Stroke Rehab Management

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Contents

Introduction

With Stroke, rehabilitation aims at restoring motor and cognitive functions[1][2][3][4]. After the acute treatment in the months following a stroke, there is a progressive shift of the intervention from the inpatient setting to the outpatient setting and the home when a stroke home care program is available. The implementation of interventions in the home environment requires technology to monitor patients and facilitate the administration of rehabilitation protocols[5].


Issues

Effectively implementing interventions and improving outcomes in individuals post stroke requires relying on measures of the recovery of motor and cognitive functions in response to interventions. The use of monitoring technology (e.g. wearable sensors) is attractive in this context because it opens the possibility of assessing individual responses and consequently adjusting rehabilitation interventions on the basis of data gathered in the home and community settings. Data collected in such context has the potential to reflect the impact of interventions on the real life of stroke survivors.

The administration of rehabilitation interventions can be facilitated by computer and robotic technologies. Their use in the home settings can potentially extend duration and intensity of rehabilitation thus leading to larger gains in motor and cognitive functions. Technologies to facilitate the administration of rehabilitation protocols in the home setting and methods to evaluate the effectiveness of such interventions are under development.


Justification

Given the need to limit the increase in healthcare costs, prolonged and intensive rehabilitation interventions cannot be delivered solely by relying on services provided in inpatient or outpatient settings. Researchers are faced with the challenge of developing low-cost, home-based interventions that have an impact similar if not superior to that achieved by using traditional therapeutic interventions and more recently introduced rehabilitation approaches that require a significant amount of high-cost labor as it is the case for specialized clinical personnel.

Related Elderly Aspects

Enabling Technologies

Research

Monitoring technology (e.g. wearable, miniature sensors[6]) has been recently developed that could facilitate stroke rehabilitation. Researchers have designed and implemented systems for tracking limb movements using inertial sensors. Others have focused on the development of e-textile solutions to capture movement characteristics in individuals post stroke. Similarly, researchers have implemented and tested several robotic systems aimed at facilitating stroke rehabilitation [7][8][9][10][11]. Several agencies support this work, including the European Commission, the National Institutes of Health[12], the National Science Foundation, and the Japan Science and Technology Agency.

Commercial

Although several companies have developed wearable sensors, there are no commercially available systems to unobtrusively monitor motor gains in subjects post stroke providing methods to assess motor gains associated with rehabilitation.

Noticeable companies in the field of wearable systems are RealTime and Smartex. RealTime licensed from Intel a wireless sensor platform called SHIMMER (Sensing Health with Intelligence, Modularity, Mobility, and Experimental Reusability) that monitors real-time motion and physiological data. This platform is marked by low-power consumption and large storage capacity. Smartex develops e-textile solutions to monitor individuals over extended periods of time.

A few companies produce systems that rely on robotics for stroke rehabilitation. Among others, Hocoma, Interactive Motion Technologies, and Motorika have developed systems that are now utilized in several clinical centers. Hocoma's flagship product is the Lokomat, a robotic gait orthosis that facilitates treadmill gait retraining in patients with neurological conditions such as spinal cord injury, stroke, and multiple sclerosis. Hocoma has recently launched a robotic system for upper extremity rehabilitation, the Armeo system[13]. The Armeo is an exoskeleton that provides weight support to facilitate the performance of therapeutic exercises in individuals with hemiparesis. Interactive Motion Technologies is a spin-off of MIT's Newman Laboratory for Biomechanics and Human Rehabilitation. This company manufactures the MANUS system[14][15][16], a robot for upper extremity rehabilitation. Motorika’s product is the ReoTherapy system, a joystick-like robot that patients hold with their hand thus providing guidance during performance of therapeutic exercises of the hemiparetic arm.

The Hocoma Lokomat's(TM)robotic gait orthosis system


Currently available systems are not developed as yet for application in the home environment. These technologies are currently adopted by academic clinical centers for experimentation, but are not part as yet of standard therapy programs. When technologies ready for home therapy will be introduced, it is likely that associated costs will be covered via billing in the same way as currently done for traditional therapeutic interventions. It is conceivable that these services will be initially provided by requiring out-of-pocket payment by patients and their families as it is unlikely at this point in time that specific reimbursement codes will be soon available to cover these treatment modalities.

Standards

Although the development of standard protocols concerning the use of monitoring and robotic technologies to facilitate stroke rehabilitation is of paramount importance, the field is still in its infancy and no standards have been developed so far. Future work is necessary to define procedures that would allow one to obtain reliable assessment data concerning individual patient response to rehabilitation interventions in the home setting. Rehabilitation interventions in the home setting that use robotics and computer systems should be standardized.

Gaps

Further advances are needed to make it possible to use monitoring, computer, and robotic technologies for stroke rehabilitation in the home setting. These technologies are still too obtrusive and insufficiently user-friendly to envision their use in the medical home.

Although pilot studies have reported preliminary evidence of increased motor gains associated with the use of the above-mentioned technologies over traditional therapy, larger clinical trials are needed to determine clinical criteria for its use. For instance, researchers have still not fully investigated the complex relationship among therapy dosage, expected motor gains, and baseline impairment and functional limitation levels.


Future Vision

Current trends indicate that the duration of inpatient stay and the number of outpatient visits reimbursed by healthcare systems across the world are decreasing. It is expected that growing emphasis will be put on developing home-based interventions to provide intensive therapy, which is known to be associated with increased improvements in motor and cognitive outcomes. Monitoring systems, robotic and computer technologies to deliver interventions will be developed soon to the extent necessary for adoption as complementary to interventions delivered in a clinical setting.


Related Aspects of Ageing in CAPSIL:



Related Enabling Technologies in CAPSIL:


References

  1. ↑ J. Blennerhassett and W. Dite, "Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial," Aust J Physiother, vol. 50, pp. 219-24, 2004.
  2. ↑ J. H. Cauraugh, S. B. Kim, and J. J. Summers, "Chronic stroke longitudinal motor improvements: cumulative learning evidence found in the upper extremity," Cerebrovasc Dis, vol. 25, pp. 115-21, 2008.
  3. ↑ N. E. Mayo, S. Wood-Dauphinee, S. Ahmed, C. Gordon, J. Higgins, S. McEwen, and N. Salbach, "Disablement following stroke," Disabil Rehabil, vol. 21, pp. 258-68, 1999.
  4. ↑ S. Young and K. H. Kong, "Emerging therapies in stroke rehabilitation," Ann Acad Med Singapore, vol. 36, pp. 58-61, 2007.
  5. ↑ C. R. Carignan and H. I. Krebs, "Telerehabilitation robotics: bright lights, big future?," J Rehabil Res Dev, vol. 43, pp. 695-710, 2006.
  6. ↑ P. Bonato, "Advances in wearable technology and applications in physical medicine and rehabilitation," J Neuroeng Rehabil, vol. 2, pp. 2, 2005.
  7. ↑ J. Hidler, D. Nichols, M. Pelliccio, and K. Brady, "Advances in the understanding and treatment of stroke impairment using robotic devices," Top Stroke Rehabil, vol. 12, pp. 22-35, 2005.
  8. ↑ B. Husemann, F. Muller, C. Krewer, S. Heller, and E. Koenig, "Effects of locomotion training with assistance of a robot-driven gait orthosis in hemiparetic patients after stroke: a randomized controlled pilot study," Stroke, vol. 38, pp. 349-54, 2007.
  9. ↑ R. J. Jaeger, "Rehabilitation robotics research at the National Institute on Disability and Rehabilitation Research," J Rehabil Res Dev, vol. 43, pp. xvii-xx, 2006.
  10. ↑ H. I. Krebs, N. Hogan, B. T. Volpe, M. L. Aisen, L. Edelstein, and C. Diels, "Overview of clinical trials with MIT-MANUS: a robot-aided neuro-rehabilitation facility," Technol Health Care, vol. 7, pp. 419-23, 1999.
  11. ↑ H. Schmidt, C. Werner, R. Bernhardt, S. Hesse, and J. Kruger, "Gait rehabilitation machines based on programmable footplates," J Neuroengineering Rehabil, vol. 4, pp. 2, 2007.
  12. ↑ M. Weinrich, "National Institutes of Health support of rehabilitation robotics research," J Rehabil Res Dev, vol. 43, pp. xxi-xxii, 2006.
  13. ↑ R. J. Sanchez, J. Liu, S. Rao, P. Shah, R. Smith, T. Rahman, S. C. Cramer, J. E. Bobrow, and D. J. Reinkensmeyer, "Automating arm movement training following severe stroke: functional exercises with quantitative feedback in a gravity-reduced environment," IEEE Trans Neural Syst Rehabil Eng, vol. 14, pp. 378-89, 2006.
  14. ↑ M. L. Aisen, H. I. Krebs, N. Hogan, F. McDowell, and B. T. Volpe, "The effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke," Arch Neurol, vol. 54, pp. 443-6, 1997.
  15. ↑ S. E. Fasoli, H. I. Krebs, and N. Hogan, "Robotic technology and stroke rehabilitation: translating research into practice," Top Stroke Rehabil, vol. 11, pp. 11-9, 2004.
  16. ↑ H. I. Krebs, M. Ferraro, S. P. Buerger, M. J. Newbery, A. Makiyama, M. Sandmann, D. Lynch, B. T. Volpe, and N. Hogan, "Rehabilitation robotics: pilot trial of a spatial extension for MIT-Manus," J Neuroeng Rehabil, vol. 1, pp. 5, 2004.

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