Healing
Motivate to Rehabilitate
Recently a number of new devices, designed with the hope of improving outcomes, have become available in the realm of rehabilitation therapy.
http://strokeconnection.strokeassociation.org/Summer-2015/Motivate-to-R…
BY JON CASWELL
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The MusicGlove rehab therapy device for hands (above)
Recently a number of new devices, designed with the hope of improving outcomes, have become available in the realm of rehabilitation therapy. Though further scientific study is necessary to understand the true potential impact of these devices, some of them appear to be showing some promise for the future. They use computers, sensors and tiny motors to change how survivors do therapy. The three devices that we explore here are worn by the patient and all provide detailed feedback that serves to motivate survivors to keep working at therapy.
Not that long ago, stroke survivors were told whatever they got back in the first six months was as good as it would get. Now we know those first six months are golden because the brain is most plastic then. Doing as many repetitions of therapy exercises as possible during this period may maximize recovery.
One secret to more reps is to make them more fun. New therapy devices are attempting to do that by applying gamification principles. Gamification uses game elements, like rewards and positive reinforcement, to make therapy more fun and engaging.
Making Homework a 'Get-To'
Harriet and Marc Manis
As is often the case with stroke, insurance for rehab ran out before Marc Manis of Winter Springs, Florida, had made much recovery. At age 46, Manis had a left-hemisphere stroke due to a carotid dissection in September 2001. He did about six weeks of inpatient therapy and worked with home therapists for another two months. "That’s when they said ‘We’ve taken him as far as we can,’" said Harriet, his wife of 28 years. "They said to keep doing repetitive motion." At that point he had no controllable movement in his right arm and hand. He could make a fist, but he couldn’t intentionally open his fist, nor could he move his arm and shoulder at all. After years of investigating rehab devices, Harriet saw an ad for MediTouch.
MediTouch offers four devices — Hand Tutor, Arm Tutor, Leg Tutor and 3D Tutor. These FDA-approved devices are connected to the computer, and this allows the therapist to turn the instructions for customized repetitive exercises into rehabilitation games. The purchase price — $2,000 per device — includes instructions on setting up the system, however, extra therapy sessions need to be purchased to enable the patient and the caregiver to practice intensively with the MediTouch system. The devices themselves are currently considered experimental and are not reimbursed by insurance.
Physiologist Alan Waterman has been using the MediTouch for eight years. "The MediTouch Tutors are movement biofeedback devices," Waterman said. "They measure the patient’s movement, then we demonstrate the correct movements and set up the exercise in the memory so the family can do the exercises on their own. The instructions are in the system and the system gives them feedback on how well they are doing. In essence we’re creating a biofeedback learning loop."
Waterman does an hour-long therapy session over Skype with Marc every Sunday morning using different devices. Together they define what Marc wants to accomplish, and then Waterman designs exercises to reach those goals given Marc’s current abilities. During the next week, Marc and Harriet do homework based on the exercises that have been programmed into each device. Since Marc can’t put the devices on by himself, they do this after she gets home from work.
Each MediTouch device stores the data from each homework session, which Waterman can retrieve online. "This allows me to see what they are doing and how well they’re doing," Waterman said.
MediTouch incorporates games to promote repetitive motion, and this motivates Marc. "If you tell someone, ‘Go do your arm exercises,’ they’ll eventually stop doing it altogether without something to keep them motivated," Harriet said. "With MediTouch when I get home from work, Marc’s asking me to do homework."
And that enthusiasm has paid off in functional changes. "He’s able to move his arm, which he wasn’t able to do before. It was just hanging there," Harriet said. "His balance is much better; he hasn’t fallen the way he used to. And because he can manipulate his leg a little bit and his arm, he’s actually gotten up the few times he has fallen. At the gym on Saturday, I see him actually lifting his arm and putting it on the equipment himself, which he couldn’t do before."
MediTouch always includes some therapy in order to train the family. "This system allows us to teach family members how to do the exercises exactly right," Waterman said. "It is motivating to the patient to know what exercises to do, how to do those exercises and to get feedback on how well they are doing them. All of this motivates them to do their homework." And just like in high school, doing your homework pays off.
Practicing Pinches to the Music
Occupational therapist Susan Katzmann believes the MusicGlove offers numerous benefits.
At age 25, Rachel Johnson had never used her right hand for more than gross motor movement. Her whole right side was weak because of a hemorrhagic stroke when she was an infant. Then her mother saw an ad for MusicGlove, an over-the-counter rehab device for hands. She ordered a free, 15-day trial and quickly noticed an improvement. Using crowdfunding she raised the $1,100 purchase price. "I haven’t done any therapy in 15 years, because I quit when I was 10 years old — it was just too boring," said Johnson of Stony Point, New York.
"With MusicGlove, both patients and clinicians can detect small improvements in hand function that would otherwise be difficult to detect."
MusicGlove uses a glove with sensors on the fingers and thumb. The therapy works much like the popular video console game, Guitar Hero. But instead of using a guitar-shaped game controller to ‘play along’ with scrolling notes, a MusicGlove patient completes specific movements as scrolling notes are timed to the rhythm of upbeat songs. Different songs feature different pinch combinations at different tempos. In addition there are three levels of difficulty. It is available for use at home or in a clinic.
Occupational therapist Susan Katzmann of St. Jude Medical Center in Fullerton, California, has used the clinic version for about a year. She uses it one-on-one with patients but can also set them up to use it independently. "I really like it for two reasons," she said. "It gives objective feedback by individual finger: ‘You hit this many notes in this much time.’ And second, the patient can get several hundred repetitions in 15-30 minutes. And the brain likes high reps for maximum healing and recovery." She notes that the fine motor skills it develops transfer to functional movements like carrying a coffee mug or zipping a zipper.
That mirrors Johnson’s experience: "I’m a cashier and after three weeks I noticed I was scanning items and putting them in bags with my right hand. The basic things that most able-bodied people take for granted — moving my fingers independently, for one — started becoming easier almost right away," she said. That was huge for her. "I lived my whole life one-handed, so to use my right hand was so fantastic. When I noticed that, I was absolutely ecstatic."
The auditory and motor centers of the brain are linked — think tapping your foot to the music. That means the music is an important part of the process. "When a person listens to a song, the parts of the brain that are responsible for movement start firing," said Nizan Friedman, Ph.D., president and co-founder of Flint Rehabilitation Devices LLC. "Since music is naturally highly repetitive, people using MusicGlove typically make over 2000 movements in a 45-minute session."
The options for hand therapy are pretty limited, especially for use at home. Often survivors are given Play-Doh or rubber bands and a handout of exercises. People lose motivation to do exercises at home and so don’t get the reps necessary to recover to their full potential.
MusicGlove saves game scores and other information, which allows therapists and users to track progress over time and set goals. Its objective data can be correlated to functional improvement, which can be used to support a request to an insurer for more therapy. "Insurance companies like objective data," Katzmann said.
"With MusicGlove, both patients and clinicians can detect small improvements in hand function that would otherwise be difficult to detect," said Friedman. "This feedback motivates the user to continue their therapy and to continue improving."
That’s certainly true for Johnson. She uses her MusicGlove for an hour a day, and after six weeks she’s at the medium level of difficulty. It is repetitive motion, which she hated as a child, "but because there’s music, it’s like I’m playing a game. I get engaged. It doesn’t feel like therapy, it’s fun."
MusicGlove is FDA-listed as a Class I device that can be sold over the counter. Because it is a non-obtrusive device, an FDA approval process was not required, although it complies with all regulations set forth by the Class I FDA classification. It is not currently covered by Medicare or other insurance. The cost is $1,100 for the home unit. Flint Rehabilitation does offer a payment plan of $99 a month for 12 months. Discounts are also available for individuals on limited income.
Exoskeleton Improves Gail Training
The Ekso GT robotic therapy exoskeleton
Gravity is pretty unforgiving, and that makes gait training tricky, because people — even small people — are heavy. In the past, survivors have been put in hoists and supported over treadmills, but this method produced poor results. In the past few years, exoskeletons have been developed by several companies, including Ekso Bionics and Honda. These devices, which are strapped to the torso, augment not only the individual’s strength, but the therapist’s ability to work with his or her patients.
Karen J. Nolan, Ph.D., a research scientist in human performance and engineering research at Kessler Foundation in New Jersey, has been investigating the Ekso GT by Ekso Bionics in survivors. "This device is well suited to address gait retraining, especially gait retraining for the person who has one side that is not functioning or is not as strong, as the other side," Nolan said. "A robotic exoskeleton allows the therapist to provide different levels of assistance to the impaired versus less impaired limb."
The Ekso GT consists of a backpack and two leg sections that go down the outside of each leg and strap at the thigh, below the knee and at the foot. The battery in the backpack powers motors in the legs. When the patient’s weight shifts, sensors in the device activate to initiate steps.
In the Kessler Foundation study, the Ekso GT is being used during the acute phase of rehab when the injured brain is most plastic, sometimes called the "golden period." Survivor William James of Plainfield, New Jersey, began using the device this past February, just a week after his stroke. He has right hemiplegia that affected his ability to walk. He had traditional gait training therapy, as well, but felt the Ekso GT, which he used three times, made a noticeable difference. "It got me standing and walking up straight," he said. He saw improvements after each session.
Because the exoskeleton provides support during standing, the therapist can concentrate more on the patient’s walking pattern and focus on re-training healthy mobility. Nolan’s team has implemented the exoskeleton into inpatient gait training, but outcomes are still preliminary. "We have found that patients using the exoskeleton are able to take more steps in a given gaittraining session" Nolan said.
Nolan is examining the way the exoskeleton keeps individuals "in plane." What often happens after stroke is that survivors relearn how to walk, but in the process acquire different compensations so their walking pattern is neither symmetrical nor as energy efficient as it used to be. "When we can get patients in the Ekso GT early on, we may be able to retrain a better quality gait because the rigid aspect of the exoskeleton keeps their legs walking in a symmetrical pattern," Nolan said. "It is designed to keep their limbs in the correct plane of movement and may prevent a gait pattern that would be considered unhealthy or abnormal."
Patients have to shift their weight to trigger the device to step. They are not just going for a ride. "They actually have to actively participate in taking each step," Nolan said. "We have observed that their limbs are walking in a better sequence symmetrically with the exoskeleton in contrast to when they are being guided to walk by the therapist. That’s important in order to get task-specific movements with good repetition. The ongoing research will be measuring these changes more comprehensively."
Survivor William James uses the Ekso GT as part of his therapy under the supervision of Dr. Karen Nolan (right)
Because the exoskeleton provides support during standing, the therapist can concentrate more on the patient’s walking pattern and focus on re-training healthy mobility.
"We’re using this at a critical time in recovery while the brain is healing," Nolan said. "Our goal is to show that providing quality gait training during this critical period may positively change the course of the recovery so that patients recover quicker and gain back healthy mobility."
In addition to using the Ekso GT, survivor James has done gait training on a treadmill and walking with a cane. He found the exoskeleton to be the most rewarding. He says it motivated him to do more therapy. "The more I do, the better I get," he said.
The Ekso GT is currently allowed to be used for gait training while it is being evaluated for a new FDA classification. It is not available for home use but is currently in use at 80 centers around the world.
The potential of these three devices to enhance the therapy experience of survivors by tailoring therapy to their individual abilities and deficits needs further scientific study. Devices that provide an unprecedented amount of accurate feedback may allow therapists to be more effective. And if they can ultimately make therapy fun, that could be a very good thing.
Recently a number of new devices, designed with the hope of improving outcomes, have become available in the realm of rehabilitation therapy.
http://strokeconnection.strokeassociation.org/Summer-2015/Motivate-to-R…
BY JON CASWELL
Share on twitterShare on gmailShare on emailShare on gluvsnapMore Sharing Services0
The MusicGlove rehab therapy device for hands (above)
Recently a number of new devices, designed with the hope of improving outcomes, have become available in the realm of rehabilitation therapy. Though further scientific study is necessary to understand the true potential impact of these devices, some of them appear to be showing some promise for the future. They use computers, sensors and tiny motors to change how survivors do therapy. The three devices that we explore here are worn by the patient and all provide detailed feedback that serves to motivate survivors to keep working at therapy.
Not that long ago, stroke survivors were told whatever they got back in the first six months was as good as it would get. Now we know those first six months are golden because the brain is most plastic then. Doing as many repetitions of therapy exercises as possible during this period may maximize recovery.
One secret to more reps is to make them more fun. New therapy devices are attempting to do that by applying gamification principles. Gamification uses game elements, like rewards and positive reinforcement, to make therapy more fun and engaging.
Making Homework a 'Get-To'
Harriet and Marc Manis
As is often the case with stroke, insurance for rehab ran out before Marc Manis of Winter Springs, Florida, had made much recovery. At age 46, Manis had a left-hemisphere stroke due to a carotid dissection in September 2001. He did about six weeks of inpatient therapy and worked with home therapists for another two months. "That’s when they said ‘We’ve taken him as far as we can,’" said Harriet, his wife of 28 years. "They said to keep doing repetitive motion." At that point he had no controllable movement in his right arm and hand. He could make a fist, but he couldn’t intentionally open his fist, nor could he move his arm and shoulder at all. After years of investigating rehab devices, Harriet saw an ad for MediTouch.
MediTouch offers four devices — Hand Tutor, Arm Tutor, Leg Tutor and 3D Tutor. These FDA-approved devices are connected to the computer, and this allows the therapist to turn the instructions for customized repetitive exercises into rehabilitation games. The purchase price — $2,000 per device — includes instructions on setting up the system, however, extra therapy sessions need to be purchased to enable the patient and the caregiver to practice intensively with the MediTouch system. The devices themselves are currently considered experimental and are not reimbursed by insurance.
Physiologist Alan Waterman has been using the MediTouch for eight years. "The MediTouch Tutors are movement biofeedback devices," Waterman said. "They measure the patient’s movement, then we demonstrate the correct movements and set up the exercise in the memory so the family can do the exercises on their own. The instructions are in the system and the system gives them feedback on how well they are doing. In essence we’re creating a biofeedback learning loop."
Waterman does an hour-long therapy session over Skype with Marc every Sunday morning using different devices. Together they define what Marc wants to accomplish, and then Waterman designs exercises to reach those goals given Marc’s current abilities. During the next week, Marc and Harriet do homework based on the exercises that have been programmed into each device. Since Marc can’t put the devices on by himself, they do this after she gets home from work.
Each MediTouch device stores the data from each homework session, which Waterman can retrieve online. "This allows me to see what they are doing and how well they’re doing," Waterman said.
MediTouch incorporates games to promote repetitive motion, and this motivates Marc. "If you tell someone, ‘Go do your arm exercises,’ they’ll eventually stop doing it altogether without something to keep them motivated," Harriet said. "With MediTouch when I get home from work, Marc’s asking me to do homework."
And that enthusiasm has paid off in functional changes. "He’s able to move his arm, which he wasn’t able to do before. It was just hanging there," Harriet said. "His balance is much better; he hasn’t fallen the way he used to. And because he can manipulate his leg a little bit and his arm, he’s actually gotten up the few times he has fallen. At the gym on Saturday, I see him actually lifting his arm and putting it on the equipment himself, which he couldn’t do before."
MediTouch always includes some therapy in order to train the family. "This system allows us to teach family members how to do the exercises exactly right," Waterman said. "It is motivating to the patient to know what exercises to do, how to do those exercises and to get feedback on how well they are doing them. All of this motivates them to do their homework." And just like in high school, doing your homework pays off.
Practicing Pinches to the Music
Occupational therapist Susan Katzmann believes the MusicGlove offers numerous benefits.
At age 25, Rachel Johnson had never used her right hand for more than gross motor movement. Her whole right side was weak because of a hemorrhagic stroke when she was an infant. Then her mother saw an ad for MusicGlove, an over-the-counter rehab device for hands. She ordered a free, 15-day trial and quickly noticed an improvement. Using crowdfunding she raised the $1,100 purchase price. "I haven’t done any therapy in 15 years, because I quit when I was 10 years old — it was just too boring," said Johnson of Stony Point, New York.
"With MusicGlove, both patients and clinicians can detect small improvements in hand function that would otherwise be difficult to detect."
MusicGlove uses a glove with sensors on the fingers and thumb. The therapy works much like the popular video console game, Guitar Hero. But instead of using a guitar-shaped game controller to ‘play along’ with scrolling notes, a MusicGlove patient completes specific movements as scrolling notes are timed to the rhythm of upbeat songs. Different songs feature different pinch combinations at different tempos. In addition there are three levels of difficulty. It is available for use at home or in a clinic.
Occupational therapist Susan Katzmann of St. Jude Medical Center in Fullerton, California, has used the clinic version for about a year. She uses it one-on-one with patients but can also set them up to use it independently. "I really like it for two reasons," she said. "It gives objective feedback by individual finger: ‘You hit this many notes in this much time.’ And second, the patient can get several hundred repetitions in 15-30 minutes. And the brain likes high reps for maximum healing and recovery." She notes that the fine motor skills it develops transfer to functional movements like carrying a coffee mug or zipping a zipper.
That mirrors Johnson’s experience: "I’m a cashier and after three weeks I noticed I was scanning items and putting them in bags with my right hand. The basic things that most able-bodied people take for granted — moving my fingers independently, for one — started becoming easier almost right away," she said. That was huge for her. "I lived my whole life one-handed, so to use my right hand was so fantastic. When I noticed that, I was absolutely ecstatic."
The auditory and motor centers of the brain are linked — think tapping your foot to the music. That means the music is an important part of the process. "When a person listens to a song, the parts of the brain that are responsible for movement start firing," said Nizan Friedman, Ph.D., president and co-founder of Flint Rehabilitation Devices LLC. "Since music is naturally highly repetitive, people using MusicGlove typically make over 2000 movements in a 45-minute session."
The options for hand therapy are pretty limited, especially for use at home. Often survivors are given Play-Doh or rubber bands and a handout of exercises. People lose motivation to do exercises at home and so don’t get the reps necessary to recover to their full potential.
MusicGlove saves game scores and other information, which allows therapists and users to track progress over time and set goals. Its objective data can be correlated to functional improvement, which can be used to support a request to an insurer for more therapy. "Insurance companies like objective data," Katzmann said.
"With MusicGlove, both patients and clinicians can detect small improvements in hand function that would otherwise be difficult to detect," said Friedman. "This feedback motivates the user to continue their therapy and to continue improving."
That’s certainly true for Johnson. She uses her MusicGlove for an hour a day, and after six weeks she’s at the medium level of difficulty. It is repetitive motion, which she hated as a child, "but because there’s music, it’s like I’m playing a game. I get engaged. It doesn’t feel like therapy, it’s fun."
MusicGlove is FDA-listed as a Class I device that can be sold over the counter. Because it is a non-obtrusive device, an FDA approval process was not required, although it complies with all regulations set forth by the Class I FDA classification. It is not currently covered by Medicare or other insurance. The cost is $1,100 for the home unit. Flint Rehabilitation does offer a payment plan of $99 a month for 12 months. Discounts are also available for individuals on limited income.
Exoskeleton Improves Gail Training
The Ekso GT robotic therapy exoskeleton
Gravity is pretty unforgiving, and that makes gait training tricky, because people — even small people — are heavy. In the past, survivors have been put in hoists and supported over treadmills, but this method produced poor results. In the past few years, exoskeletons have been developed by several companies, including Ekso Bionics and Honda. These devices, which are strapped to the torso, augment not only the individual’s strength, but the therapist’s ability to work with his or her patients.
Karen J. Nolan, Ph.D., a research scientist in human performance and engineering research at Kessler Foundation in New Jersey, has been investigating the Ekso GT by Ekso Bionics in survivors. "This device is well suited to address gait retraining, especially gait retraining for the person who has one side that is not functioning or is not as strong, as the other side," Nolan said. "A robotic exoskeleton allows the therapist to provide different levels of assistance to the impaired versus less impaired limb."
The Ekso GT consists of a backpack and two leg sections that go down the outside of each leg and strap at the thigh, below the knee and at the foot. The battery in the backpack powers motors in the legs. When the patient’s weight shifts, sensors in the device activate to initiate steps.
In the Kessler Foundation study, the Ekso GT is being used during the acute phase of rehab when the injured brain is most plastic, sometimes called the "golden period." Survivor William James of Plainfield, New Jersey, began using the device this past February, just a week after his stroke. He has right hemiplegia that affected his ability to walk. He had traditional gait training therapy, as well, but felt the Ekso GT, which he used three times, made a noticeable difference. "It got me standing and walking up straight," he said. He saw improvements after each session.
Because the exoskeleton provides support during standing, the therapist can concentrate more on the patient’s walking pattern and focus on re-training healthy mobility. Nolan’s team has implemented the exoskeleton into inpatient gait training, but outcomes are still preliminary. "We have found that patients using the exoskeleton are able to take more steps in a given gaittraining session" Nolan said.
Nolan is examining the way the exoskeleton keeps individuals "in plane." What often happens after stroke is that survivors relearn how to walk, but in the process acquire different compensations so their walking pattern is neither symmetrical nor as energy efficient as it used to be. "When we can get patients in the Ekso GT early on, we may be able to retrain a better quality gait because the rigid aspect of the exoskeleton keeps their legs walking in a symmetrical pattern," Nolan said. "It is designed to keep their limbs in the correct plane of movement and may prevent a gait pattern that would be considered unhealthy or abnormal."
Patients have to shift their weight to trigger the device to step. They are not just going for a ride. "They actually have to actively participate in taking each step," Nolan said. "We have observed that their limbs are walking in a better sequence symmetrically with the exoskeleton in contrast to when they are being guided to walk by the therapist. That’s important in order to get task-specific movements with good repetition. The ongoing research will be measuring these changes more comprehensively."
Survivor William James uses the Ekso GT as part of his therapy under the supervision of Dr. Karen Nolan (right)
Because the exoskeleton provides support during standing, the therapist can concentrate more on the patient’s walking pattern and focus on re-training healthy mobility.
"We’re using this at a critical time in recovery while the brain is healing," Nolan said. "Our goal is to show that providing quality gait training during this critical period may positively change the course of the recovery so that patients recover quicker and gain back healthy mobility."
In addition to using the Ekso GT, survivor James has done gait training on a treadmill and walking with a cane. He found the exoskeleton to be the most rewarding. He says it motivated him to do more therapy. "The more I do, the better I get," he said.
The Ekso GT is currently allowed to be used for gait training while it is being evaluated for a new FDA classification. It is not available for home use but is currently in use at 80 centers around the world.
The potential of these three devices to enhance the therapy experience of survivors by tailoring therapy to their individual abilities and deficits needs further scientific study. Devices that provide an unprecedented amount of accurate feedback may allow therapists to be more effective. And if they can ultimately make therapy fun, that could be a very good thing.