retrospective study powerful enough to draw conclusions on functional outcome in stroke when there are so many independent variables including treatment protocols, assessment tools to name just two?

HandTutor system teaches the correct movement pattern and prevents compensatory movement strategies

In the December edition of study published in Topics in Stroke Rehabilitation Dr. Flynn and her group discuss the “Development of an Interactive Game-Based Rehabilitation Tool for Dynamic Balance”. The group tested commercially available gaming systems and found that current commercial games are not compatible with controlled, specific exercise required to meet therapy goals http://bit.ly/dYbkxH

Is this finding all so due to the sensors being used in commercially available games only testing to see that the end point of the movement has been reached and therefore do not prevent compensatory movement strategies?

MediTouch have developed the LegTutor system that allows for the implementation of virtual functional lower extremity tasks. The system incorporates 3D position information on the hip and allows the patient to practice intensive isolated knee and hip exercises. Using the LegTutor system in combination with traditional functional exercises promotes functional rehabilitation.

HandTutor treats pateints with high spasticity post stroke

The Journal of Rehabilitation Medicine reports on an upcoming double-blind, prospective, randomized, European and Canadian study: Evaluating patient outcomes and costs of managing adults with post-stroke focal spasticity http://bit.ly/gOMxLq

The trail to be conducted by Division of Rehabilitation Medicine; Department of Clinical Sciences Karolinska Institutet; Sweden led by Dr. Borg is aiming to provide evidence for the extended use of botulinum toxin A in focal post-stroke upper and lower limb spasticity and to evaluate the impact of incorporating botulinum toxin treatment into the rehabilitation of patients with spasticity.

Occupational and Physical therapists can reduce the patient’s spasticity level during training. It is important that during this training the patient undertakes repetitive customized exercises that improve their sensory and motor movement ability. The HandTutor system provides virtual functional task practice exercises that motivates and allows the patient to exercise even if they have limited movement ability. This limited movement ability prevents the patient from doing traditional task practice exercises. Intensive repetitive exercises using the HandTutor, therefore improves the patients functional recovery.

Developemnt of the Infrastructure for tele-rehabilitation

In a recent article in Rehabilitation Engineering, Dr Colombo and his team from Rehabilitation Institute Veruno and Pavia Italy discuss the development of systems architecture for robot aided tele-rehabilitation http://bit.ly/gZ2AFQ

The group note that to date, previous tele-rehabilitation studies have NOT studied a modular combination of rehabilitation devices that can be used by patients with a wide range of different ages, education, technology background and level of movement ability. Because patient motivation is an important factor in rehabilitation outcome a tele-rehabiliation system needs to increases patient satisfaction and motivation above or equal to that gained with traditional clinic based rehabilitation services. In addition the system needs to increase intensity of patient exercise performance and reduce health care costs. They point out that the technology has to be very user friendly so that the patient and therapist will concentrate on the task and not on the technology. Tele-rehabilitation holds the promise of allowing for improved continuity of care, increased exercise time and continuity of treatment with a reduction in the rehabilitation resources required. Interaction between the therapist and the patient can be through real time concurrent monitoring of the patient doing the virtual rehabilitation task with the patient and therapist being online at the same time during the session. Alternatively, intermittent online therapy consists of the therapist going online to update the exercise task and monitor the patient’s adherence to exercise regimen.

The HandTutor and ArmTutor system consists of a comfortable ergonomic glove and elbow brace with 3D shoulder position feedback. The patient wears the HandTutor and ArmTutor and the system allows the patient to practice multi-joint virtual functional tasks. The tasks are formulated so that they mimic ADL tasks like hair brushing, hand reaching and grasping. Continuous and intermittent online therapy is possible with the HandTutor system as the virtual functional tasks motivate the patient to practice on their own and either the patient or the therapist updating the task. Additionally evaluations on the patient’s quality, accuracy, speed of movement are incorporated into the HandTutor system allowing the therapist to quantitatively monitor the patient’s progress.

Effectiveness of very early mobilization after stroke

In the December edition of Stroke http://bit.ly/hYnXS6 Dr Cumming and his group from University; and School of Physiotherapy La Trobe University, Melbourne, Australia and Department of Medicine University of Melbourne report on a clinical trial to show the effectiveness of Very Early Mobilization After Stroke Fast-Tracks Return to Walking. The group show that very early and intensive mobilization allowed patients to return to walking significantly faster than did standard stroke unit care controls. The LegTutor is a Knee brace and 3D hip position system that allows the patient to perform virtual functional tasks. The LegTutor system allows the patient to practice virtual sitting to standing movement patterns without weight baring. The exercises can also be performed with the therapist assisting the patient to move his legs even if the patient does not have the required range of motion. The LegTutor system therefore allows the patient to perform motivating early mobilization exercises.

HandTutor used treat incomplete Spinal Cord Injury

In the December edition of Spinal Cord http://bit.ly/fvsyes Dr. Amatachaya and his group from the School of Physical Therapy Khon Kaen University Thailand undertook a prospective trial to see the functional abilities, incidences of complications and falls of patients with spinal cord injury 6 months after discharge. They found that the functional ability of subjects with SCI, particularly those with chronic motor incomplete SCI, significantly decreased after discharge. The group confirmed important roles of community rehabilitation after discharge.

The HandTutor is used by incomplete spinal cord injury patients in rehabilitation clinic, community OT and PT and by the home care patient. The use of the HandTutor system contributes to continuity of care between the hospital and community rehabilitation settings.

Successful Physical Tele-rehabilitation

A summary document prepared by the Institute of Health Economics Canada and the Finnish Office for health Technology Assessment, 2010 entitled evidence on the effectiveness of tele-rehabilitation applications can be found at http://bit.ly/fMlLe1

In reference to tele-rehabilitation (TRH) within the neurology area the report discusses five studies on support for stroke patients, TRH was successful in three, but of limited or no benefit in two. In addition the report details studies in TBI and MS.

HandTutor and the treatment of neglect

In the January issue of Brain A journal of Neurology, Dr. Hans-Otto Karnath and his team at University of Tübingen Germany investigate The anatomy underlying acute versus chronic spatial neglect: a longitudinal study http://bit.ly/fzwHkV

Acute brain imaging (acquired on average 6.2 days post-injury) was used to evaluate neglect symptoms at the initial (mean 12.4 days post-stroke) and the chronic (mean 491 days) phase of the stroke. Chronic neglect was found in about one-third of the patients with acute neglect.

The team’s findings infer that individuals who experience spatial neglect in the initial phase of the stroke yet do not have injury to cortical including the superior and middle temporal gyri and subcortical including basal ganglia and inferior occipitofrontal fasciculus/extreme are likely to recover, and thus have a favourable prognosis.

The HandTutor system has virtual tasks that purposely draw the patient’s attention to the right and left side of the screen during exercise practice. This gives the pateitn augmented feedback and stimulation in these areas of the screen.

PT Tele-mentoring with the HandTutor system contributes to standardization

In the December edition of Stroke, http://bit.ly/eeasb3 Dr Sullivan and her team from the University of Southern California, Los Angeles and the University of Florida and the Gainesville Veterans Administration Hospital report on a clinical study to determine the reliability of the Fugl-Meyer Assessment of Sensorimotor Function comparing the fidelity of motor (total, upper extremity, and lower extremity subscores) and sensory (total, light touch, and proprioception subscores) across 5 regional clinical sites.

The HandTutor system incorporates evaluations on the patient’s movement impairments. Therapists are trained on the correct protocol for using these evaluations and this ensures fidelity in outcome measurements which allows for meaningful comparisons of patient physical rehabilitation outcome. The HandTutor system thus allows for standardization in OT and PT measurement method training. Because the HandTutor system allows for tele-rehabilitation, the OT and PT can be taught the correct protocol through tele-mentoring.

HandTutor and Health related Quality of Life

In the December edition of Neuro rehabilitation http://bit.ly/g4Zvxk Dr. Arango-Lasprilla and her team from Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA assess health-related quality of life (HRQOL) in individuals with Spinal Cord Injury (SCI) in Neiva, Colombia. They conclude that individuals with SCI report having poorer quality of life across various domains, primarily in the area of physical functioning, compared to healthy controls. These findings suggest the need for rehabilitation health professionals to develop and implement interventions to improve HRQOL in individuals with SCI. The HandTutor system has been proven to improve hand and arm functional movement ability and has been shown to improve ADL task performance which is known to improve health related quality of life.

Functional gain in hemorrhagic stroke patients is dependent on the functional level and cognitive abilities measured at hospital admission

In the December edition of Neurorehabilitation http://bit.ly/gv6q1R Dr. Cheng and his team from Occupational Therapy Department, MacLehose Medical Rehabilitation Centre, Hong Kong, China confirm that Functional gain in hemorrhagic stroke patients is dependent on the functional level and cognitive abilities measured at hospital admission. The functional ability can be predicted by age, pre-training functional level, and cognitive abilities measured at admission.

The HandTutor system can optimize rehabilitation outcome and functional movement ability by providing motivating virtual functional task practice.

Virtual functional tasks and intensive task practice

In the January edition of Neurorehabil Neural Repair http://bit.ly/gEyIUb Dr. Murphy and her group from Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden discuss Kinematic Variables Quantifying Upper-Extremity Performance After Stroke During Reaching and Drinking From a Glass. In the trial, 19 chronic stroke patients (2 groups moderate and mild Fugl Meyer scores) and 19 healthy controls reached for a glass of water, took a sip, and placed it back on a table in a standardized way. The group looked at kinematical parameters describing movement time, velocity, strategy and smoothness, interjoint coordination, and compensatory movements. They conclude that patient movement impairments such as range of movement, total movement time, and peak angular velocity of the elbow during the functional task discriminated between the two stroke groups.

The HandTutor and ArmTutor systems encourage intensive exercise practice through virtual functional tasks. The tasks have been designed to exercise individual and combinations of isolated movement parameters. This impairment oriented training has been shown to improve functional movement ability.