Making the Case for Continuous Physical Rehabilitation for Parkinson’s Disease Patients

In a controlled clinical trial conducted by Comelia L. Cynthia , MD, Glenn T. Stebbins, PhD, Nancy Brown-Toms, BA and Christopher G. Goetz, MD of the Department of Neurological Sciences, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL. an evaluation was made of the effects of physical disability in moderately advanced Parkinson’s patients following 4 weeks of normal physical activity and 4 weeks of a more intensive physical rehabilitation program. They used a timed motor task and a standard assessment of PD severity (the Unified Parkinson’s Disease Rating Scale [UPDRS] with subscales for mentation, activities of daily living [ADL], and motor function. The test was conducted by an investigator who did not know about the physical rehabilitation status of the patient. Following physical rehabilitation, there was significant improvement in the UPDRS ADL and motor scores, but no change in mentation score. During the 6 months following physical rehabilitation, patients did not regularly exercise, and the UPDRS scores returned to their baseline. The conclusion the researchers reached was that physical disability in moderately advanced PD improves with a regular physical rehabilitation program, but the improvement is not sustained when normal activity is resumed. Parkinson’s disease patients have a physical therapy solution that has shown to be very effective in restoring movement ability to disabled limbs due to the disease. The HANDTUTOR, ARMTUTOR, LEGTUTOR and 3 DTUTOR are physical therapy products that are currently being utilized in leading U.S. and European hospitals and rehabilitation clinics. The TUTORs are gloves and braces that are strategically placed on affected hands, arms, elbows, legs and other joints. The sensors in these devices pick up the patient’s movements through dedicated software. Physical therapists monitor, evaluate and design these movements into a customized program for that specific patient. Fully certified by the FDA and CE the cost effective TUTORs are available for children as young as 5 and in the patient’s home through the use of telerehabilitation. See WWW.MEDITOUCH.CO.IL for further information.

ArmTutor, HandTutor and LegTutor systems used in inpatient and outpatient to treat Apraxia

In the April edition of Neurorehabilitation http://bit.ly/jo56wP Dr. Vanbellingen and Dr. Bohlhalter from the Departments of Neurology and Clinical Research, Inselspital, University Hospital Bern, Switzerland define Apraxia as a higher-order motor disorder impairing the ability to correctly perform skilled, purposive movements as the result of neurological disorders most commonly stroke, dementia and movement disorders. It is increasingly recognised that apraxia negatively influences activities of daily living (ADL). Early diagnosis and treatment should be part of the neurorehabilitation programme. In their article they describe the most important subtypes of apraxia such as ideational and ideomotor apraxia as well as their impact on ADL and outcome. Furthermore, the relationship to associated disorders such as aphasia is discussed. Finally, strategies concerning assessment, management and treatment of the disorder are presented.
The HandTutor, ArmTutor system improve arm and hand functional ability and quality of life. The LegTutor system is used in inpatient and outpatient to treat knee and hip movement ability.

The HandTutor assists recovery of upper limb dexterity in stroke patients

In the April edition of NeuroRehabilitation http://bit.ly/jCIipo Dr. Kong and his group from Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore look at the arm and hand functional ability of one hundred and forty patients more than a year after stroke onset. The group found that upper extremity functional deficit was present in almost 70% of patients with chronic stroke. The lack of functional ability correlated to upper limb strength and spasticity. The group concluded that the most significant predictor of dexterity, functional outcome and quality of life was the severity of upper limb paresis on admission to rehabilitation.
The HandTutor is used in both acute and chronic hand and arm rehabilitation by occupational and physical therapists based both in hospital and outpatient clinics.

The LegTutor system is used to customize isolated and coordinated knee and hip exercises and is used to improve patient functional walking ability

In the April edition of Physical Medicine and Rehabilitation http://bit.ly/iJ4Fzr, Dr Watt and his team from Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA discuss Effect of a Supervised Hip Flexor Stretching Program on Gait in Elderly Individuals.
The group looked at eighty-two healthy elderly individuals, with 39 subjects in the control group and 43 subjects in the treatment group. The treatment group completed a 10-week, twice-daily hip flexor stretching program, which was supervised twice weekly by a rehabilitation clinician. The 10-week supervised hip flexor stretching program was effective in increasing stride length and peak hip extension during walking in elderly adults who had limited preintervention hip extension during walking. These results support the use of a simple stretching program for elderly individuals in counteracting age-related decline in gait function.
The LegTutor system is used to customize isolated and coordinated knee and hip exercises and is used to improve patient functional walking ability.

HandTutor improves fine motor co-ordination in children

Fine Motor Coordination

Fine motor coordination requires the use of the small muscles for finger dexterity to manipulate objects. Various functional and play activities will ensure the development of mature grasp patterns. Children with developmental delay have an impairment in the development of fine motor skills and will have difficulty picking up and manipulating small objects, button/zip clothes, color, build with Legos, dress doll babies and eat appropriately with fingers and utensils as well as difficulty in performing everyday daily tasks and activities.

Because fine motor coordination is developed through strengthening and using our hands, it is important to provide a variety of activities to develop well balanced muscles and coordination. In addition it is advisable to limit the use of hand held video games, watching TV, and computer activities.

Some ideas: Children need to dance, run and play outside, act out a story with dolls or action figures etc. Additionally, they need to color and draw . The below examples are fun ways to develop strength and coordination.

Strengthening:

* Dig in sand or dirt
* Play dough
* Stretch rubber bands around a cup or can
* Pop bubble wrap
* Squeeze a hole puncher
* Pick up cotton balls, small blocks, puzzle pieces with clips
* Squeeze clothes pins.
* Water play squirt toys, fill up and pour water out of various size bottles

Coordination

* Play with finger puppets
* Pick up objects with tweezers
* Puzzles
* String beads, noodles or cereal on pipe cleaners or string
* Play games such as memory, Hi HO Cherry Oh, Candy Land
* Wind up toys or spin tops
* Use tongs to stack block or pick up objects
* Flip coins over so all are “heads up” and place coins in a bank or container
* Find objects (buttons, shapes, letters) in a bowl of dry beans or rice
* While at restaurants keep busy by coloring, have small squeeze flashlight to shine on objects on the table, spinners or wind up toys.

he HandTutor system has been shown to improve fine motor movement ability in patients with DCD.

HandTutor used with mental practice to improve hand movement ability

Mental practice or movement imagination is a training method where the patient imagines a movement without actually moving the limb that has movement dysfunction. Recently researchers have proposed the use of mental practice to facilitate motor recovery in stroke patients and other patients with motor disorders. Mental practice is the imagined rehearsal of a movement with the specific intent of improving that movement and it is suggested that during mental practice the motor control structures in the brain are activated in more or less the same way as during the actual performance of movements. This mechanism of improving limb movement has been reinforced by neuroimaging studies taken during motor imagery and show that the same brain areas are active as during actual movement. In addition, studies with healthy individuals have shown that motor imagery and actual action share some striking similarities. When someone is asked to perform a movement, for example, “walk along this line”, and to imagine the same movement, the time to complete the actual walking movement is similar to the time needed for completing the imagined walking movement.

HandTutor system increases the dose of exercise training in order to improve functional hand movement ability

In the April edition of Neurorehabilitation and Neural Repair http://bit.ly/gXjd8x Dr. Anthony Rudd Consultant Physician in Stroke Medicine St. Thomas' Hospital London and Professor of Stroke Medicine King's College London discuss a study looking to find the optimum Dose–Response of Mobilisation and Tactile Stimulation Therapy for the Upper Extremity Early After Stroke. The group state that Physical therapy doses may need to be higher than provided in current clinical practice, especially for patients with severe paresis.
The HandTutor system allows the patient to undertake motivating and challenging active intensive exercise practice. It is suitable for patients with severe movement impairments as well as patients that need to improve their fine motor movement ability. The HandTutor system is used in acute, sub acute and outpatient treatments. The HandTutor system is also used by the patient at home and can be supported by telerehabilitation. This allows for an optimum and higher dose of exercise training.

HandTutor system answers the 2009 American Heart Association (AHA) Policy Statement on stroke systems of care

In 2009 the American Heart Association issued a AHA Policy Statement that appears in Stroke magazine http://stroke.ahajournals.org/cgi/content/full/40/7/2635 discussing recommendations for the implementation of telemedicine within stroke systems of care. In regards to sub acute stroke treatment, the report states that many small hospitals do not have specialists with training and expertise to treat patients in medical sub specialties, including physical, occupational and speech therapy, and rehabilitation medicine.
Stroke rehabilitation involves coordinated interventions from a multidisciplinary team in order to achieve the best potential functional outcome. and should be provided by an appropriately trained and staffed that follows established practice guidelines. Impaired recovery outcomes has been noted in patients with geographically and or financially limited access to appropriate rehabilitation services. The report concludes that telemedicine for rehabilitation (telerehabilitation) may be a practical and valuable approach to delivering post stroke care when limited resources, manpower shortages, long distances, or limited patient mobility prevent or limit access to indicated rehabilitation therapies.
In a recent statement by Steven L. Wolf, PhD, professor of rehabilitation medicine at Emory University School of Medicine millions of Americans face challenges in accessing health care, with rural residents experiencing more limitations of activity caused by chronic conditions such as stroke than urban residents. Additionally, insurance carriers often do not cover lengthy rehabilitation programs for stroke survivors, causing many patients to lose the proven benefits of aggressive therapy following a stroke.
Prof Wolf also states that “A tremendous amount of research has led to advances in stroke therapy through the identification of the importance of task practice and intensity of therapy. However, we know that many patients, in particular those living in rural and under served areas, do not receive quality post-stroke rehabilitation.

The EU policy states all European stroke patients should have access to a continuum of care, including organized acute stroke units, appropriate rehabilitation, and secondary prevention measures and the 2006 World Health Organization Helsingborg Declaration on European Stroke Strategies declared that tele-rehabilitation is a vital element to achieving this goal.
The HandTutor system is being used for stroke and other brain and spinal cord injury, cerebral palsy, brachial plexus injury patients, with the patient undergoing intensive exercise practice at home with tele-monitoring from a remote location ensuring patient compliance and maximum motivation.

Community-based upper-extremity rehabilitation improves motor function and performance of functional activities in chronic stroke

In the Arch Physical Medical Rehabilitation http://1.usa.gov/hAQpOz Dr. Pang and his colleagues from School of Rehabilitation Sciences, University of British Columbia, Rehabilitation Research Laboratory, GF Strong Centre, Vancouver, BC, Canada assess the effects of a community-based exercise program on motor recovery and functional abilities of the paretic upper extremity in persons with chronic stroke. The patients underwent an exercise program designed to improve upper-extremity function (1h/session, 3 sessions/wk for 19wk). The group found that community-based exercise program can improve upper-extremity function in persons with chronic stroke.
The HandTutor and ArmTutor system is proven to improve upper extremity function in pateints with arm movement dysfunction in both rehabiliation clinic and the home.

HandTutor and ArmTutor systems used to give customized and motivating intensive exercise practice

In the March edition of Clinical Rehabilitation http://bit.ly/hC2IvQ, Dr. Stephen Page and his group from the Departments of Rehabilitation Sciences, Physical Medicine and Rehabilitation, University of Cincinnati Academic Medical Center, Cincinnati, OH, USA compare longer versus shorter mental practice sessions for affected upper extremity movement after stroke. The group found that regardless of dosing condition, subjects administered mental practice exhibited markedly larger score changes on both the FM and ARAT than subjects not receiving mental practice.
Mental practice can be used in Arm and HandTutor system treatments as the dedicated rehabilitation devices allow the therapists to tailor and customize the patients exercise to their movement ability. This keeps the patient motivated to continue intensive exercise practice.

Effective rehabilitation of older people in a district rehabilitation centre

In the March edition of Journal of Rehabilitation Medicine http://bit.ly/gdpzXF Dr. Inger Johansen and her group from Department of General Practice/General Practice Research Unit University of Oslo, Oslo, Norway assess the outcome of rehabilitation of older patients in a district rehabilitation centre following referral from district hospital, nursing homes or their own homes following stroke, arthrosis, hip fracture and other neurological and orthopedic injuries and chronic diseases. The group found that significant and persisting improvements in activities of daily living were achieved by rehabilitation of older patients with stroke, arthrosis, hip fracture and other chronic diseases in a district inpatient rehabilitation centre with co-ordinated and multi-disciplinary rehabilitation.
The HandTutor and ArmTutor are used in clinic, nursing home and home care to give patients upper extremity arm and hand intensive active exercise rehabilitation and the LegTutor and 3DTTutor allow physical therapists to customize lower extremity rehabilitation exercises that motivate the pateints to achieve optimum rehabilitation outcome.

Virtual functional tasks train sensory, cognitve and movement impairments

In the March edition of Clinical Rehabilitation http://bit.ly/hrDpIi , Dr. Makoto Hiyamizu and her group from Department of Physical Therapy, Faculty of Health Science, Kio University, Nara, Japan look at the effects of dual task balance training on dual task performance ability in elderly people. The group found that dual task balance training in elderly people improves their dual task performance during standing postural control.
The LegTutor and 3DTTutor allow the therapist to train sensory, cognitive and movement impairments and to motivate patients with challenging tasks that enable them to do intensive active exercise practice.

Inpatient and Postdischarge Rehabilitation Services Provided in the First Year After Spinal Cord Injury: Findings From the SCIRehab Study

In the March edition of the Archives of Physical Medicine and Rehabilitation Dr. Whiteneck and his group from Craig Hospital Engelwood NJ look at the break down in rehabilaition treatments given before and after hospital discharge for Spinal Cord Injury patient. The group found that of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours.
The HandTutor, ArmTutor and LegTutor system is being used by OT's and PT's with SCI patietns both in acute, sub acute, outpatient and home care environments.

Use it or lose it: The HandTutor system enncourages intensive massed exercise practice to regain lost movement ability following stroke

In the past Stroke patients who couldn't use an injured arm or hand were taught to dress and bathe with their good arm. This means the patient was taught a compensatory strategy to achieve the active daily living (ADL) function. This was because until recently scientists thought that when a region of the brain was damaged, its function was lost forever.

However, sophisticated imaging tests of the brain e.g. fMRI have revealed that the brain amazingly can reorganize itself after injury so that when nerve cells die, their functions are taken over by other areas of the brain. This concept is known as neuroplasticity. The concept of neuroplasticity has changed stroke rehabilitation therapy considerably.

"Now we know that if you want to get motor recovery on the affected side, you have to use the affected side—repetitively and intensively," says Richard Zorowitz, M.D., chief of physical medicine and rehabilitation at the Johns Hopkins Bayview Medical Center in Baltimore, Md. "That stimulates the brain to make those new connections."

Neuroplasticity is the principle behind the HandTutor, ArmTutor and LegTutor systems that provide motivating and customized virtual task exercise therapy that allow the patients regardless of their movement ability to do intensive and massed exercise practice.

Neurotransmitter could improve post-stroke rehabilitation

Neurotransmitter could improve post-stroke rehabilitation

March 10, 2011
Christian Grefkes from the Max Planck Institute for Neurological Research in cooperation with scientists from the Institute of Neurosciences and Medicine of the Forschungszentrum Jülich and the Department of Neurology of the University Hospital of Cologne looked at eleven stroke patients (between 42 and 74 years old) with fine motor deficits. The group carried out a range of motor tasks which involved the determination of maximum grip power and finger-tapping frequency and the execution of pointing movements. The group showed that by reducing the rate of uptake of noradrenaline which in effect prolongs the efficiency of noradrenaline improves motor skills in stroke patient.

Intensive active exercise practice provided by the HandTutor, ArmTutor and LegTutor system has proven effective in improving functional movement ability in post stroke patients.

HandTutor, ArmTutor and LegTutor provide evidence based stroke functional rehabilitation

In the March edition of the BMJ http://bit.ly/fVDXca Dr. Bhalla consultant stroke physician from and her group from Kings College London compare the provision of acute care in South London from 1995-2007. The group found that the likelihood of those with a functional deficit receiving rehabilitation increased significantly over time with patients aged 75 or more being more likely to receive occupational therapy or physiotherapy. however the group found that implementation of evidence based care was not optimal.
The HandTutor, ArmTutor, LegTutor allows physios and occupational therapists to provide evidence based active exercise rehabilitation task training.