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Scientific Evidence for New Technologies
2
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
4
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
6
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
Scientific Evidence of New Technologies
8
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
9
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)
10
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
11
• 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 €
Scientific Evidence of New Technologies
13
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)
Scientific Evidence of New Technologies
15
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)
Scientific Evidence of New Technologies
18
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)
Scientific Evidence of New Technologies
20
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)
21
Contact
International Industry Society in Advanced Rehabilitation Technology
(IISART)
General [email protected]
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.
22
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