Who we are…

Alison McDonald

Physiotherapist, Clinical Specialist (Neurosciences), on ABI Inpatient and

Outpatient Services at the Nova Scotia Rehabilitation and Arthritis Centre.

Alayne MacDonald

S-LP with inpatient and outpatient ABI Rehab Services & AAC Consultant

Natalie Thornley

Occupational Therapist in Outpatient ABI Services and Interprofessional Clinical

Leader for ABI services at NSHA.

Faculty/Presenter Disclosure

Faculty: Alayne MacDonald, Natalie Thornley, Alison

McDonald

Relationships with financial sponsors:

Grants/Research Support: None

Speakers Bureau/Honoraria: None

Consulting Fees: None

Patents: None

Other: None

CFPC CoI Templates: Slide 1 – used in Faculty presentation only.

Disclosure of Financial Support The development of the iWalk research study program

received financial support from CIHR and Ontario Stroke Network in the form of research grant funds.

Potential for conflict(s) of interest:

Alison McDonald has participated in the research study for iWalk: A guide to an Evidence-Informed Approach to Using the 10-metre and 6-Minute Walk Test Post-Stroke Research Study and gave input into development of the iWalkAssess app but receives no funding past/present/future for this.

Mitigating Potential Bias:

The iWalkAssess app is being presented as part of a series of apps that are being discussed.

CFPC CoI Templates: Slide 2

The Use of Apps to Support

Stroke Rehabilitation and

Recovery

Learning objectives

Participants will be able to:

Identify the characteristics of a good app for stroke rehabilitation and recovery.

Identify a selection of apps suitable for stroke rehabilitation and recovery including apps for stroke education, assessment, treatment and community living skills.

Why are we using apps?

An estimated 80% of the world population has a mobile phone. 5

Patients and families are looking to us for advice on the use apps

to assist in their recovery.

The use of apps can be an effective supplement to direct care;

especially with the aging population and growing demand on

our resources.

Why are we using apps?

The use of apps may help reduce the demands placed on

caregivers to provide “therapy sessions” with the patient

allowing the caregiver more time to fulfill other roles.

The use of apps may increase patient autonomy.

The use of apps is a way to modernize our “toolkits”

- efficient, less prep work, automatic scoring -

Evidence related to the use of apps

Research appears to be relatively new and rapidly growing in this area

Khalid Ameer and Khalid Ali, iPad Use in Stroke Neuro-Rehabilitation

Geriatrics 2017,2,2

Literature review from 4 databases/104 articles found

Criteria for inclusion: No date restrictions

English publications only

iPad only (no android, smart phone, or PC)

Stroke neuro-rehab trials only

Evidence related to the use of apps (cont’d)

16 eligible articles

Articles were analyzed in terms of iPAD use:

1. Feasibility

2. Acceptability

3. Role in community/home rehab

4. Impact on

Clinical outcomes

Pt engagement

Social isolation/boredom

Evidence related to the use of apps (cont’d)

Conclusions

Apps have the potential to:

Increase Pt engagement for repetitive tasks

Improve rehab outcomes

Reduce post stroke social isolation

What makes a good app?

Developer website is robust and provides empirical evidence

that use of the app leads to clinically meaningful

improvements. 5

Treatment app is designed with evidence based practice

protocols.

The app evolves with feedback and research.

Reliable – Developers are able to keep up with operating

system upgrades.

What makes a good app?

Customizable

Provides data for clinician monitoring.

Age appropriate content, images, voices, feedback.

Engaging, motivating.

What makes a good app?

User friendly /simple / suitable interface for diverse populations.

Seamless performance (fast, no glitches).

Offer a lite version to trial.

Available in multiple languages.

How We Use Apps in Clinical Practice

1. Education targeted to patients and support persons

2. Education and clinical reasoning targeted to practitioners

3. Assessment / screening tools

4. Symptom tracking

5. Intervention Remediation, Compensation, Coping and Adjustment

6. Tools for everyday living

1. Educate Patients & Support Persons

Dysphagia - Northern Speech Services

Neuro Hero One Skill Videos

(3 min – targets specific skills)

Neuro Hero One Skill Videos

3 minute videos targeting supportive communication

techniques:

What can go wrong

How to better support conversation

Reviews key points

Sample Concepts

– write key words, background noise, time to respond, offer

written choices…

https://www.neurohero.com/communication-difficulties/

2. Self Advocacy

Neuro Hero One Skill videos

(3 min – targets specific skills)

I Have Aphasia (1.5 mins)

(Dogfish Mobile Ltd)

3. Education and Clinical Reasoning

– Tactus Dysphagia Therapy

Guides Oral Mechanism Exam (OME) assessment based on relevant

cranial nerves and physiology.

Suggests treatment options based on OME and instrumental findings.

Provides citations for Evidence Based Practice.

Provides patient education instructions/handouts.

Assessment

Assessment

Education and Clinical Reasoning

– Via Therapy

Best practice and evidence-based recovery interventions for

upper extremity stroke rehabilitation.

Suggests treatment options based on your patient’s motor

impairment, time post-stroke and match to patients goals.

Provides opportunity to learn about the latest therapies and

recall established therapies

4. Assessment / Screening

Assessment is arguably the most important step in the

rehabilitation process, as our clinical reasoning is based on the

information it provides and it is also the basis for our decision-

making throughout the rehabilitation process.

Screening: Stroke Riskometer

Function: to assess individual stroke-related risk

Results

Manage

Education

The Stroke Riskometer Pro has been endorsed by:

World Federation of Neurology

International Association of Neurology and

Epidemiology

Auckland University of Technology

New Zealand Stroke Education Trust

Screening

Assessment: Berg

Balance Scale

The Berg Balance Scale is a widely used

clinical test of a person's static and dynamic

balance abilities to determine fall risk.

Presently, usually a paper and pen test

Categorizes results as low/medium/high fall risk

Compare overall score of tests but not each

item

Can secure test results with a PIN entry

requirement for confidentiality and lists results.

Assessment: iWalkAssess

The iWalk Toolkit, developed through a collaboration of stroke rehab researchers.

Led by University of Toronto’s Associate Professor Nancy Salbach, of the Department of Physical Therapy.

Easy-to-use app to help therapists administer walk tests, and interpret test performance for treatment, education, and goal setting.

Assessment: iWalk Assess The 10 metre walk test and the 6 minute walk test Evidence-

based mobility outcome measures for stroke.

The iWalk Assess app is supported by a guide e-book that is is available on the website and contains 4 educational modules that outline an evidence-informed approach to using the 10-metre walk test and 6-minute walk test.

The iWalk Assess app provides:

stroke-specific walk test protocols – written and videos

timing tools

algorithms to automatically compare test performance with walk test typical values, crosswalk speed, distances to walk at community locations, and minimal detectable change values.

The iWalk Assess app makes it easy for therapists to perform the walk tests and quickly interpret test results to support clinical decision-making

5. Symptom tracking

Tracking symptoms alone may not lead to better outcomes. 5

However there are benefits to tracking.

Tracking can provide opportunity for increased awareness, can identify trends in moods and symptoms, which can help in understanding and better informing our decisions around interventions which in turn can improve outcomes.

https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Operations/Clinical-Support-Division/Connected-Health/mHealth-Clinical-Integration

Symptom tracking

T2 Mood Tracker allows users to monitor their moods and symptoms on either pre-loaded or custom built scales.

Depression, Stress, Stroke / Brain Injury, General Well-Being, Fatigue, Pain, plus more.

Users rate their moods / symptoms by swiping a small bar to the left or to the right.

Ratings can be positive / negative / desirable / undesirable.

The ratings are displayed on graphs to help users track their moods / symptoms over time.

Symptom tracking

Notes can be recorded to document daily events, medication

changes and treatments that may be associated with mood

changes, providing accurate information to help health care

providers make treatment decisions.

Integrated FitBit capabilities to allow step tracking in addition to

moods.

Reminders can be set up to input ratings

A PIN can be set to secure mood tracker access on your device.

Post stroke depression

6. Interventions

“ Some things will get better, some things we will make

better, and some things we will learn to live with”

If we break that down….

“Some things will get better” - Remediation

“Some things we will make better“ -Compensatory Approaches

“Some things we will learn to live with” -Coping and Adjustment

Remediation- hand function

There are many therapeutic approaches and treatment

modalities that can be used to improve hand and upper-

limb function following stroke. 10

Task-oriented training involves practicing real-life tasks (such

as answering a telephone), with the intention of acquiring or

reacquiring a skill. 10

Repetitive training, whereby a task is usually divided into

component parts and then reassembled into an overall task

once each component is learned. 10

Remediation- hand function

We are using apps to achieve a higher volume of repetition of

movements, to improve arm activity, to isolate movements

including (finger isolation, wrist extension) and for coordination of

movements in a way that is motivating and enjoyable to the

patients.

Example – Magic Piano by Smule, Pigment or Color Therapy

coloring apps, Tap Typing, Typing Rehab

Remediation – Strategy practice- scanning

We are using apps as a tool to provide the opportunity for individuals for repeated practice of strategies that may assist with difficulties noted with visual attention.

The apps are engaging which may in turn provide motivation to some patients to practice strategies

There is conflicting evidence of the effectiveness of visual scanning interventions. 10

Example - Word Mess, Tactus – Visual Attention Therapy, Category Therapy

Remediation – fitness trackers

Physical activity levels are significantly reduced post-stroke with high levels of time spent inactive and sedentary.

People post-stroke took an average of 5535 steps per day in the subacute phase and 4078 steps per day in the chronic phase

age-matched healthy controls took an

average of 8338 steps per day

6500 – 8500 steps/day are recommended for

people with disability/chronic illness

Average daily walking duration was higher in the chronic phase than subacute phase

Sedentary time was > 78% regardless of time post stroke12

Step counting increases physical activity by ~ 2000-2500 steps/day

Daily monitoring is effective especially combined with purposeful goals

Remediation – SLP-Tactus Therapy Apps

Meet all 12 criteria for “what makes a good app”

Remediation- Tactus Therapy

Evidenced Based – cited within the app

• ACRT - Anagram, copy, and recall treatment

• Cueing hierarchies - semantic, phonemic, orthographic

• Multi-modal presentation

• Semantic feature analysis - nouns and verbs

• Phonological component analysis

• RET - Response Elaboration Treatment

• VNeST -Verbal Network Strengthening Treatment

• Motor Learning principles- Integral Stimulation Therapy

Remediation- Tactus Therapy

Robust Website

• Excellent resources

• Therapy ideas that go beyond the apps

• Newsletter

Remediation –S-LP Other Options

Constant Therapy Small Talk

Lingraphica Dexteria

Remediation –S-LP Other Options

Language Rehabilitation Bundle – Virtual Speech Centre – US

5 apps – word retrieval, verbal reasoning, comprehension, problem solving, reading

Talk Around It-Neuro Hero - UK

Topic/Catgory specific “card decks”

Targets word retrieval, self-cueing, circumlocution

Aphasia Toolkit – Aptus -UK

4 apps

Keyword Understanding, Therapy for Verbs, Noun Trainer home & Noun Trainer personal.

Compensatory- AAC Apps

Personally relevant scripts

Talking photo album – Pictello (AssistiveWare)

Visual Scene displays – Scene & Heard (Therapy Box)

– Snap Scene (Tobii Dynavox)

Simple communication apps - ex Small Talk’s:

Pain Scale, ICU, ADL apps

Aphasia, Common Phrases

Self-cueing apps for speech – ex Small Talk apps

Compensatory- AAC Apps

GPS Enhanced Apps –ex Locabulary

Word and phrases made available by GPS location

Ex local coffee shop

Compensatory- Social Interaction

Mainstream Apps for Social Interaction:

Skype, Facetime – can use multimodal strategies, social

interaction.

Facebook – like comments & images, use of emoticons.

Game apps – ex angry birds with grandchildren.4

Compensatory -Organization & Pacing

Notes (apple ios) Reminders (apple ios)

Wunderlist Alarmed

Medisafe Anylist- shopping list & recipe

Voice memo Pace my day to manage fatigue

Calendar 30/30

Coping &Adjustment -mood, meditation & mindfulness

Virtual Hope Box Mindshift

Headspace Relax melodies

Resources to help you find Apps

https://www.aphasiasoftwarefinder.org/

Tavistock Software Finder

Resources to help you find Apps

https://www.my-therappy.co.uk/medical-condition/stroke-brain-injury

In Summary…

Apps DO have a role to play in stroke rehabilitation

and recovery.

Emerging research indicates use of apps

Increase Pt engagement for repetitive tasks

Improve rehab outcomes.

Reduce post stroke social isolation.

App Caveats

Apps must not replace clinical expertise, judgement and

guidance.

Apps are just one of the tools that clinicians employ.

Apps may not be for everyone – simple non technical supports /

compensation may be faster and easier.

App Caveats

Apps may make false claims that are not based on evidence and best practices. 5 .

Apps may lack of reference for app content. 5 Look for evidenced based references/protocols.

Apps may claim to be appropriate for adults but are based on platform for pediatrics.

Free & inexpensive apps may become obsolete with ios or software updates or have ads, nag window, or in app purchases.

App Caveats

Apps may be designed for limited platforms ( e.g. may be

available on ios but not android or vice versa).

Some apps are web-based and require reliable wifi to operate.

Useful websites

Aphasia Software Finder by The Tavistock Trust for Aphasia https://www.aphasiasoftwarefinder.org/

Constant Therapy (on-line) https://www.constanttherapy.com/

GPS Supported AAC http://locabulary.com/

Lingraphica TalkPath Therapy (on-line) https://therapy.aphasia.com/

Therapy app finder https://www.my-therappy.co.uk/medical-condition/stroke-brain-injury

Self Advocacy/Education https://www.neurohero.com/communication-difficulties/

Useful websites

Neuro Hero EducationResourceshttps://www.pinterest.ca/NeuroHero/pins/?showPulsar=true

Tactus Website https://tactustherapy.com/

Tactus 150+ apps FOR Neuro SLP https://tactustherapy.com/downloads/

Sign-up for emailed Tx Newsletterhttps://tactustherapy.com/newsletter/

Virtual Speech Centre https://www.virtualspeechcenter.com/Apps#

http://www.tbistafftraining.info/SmartPhones/SmartPhones1.htmltoolkit for smart phone in ABI

iWalk http://www.iwalkassess.com/

References

1. Stoyanov, S. R., Hides, L., Kavanagh, D. J., Zelenko, O., Tjondronegoro, D., & Mani, M. (2015). Mobile App Rating Scale: A New Tool for Assessing the Quality of Health Mobile Apps. JMIR MHealth and UHealth, 3(1). doi:10.2196/mhealth.3422

2. Ameer, K., & Ali, K. (2017). IPad Use in Stroke Neuro-Rehabilitation. Geriatrics,2(1), 2. doi:10.3390/geriatrics2010002

3. DesRoches, C. A., Balachandran, I., Ascenso, E. M., Tripodis, Y., & Kiran, S. (2015). Effectiveness of an impairment-based individualized rehabilitation program using an iPad-based software platform. Frontiers in Human Neuroscience, 8. doi:10.3389/fnhum.2014.01015

4. Holland, A., Weinberg, P., & Dittelman, J. (2012). How to Use Apps Clinically in the Treatment of Aphasia. Seminars in Speech and Language, 33(03), 223-233. doi:10.1055/s-0032-1320042

5. Kwan, V., Bichelek, N., Anderson, v. and Yeates, K. A Review of Smartphone Applications for Persons with Traumatic Brain Injury: What is Available and What is the Evidence? J Head Trauma Rehabil – Copyright © 2018 Wolters Kluwer Health. Inc

6. Palmer, R. (2012). Computer therapy versus usual stimulation for people with long standing aphasia. Http://isrctn.org/. doi:10.1186/isrctn91534629

References

7. Short, N., Harmsen, R., Kjellgren, G., Oneill, C., Pinney, H., Rivera, A. D., & Warnaar, V. (2017). Use of Dexteria application to improve fine motor coordination in the nondominant hand. Journal of Hand Therapy, 30(1), 106-108. doi:10.1016/j.jht.2016.03.014

8. Stark, B. C., & Warburton, E. A. (2016). Improved language in chronic aphasia after self-delivered iPad speech therapy. Neuropsychological Rehabilitation, 28(5), 818-831. doi:10.1080/09602011.2016.1146150

9. Wilkins, A., Stokes, P., & Kurland, J. (2014). IPractice: Piloting the Effectiveness of a Tablet-Based Home Practice Program in Aphasia Treatment. Seminars in Speech and Language, 35(01), 051-064. doi:10.1055/s-0033-1362991

10. Canadian Stroke Best Practices – Management of Upper Extremity Following Stroke http://www.strokebestpractices.ca/ October 30, 2018

11. Stroke Engine https://www.strokengine.ca October 30, 2018

12. Fini NA, Holland AE, Keating J, Simek J and Bernhardt J (2017) How Physically Active are People Following Stroke? Systematic Review and Quantitative Synthesis. Physical Therapy. 97;7;707-717

Comments / Questions /Discussion