Although motor learning theory has led to evidence-based practices, few trials have revealed the superiority of one theory-based therapy over another after stroke. Nor have improvements in skills ...been as clinically robust as one might hope. We review some possible explanations, then potential technology-enabled solutions. Over the Internet, the type, quantity, and quality of practice and exercise in the home and community can be monitored remotely and feedback provided to optimize training frequency, intensity, and progression at home. A theory-driven foundation of synergistic interventions for walking, reaching and grasping, strengthening, and fitness could be provided by a bundle of home-based Rehabilitation Internet-of-Things (RIoT) devices. A RIoT might include wearable, activity-recognition sensors and instrumented rehabilitation devices with radio transmission to a smartphone or tablet to continuously measure repetitions, speed, accuracy, forces, and temporal spatial features of movement. Using telerehabilitation resources, a therapist would interpret the data and provide behavioral training for self-management via goal setting and instruction to increase compliance and long-term carryover. On top of this user-friendly, safe, and conceptually sound foundation to support more opportunity for practice, experimental interventions could be tested or additions and replacements made, perhaps drawing from virtual reality and gaming programs or robots. RIoT devices continuously measure the actual amount of quality practice; improvements and plateaus over time in strength, fitness, and skills; and activity and participation in home and community settings. Investigators may gain more control over some of the confounders of their trials and patients will have access to inexpensive therapies.
Rehabilitation for sensorimotor impairments aims to improve daily activities, walking, exercise, and motor skills. Monitoring of practice and measuring outcomes, however, is usually restricted to ...laboratory-based procedures and self-reports. Mobile health devices may reverse these confounders of daily care and research trials.
Wearable, wireless motion sensor data, analyzed by activity pattern-recognition algorithms, can describe the type, quantity, and quality of mobility-related activities in the community. Data transmission from the sensors to a cell phone and the Internet enable continuous monitoring. Remote access to laboratory quality data about walking speed, duration and distance, gait asymmetry and smoothness of movements, as well as cycling, exercise, and skills practice, opens new opportunities to engage patients in progressive, personalized therapies with feedback about the performance. Clinical trial designs will be able to include remote verification of the integrity of complex physical interventions and compliance with practice, as well as capture repeated, ecologically sound, ratio scale outcome measures.
Given the progressively falling cost of miniaturized wearable gyroscopes, accelerometers, and other physiologic sensors, as well as inexpensive data transmission, sensing systems may become as ubiquitous as cell phones for healthcare. Neurorehabilitation can develop these mobile health platforms for daily care and clinical trials to improve exercise and fitness, skills learning, and physical functioning.
Rehabilitation trials and postacute care to lessen impairments and disability after stroke, spinal cord injury, and traumatic brain injury almost never include training to promote long-term ...self-management of skills practice, strengthening and fitness. Without behavioral training to develop self-efficacy, clinical trials, and home-based therapy may fail to show robust results.
Behavioral theories about self-management and self-efficacy for physical activity have been successfully incorporated into interventions for chronic diseases, but rarely for neurologic rehabilitation. The elements of behavioral training include education about the effects of practice and exercise that are relevant to the person, goal setting, identification of possible barriers, problem solving, feedback about performance, tailored instruction, decision making, and ongoing personal or social support. Mobile health and telerehabilitation technologies offer new ways to remotely enable such training by monitoring activity from wearable wireless sensors and instrumented exercise devices to allow real-world feedback, goal setting, and instruction.
Motivation, sense of responsibility, and confidence to practice and exercise in the home can be trained to increase adherence to skills practice and exercise both during and after formal rehabilitation. To optimize motor learning and improve long-term outcomes, self-management training should be an explicit component of rehabilitation care and clinical trials.
The Promise of mHealth Dobkin, Bruce H.; Dorsch, Andrew
Neurorehabilitation and neural repair,
11/2011, Letnik:
25, Številka:
9
Journal Article
Recenzirano
Mobile health tools that enable clinicians and researchers to monitor the type, quantity, and quality of everyday activities of patients and trial participants have long been needed to improve daily ...care, design more clinically meaningful randomized trials of interventions, and establish cost-effective, evidence-based practices. Inexpensive, unobtrusive wireless sensors, including accelerometers, gyroscopes, and pressure-sensitive textiles, combined with Internet-based communications and machine-learning algorithms trained to recognize upper- and lower-extremity movements, have begun to fulfill this need. Continuous data from ankle triaxial accelerometers, for example, can be transmitted from the home and community via WiFi or a smartphone to a remote data analysis server. Reports can include the walking speed and duration of every bout of ambulation, spatiotemporal symmetries between the legs, and the type, duration, and energy used during exercise. For daily care, this readily accessible flow of real-world information allows clinicians to monitor the amount and quality of exercise for risk factor management and compliance in the practice of skills. Feedback may motivate better self-management as well as serve home-based rehabilitation efforts. Monitoring patients with chronic diseases and after hospitalization or the start of new medications for a decline in daily activity may help detect medical complications before rehospitalization becomes necessary. For clinical trials, repeated laboratory-quality assessments of key activities in the community, rather than by clinic testing, self-report, and ordinal scales, may reduce the cost and burden of travel, improve recruitment and retention, and capture more reliable, valid, and responsive ratio-scaled outcome measures that are not mere surrogates for changes in daily impairment, disability, and functioning.
Rehabilitation after Stroke Dobkin, Bruce H
New England journal of medicine/The New England journal of medicine,
04/2005, Letnik:
352, Številka:
16
Journal Article
Recenzirano
Odprti dostop
A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited ...to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?
A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes, but four days later he still could not walk or use his right arm. What advice would you offer him and his family regarding rehabilitation?
Foreword
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.
Stage
A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?
The Clinical Problem
Approximately 400 persons per 100,000 population over the age of 45 years have a first stroke each year in the United States, Europe, and Australia. Stroke is the . . .
Brain–computer interfaces (BCIs) are a rehabilitation tool for tetraplegic patients that aim to improve quality of life by augmenting communication, control of the environment, and self‐care. The ...neurobiology of both rehabilitation and BCI control depends upon learning to modify the efficacy of spared neural ensembles that represent movement, sensation and cognition through progressive practice with feedback and reward. To serve patients, BCI systems must become safe, reliable, cosmetically acceptable, quickly mastered with minimal ongoing technical support, and highly accurate even in the face of mental distractions and the uncontrolled environment beyond a laboratory. BCI technologies may raise ethical concerns if their availability affects the decisions of patients who become locked‐in with brain stem stroke or amyotrophic lateral sclerosis to be sustained with ventilator support. If BCI technology becomes flexible and affordable, volitional control of cortical signals could be employed for the rehabilitation of motor and cognitive impairments in hemiplegic or paraplegic patients by offering on‐line feedback about cortical activity associated with mental practice, motor intention, and other neural recruitment strategies during progressive task‐oriented practice. Clinical trials with measures of quality of life will be necessary to demonstrate the value of near‐term and future BCI applications.
Rehabilitation after hemiplegic stroke has typically relied on the training of patients in compensatory strategies. The translation of neuroscientific research into care has led to new approaches and ...renewed promise for better outcomes. Improved motor control can progress with task-specific training incorporating increased use of proximal and distal movements during intensive practice of real-world activities. Functional gains are incorrectly said to plateau by 3–6 months. Many patients retain latent sensorimotor function that can be realised any time after stroke with a pulse of goal-directed therapy. The amount of practice probably best determines gains for a given level of residual movement ability. Clinicians should encourage patients to build greater strength, speed, endurance, and precision of multijoint movements on tasks that increase independence and enrich daily activity. Imaging tools may help clinicians determine the capacity of residual networks to respond to a therapeutic approach and help establish optimal doseresponse curves for training. Promising adjunct approaches include practice with robotic devices or in a virtual environment, electrical stimulation to increase cortical excitability during training, and drugs to optimise molecular mechanisms for learning. Biological strategies for neural repair may augment rehabilitation in the next decade.
Purpose of Review
Measurements obtained during real-world activity by wearable motion sensors may contribute more naturalistic accounts of clinically meaningful changes in impairment, activity, and ...participation during neurologic rehabilitation, but obstacles persist. Here we review the basics of wearable sensors, the use of existing systems for neurological and rehabilitation applications and their limitations, and strategies for future use.
Recent Findings
Commercial activity-recognition software and wearable motion sensors for community monitoring primarily calculate steps and sedentary time. Accuracy declines as walking speed slows below 0.8 m/s, less so if worn on the foot or ankle. Upper-extremity sensing is mostly limited to simple inertial activity counts. Research software and activity-recognition algorithms are beginning to provide ground truth about gait cycle variables and reveal purposeful arm actions. Increasingly, clinicians can incorporate inertial and other motion signals to monitor exercise, activities of daily living, and the practice of specific skills, as well as provide tailored feedback to encourage self-management of rehabilitation.
Summary
Efforts are growing to create a compatible collection of clinically relevant sensor applications that capture the type, quantity, and quality of everyday activity and practice in known contexts. Such data would offer more ecologically sound measurement tools, while enabling clinicians to monitor and support remote physical therapies and behavioral modification when combined with telemedicine outreach.
Novel molecular, cellular, and pharmacological therapies to stimulate repair of sensorimotor circuits after stroke are entering clinical trials. Compared with acute neuroprotection and thrombolysis ...studies, clinical trials for repair in subacute and chronic hemiplegic participants have a different time course for delivery of an intervention, different mechanisms of action within the milieu of the injury, distinct relationships to the amount of physical activity and skills practice of participants, and need to include more refined outcome measures. This review examines the biological interaction of targeted rehabilitation with neural repair strategies to optimize outcomes. We suggest practical guidelines for the incorporation of inexpensive skills training and exercise at home. In addition, we describe some novel outcome measurement tools, including wearable sensors, to obtain the more detailed outcomes that may identify at least some minimal level of success from cellular and regeneration interventions. Thus, proceeding in the shadow of acute stroke trial designs may unnecessarily limit the mechanisms of action of new repair strategies, reduce their impact on participants, and risk missing important behavioral outcomes.
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