Scientific Evidence for New Technologies

Scientific Evidence for New Technologies

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Audience

Clinicians

Scientists

Engineers

Others

Learning Goal:Know the current scientific

evidence for new technologies in rehabilitation.

3

Societal drivers

Drivers for New Technologies

Technological drivers

Clinical drivers

• Ageing of population

• Cost of health care

• Burden in daily life

• Available technology

• Fast growing• Home use

• Unused recovery potential

• Evidence-based knowledge

Scientific Evidence for New Technologies

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Usage of New Technologies

motor learning brain injury therapy assessments daily activities

New technologies for enhanced and effective

therapy …

… and assessing recovery progress

Scientific Evidence for New Technologies

Principles of New Technologies 5

Potential influence of New Technologies

Advanced Rehabilitation

Technology

Varied, goal oriented

repetitions at limit of

performance&

Feedback from successful

performance

Reduce supportIncrease challenge

Muscle strength

Neuroplasticity

Motor Learning

Improved performance

Movement & sensory input

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1. Robot-assisted Therapy

2. Non-actuator Devices

3. Functional Electrical Stimulation (FES)

4. Virtual Reality

5. Brain Stimulation

Contents

Scientific Evidence for New Technologies

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ROBOT-ASSISTED THERAPY

1

Scientific Evidence for New Technologies

Scientific Evidence of New Technologies

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Robot-Assisted Therapy: Lower Extremity

Walking improvements

Positive effect on gait speed, walking distance and basic activities of daily living

Rehabilitation Time

Non-ambulatory patients in early rehabilitation profit most from robot-assisted therapy

Dependency

Every fifth dependency in walking could be avoided using robotic-assisted training

Effectiveness

Robotic therapy in combination with conventional therapy is more effective than physiotherapy alone

(Mehrholz et al. 2013)

Scientific Evidence of New Technologies

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Robot-Assisted Therapy: Upper Extremity

Proximal Improvements

Significant effect on motor function of shoulder and elbow, muscle strength and pain reduction

Distal Improvements

Elbow and wrist training enhances motor function and muscle strength

Transfer to Daily Life

Improves generic activities of daily living and arm function

(Veerbeek et al. 2014)

Risk

No increased risk of injury with intensive training

Recovery Time

Robotic therapy improves motor function in a shorter time than physiotherapy(Mehrholz et al.

2012)

(Veerbeek et al. 2014)

(Mehrholz et al. 2012)

(Sale et al. 2014)

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Cost effectiveness

years to break even0

1

22.08

1.6Robot-as-sisted therapyConven-tional therapy

• Conventional gait training therapy costs are low

• Robot-assisted therapy fixed costs (device purchase price) are high

• In the long term robot-assisted therapy is cost effective

1st year 2nd year 3rd year 4th year 5th year-250000

-150000

-50000

50000

150000

250000

350000

450000

Robot-assisted therapy Conventional therapy

Profit

Loss

Scientific Evidence for New Technologies

• Cost

[€]

Time from start of treatment [Years]

Type of gait training

Years

to b

reak e

ven

(Morrison 2011, Wagner et al. 2011)

Cost effectivness II

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• Costs for 5 weeks of robot-assisted training with a moderate-to-low cost device can be recovery by a dehospitalization of 1.2 days earlier. Any further reduction would result in money savings (Stefano et al. 2014).

“Robotic technology can be a valuable and economically sustainableaid in the management of poststroke patient rehabilitation.”, Stefano et al. 2014

Scientific Evidence for New Technologies

Series1

328.04 €

273.64 €

5 weeks of robotic rehabilitation1 day of hospitalization

Co

st

(€)

Time

0 5 10 15 20 25 30

Chart Title

5 weeks robotic therapy 1 day of hospitalization

Time (days)

273.64 €328.04 €

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NON-ACTUATOR DEVICES

2

Scientific Evidence for New Technologies

Scientific Evidence of New Technologies

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Clinical Evidence of Non-Actuator Devices

Effectiveness

Matches gains of conventional therapy

Functionality

Arm weight support improves hand movements important for functional ability

Range of Motion

Increases range of motion for hand and arm movements

Undesired Synergies

Possibly reduces abnormal coupling between shoulder and elbow

(Prange et al. 2014)

(Kloosterman et al. 2010, Krabben et al. 2012)

(Bartolo et al. 2014)

(Krabben et al. 2012)

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FUNCTIONAL ELECTRICAL STIMULATION (FES)

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Scientific Evidence for New Technologies

Scientific Evidence of New Technologies

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Clinical Evidence of FES

Wrist and Hand

Positive effect on muscle strength and motor function

Functionality

Improves upper extremity function and motor processing

Pain

Significant reduction of pain

(Arantes et al. 2007) Spasticity

Decreased spasticity

Walking Speed

Surface-applied and implanted FES increases walking speed

(Wilson et al. 2014)

(Ring and Weingarden 2007)

(Daly and Ruff 2007, Hara 2008)

(Kottink 2007, Veerbeek et al. 2014)

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VIRTUAL REALITY

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Scientific Evidence for New Technologies

Scientific Evidence of New Technologies

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Clinical Evidence of Virtual Reality

Cognitive aspects

Supports cognitive rehabilitation

Upper Extremity

Improves upper extremity function and motor processing

Environment

VR environments stimulates neuroplastic change and enhances learning effects

Lower Extremity

Improves walking speed and muscle strength, therefore improving overall quality of life

(Rose et al. 1998)

(Rose et al. 1998)

(Kuttuva et al. 2006)

(Sviestrup 2004)

Motivation

Increases self confidence and motivation

(Riva 1998)

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BRAIN STIMULATION

5

Scientific Evidence for New Technologies

Scientific Evidence of New Technologies

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Clinical Evidence of Brain Stimulation

Pain

Relieves 20-58% of chronic pain

Optimal Effect

Best gains if paired with relevant behavioral experiences

Severely impaired

Improvements even for patients with severe motor deficits

Motor Function

Improves motor function which can last for several weeks

(Fregni et al. 2006)

(Hummel et al. 2006, Boggio et al. 2006)

+(Gladstone and Black 2000)

(Fregni et al. 2006)

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Contact

International Industry Society in Advanced Rehabilitation Technology

(IISART)

General Informationinfo@iisartonline.orgwww.iisartonline.org

Scientific Evidence for New Technologies

Literature[1] Mehrholz et al. 2013, Electromechanical-assisted training for walking after stroke.

[2] Verbeek et al. 2014, What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis.

[3] Mehrholz et al. 2012, Electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength after stroke.

[4] Sale et al. 2014, Effects of upper limb robot-assisted therapy on motor recovery in subacute stroke patients.

[5] Wagner et al. 2011, An economic analysis of robot-assisted therapy for long-term upper-limb impairment after stroke.

[6] Bartolo et al. 2014, Arm weight support training improves functional motor outcome and movement smoothness after stroke.

[7] Kloosterman et al. 2010, Influence of gravity compensation on kinematics and muscle activation patterns during reach and retrieval in subjects with cervical spinal cord injury: an explorative study.

[8] Krabben et al. 2012, Influence of gravity compensation training on synergistic movement patterns of the upper extremity after stroke, a pilot study.

[9] Prange et al. 2014, The effect of arm

support combined with rehabilitation games on upper-extremity function in subacute stroke: a randomized controlled trial.

[10] Daly and Ruff 2007, Construction of efficacious gait and upper limb functional interventions based on brain plasticity evidence and model-based measures for stroke patients.

[11] Kottink et al. 2007, A randomized controlled trial of an implantable 2-channel peroneal nerve stimulator on walking speed and activity in poststroke hemiplegia.

[12] Hara 2008, Neurorehabilitation with new functional electrical stimulation for hemiparetic upper extremity in stroke patients.

[13] Ring and Weingarden 2007, Neuromodulation by functional electrical stimulation (FES) of limb paralysis after stroke.

[14] Arantes et al. 2007, Effects on Functional Electrical Stimulation applied to the wrist and finger muscles on hemiparetic subjects: a systematic review of the literature.

[15] Wilson et al. 2014, Peripheral nerve stimulation compared with usual care for pain relief of hemiplegic shoulder pain: a randomized controlled trial.

[16] Kuttuva et al. 2006, The Rutgers

Arm, a Rehabilitation System in Virtual Reality: A Pilot Study.

[17] Sviestrup 2004, Motor Rehabilitation Using Virtual Reality.

[18] Rose et al. 1998, Virtual environments in brain damage rehabilitation: a rational from basic neuroscience.

[19] Riva 1998, Virtual reality in paraplegiga: a VR-enhanced orthopaedic appliance for walking and rehabilitation.

[20] Fregni et al. 2006, A sham-controlled, phase II trial of transcranial direct current stimulation for the treatment of central pain in traumatic spinal cord injury.

[21] Boggio et al. 2006, Hand function improvement with low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere in a severe case of stroke.

[22] Gladstone and Black 2000, Enhancing recovery after stroke with noradrenergic pharmacotherapy: a new frontier?

[23] Fregni al. 2006, A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia

[24] Hummel et al. 2006, Effects of brain polarization on reaction times and pinch force in chronic stroke.

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Image sources

Slide 2 – AudienceBackground: http://www.iisd.ca/ymb/climate/wcc3/pix/1sept/DSC_6266%20full%20room.jpg

Slide 3 – Reasons for New TechnologiesLeft: http://www.unece.org/typo3temp/pics/8346dcaa95.jpgMiddle (upper): http://emergingtech.tbr.edu/sites/default/files/styles/flexslider_full/public/NewTech_0.jpg?itok=WghHlgJOMiddle (lower): http://timpexelectronics.com/wp-content/uploads/2014/03/Electronics-0000166421891-1100x732.jpgRight: http://www.nature.com/sc/journal/v41/n12/fig_tab/3101518f1.html

Slide 4 – Usage of New Technologies1st image (motor learning): http://www.vi-hotels.com/typo3temp/pics/s_1ad5acb5b7.jpg2ndimage (brain injury): http://www.eusi.org/wp-content/uploads/2012/11/stroke.jpg3rd image (therapy): Hocoma4th image (assessments): http://www.hopkinsmedicine.org/healthlibrary/GetImage.aspx?ImageId=2683295th image (daily activities): http://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2013/10/28/1382979259350/Gardening-and-DIY-can-pro-011.jpg

Slide 5 – Usage of New Technologies IIImages: Presentation slides

23Scientific Evidence for New Technologies