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Rehab Technology: Current Evidence and Use in Adult Practice

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Megan Molnar

on 30 January 2014

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Transcript of Rehab Technology: Current Evidence and Use in Adult Practice

Rehab Technology: Current Evidence and Use in Adult Practice

Diana Boyer, OTS, Megan Molnar, OTS, Barbie Rohm, OTS

References
Nintendo Wii
OmniVR™
Armeo ®®Power

BTE PrimusRS
Dynavision D2
Who We Are...
Diana Boyer, OTS
Level IIA: UPMC Mercy- Inpatient Stroke Rehab

Level IIB- HCR ManorCare Whitehall- SNF/ Long-term care
Megan Molnar, OTS
Level IIA: CRS-UPMC St. Margaret's at Chapel Harbor- Adult OP

Level IIB: Aspire Pediatric Therapy- Pediatric OP
Barbie Rohm, OTS
Level IIA: HealthSouth Sewickley- Inpatient/ Outpatient Rehab

Level IIB: Friendship Ridge-Short-term/Long-term care facility
Who You Are...
Students?
Practitioners?
OT Faculty?
How many practitioners here currently use forms of rehab technology in their daily OT practice?

Examples of specific types?

With what client populations/diagnoses?

Current Use of Technology
Educational Objectives
Identify specific rehabilitation technologies commonly used in the adult practice setting and nontraditional uses of these technologies.

Understand how rehabilitation technology can be used across the continuum of care (inpatient rehab, outpatient rehab, SNF) to provide the most beneficial and up to date interventions.

Explain the benefits of utilizing rehabilitation technology as well as understanding the advantages and disadvantages of implementing technological interventions across the continuum of care in the adult practice setting.

Rehab Technology
Nintendo Wii
Omni VR
Armeo Power
BTE PrimusRS
Dynavision D2
A virtual rehabilitation system designed specifically for aging adults.
Has the capability to:
Recreate the client’s movements in a 3-D
Provide a real-time interactive experience giving enhanced feedback and increasing motivation
Grade the level of repetition and duration of exercises

OmniVR
TM
Six different skilled exercise modes:
Seated exercise
Wheelchair propulsion and control
Upper extremity
Balance
Walking
Cardio
Outcomes Measurement
TUG
Functional Reach
STS

Video Example
Current Best Evidence
Turolla, A., Dam, M., Ventura, L., Tonin, P., Agostini, M., Zucconi, C., Kiper, P., Cagnin, A., & Piron, L. (2013). Virtual reality for the rehabilitation of the upper limb motor function after stroke: A prospective controlled trial.
Journal of Neuro Rehabilitation, 10
(85). Doi:10.1186/1743-0003-10-85
Key factors:
Large number of subjects - 376 in a rehab hospital
VR compared to conventional UE therapy
Both treatments significantly improved FIM scores of participants, but improvement obtained with VR was greater than with conventional therapy alone.
VR was successful, but a combination of the rehab technology and conventional therapies worked best

Current Best Evidence
Ellyson, T. (2013).
Virtual therapy
. Washington, DC: McClatchy Tribune Business News.
Key factors:
Different than the Wii or Kinect in that it is specifically designed for use with aging adults.
Clients displayed improved participation and interaction during therapy.
Used to have group sessions with client competing against one another during specific gaming modes.


Armeo®Power

A rehabilitative exercise device that provides intelligent arm support in a large 3D workspace.
Typically intended for clients who have experienced strokes, traumatic brain injuries, and any other nerological disorders resulting in
hand impairments.

Video Example


Early rehabilitation with highly repetitive training for severely affected patients.
Improved therapy efficiency and patient care.
An extensive 3D workspace.
Augmented Performance Feedback with motivating exercises to train activities of daily living.
Assist-as-needed support provided by the robotic arm exoskeleton that automatically adapts to the patients’ capabilities.
Objective analysis and documentation of the patient’s progress.

Advantages to Using Armeo®Power:
Current Best Evidence
Staubli P., Nef, T., Klamroth-Marganska V., & Riener R. (2009). Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: Four single cases.
Journal of Neurological Rehabilitation, 6
(46).

Key factors:
Intensive training is required - eight weeks of training, three to four therapy sessions per week, with at least one hour of training with the device per session.
Three out of four patients had a successful outcome after use of the rehab robot (p < 0.05)
Improvements were maintained from discharge to a six-month follow up.

Current Best Evidence
Colomer, C., Baldovi, A. Torrome, S., Navarrow, M. D., Moliner, B., Ferri, J., & Noe, E. (2013). Efficacy of ArmeoSpring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis.
Neurologia, 28
(5), 261-267.

Key Factors:
23 clients who had experienced stroke completed 36 sessions, each one hour, with the Armeo robot assisted arm.
Arm movement was measured before and after the study, as well as after a four month follow-up, and found to have made significant gains.
Use of the Armeo provided the clients with gains in functional activities.

Summary
The Armeo®Power has been proven as a useful tool to use in the inpatient rehabilitation setting for clients with upper extremity deficits, specifically in relation to a neurological impairment.
Current evidence supports the use of this rehab tool in OT practice.
In order to gain best results, an intensive protocol must be used with the clients (many hours of routine training).
If using this tool during intervention, the practitioner must follow the specific protocol provided with the device to gain the best outcomes.

Questions?
Comments?
Concerns?
Do you have any suggestions or examples of alternative uses of any of these technologies in practice?

Has your opinion of using technology in practice changed?

Do you feel that you would consider implementing any of these technologies in your practice?
Technologies Across Adult Practice Settings
Inpatient Rehab
Nintendo Wii

ArmeoPower

Dynavision D2
SNF/ Long-Term Care
Omni VR
Nintendo Wii

Outpatient Rehab
BTE Primus
Dynavision D2
Advantages and Disadvantages of
Using Technology
Disadvantages
Cost
Maintenance and technical support
Fear of Technology
Time constraints
Trial and error
Advantages
Motivating and fun
Objective outcome measures
Research
Unlimited possibilities
BTE PrimusRS
A rehabilitation device that allows for the ability to replicate many functional tasks or ADL’s
Multi-functional piece of equipment, with the ability to evaluate and treat patients
Provides objective measures and tracks progress
Multi-disciplinary tool used by PTs, ATs, and OTs
Ability to Replicate Functional Activities
Has set of tool attachments that are fully adjustable
Has four resistance modes: Isometric, Isotonic, CPM, and Isokinetic

Sample Activities
Sample Work Related Activities

Sample Leisure Activities

Sample ADLs/IADLs

Sample Therapeutic Exercises/Preparatory Methods

Use as an Evaluation Tool
Has numerous research-supported testing and treatment protocols
Sample Assessments
Isometric- static testing of upper extremity including: hand, wrist, forearm, elbow, and shoulder
Consistency of Effort testing
Maximum & Repetitive Lift testing (FCEs)

Provides Objective Measures
Clients’ performance is automatically recorded and tracked
Objective reports are stored and can be retrieved at any time to review progress
In evaluation mode, offers real time, visual feedback on screen allowing you to immediately see and assess your client’s level of performance
In treatment/exercise mode, client can view real time visual feedback and progress graphs to keep them motivated

Use in OT
Hand and Upper Extremity Rehab
CVA, SCI, hand injuries, etc.
Industrial Rehab/Work hardening
FCEs
Many other uses

Example of Use for Driver Rehab
Supporting Evidence
Shechtman, O., Davenport, R., Malcolm, M., & Nabavi, D. (2003). Reliability and validity of the BTE-Primus grip tool.
Journal of Hand Therapy, 16
(1), 36-42.
Examined the reliability and validity of isometric grip tool of the BTE-Primus, in comparison to the Jamar dynamometer
The results of this study indicate that clinicians can use the BTE-Primus grip attachment at the second handle setting and know that is reliable, valid, and comparable to the second-handle setting of the Jamar dynamometer

Shechtman, O., Hope, L., & Sindhu, B. (2007). Evaluation of the torque-velocity test of the BTE-Primus as a measure of sincerity of effort of grip strength.
Journal Of Hand Therapy, 20
(4), 326-335.

The purpose was to examine whether the the torque-velocity test of the BTE-Primus would be an effective method for assessing sincerity of effort
Examine if differences exist in the linear torque-velocity relationship between maximal and submaximal grip strength effort
Findings suggest that the torque-velocity test of the BTE-Primus can distinguish between maximal and submaximal efforts during grip-strength testing
However, findings questioned adequate sensitivity for clinical use
Bradshaw, J. (2005, August). A powerful tool.
Advance for Directors in Rehabilitation.

Overview of the BTE Primus provided by a clinic that implemented its use.
Benefits:
Provides resistance through entire range of motion, compared to other units they have tried
User friendly
Has extensive patient education capabilities including: interactive human anatomy models making it easier to demonstrate cause of injury
Overall, has had a positive impact on patients and increased referrals to the clinic
BTE PrimusRS Summary
Advantages

Research supports use as an evaluation tool
Allows the ability to complete many functional activities with one piece of equipment
Provides objective measurements and data to track progress
Provides visual feedback that can be motivating for clients

BTE PrimusRS Summary
Disadvantages

Limited evidence-based research on use as rehab tool in comparison to traditional methods
Expensive- $35,000+

Dynavision D2
Visuomotor and cognitive training system used to help individuals improve visual and motor function

Originally developed for athletes but has been adapted to provide beneficial treatment to individuals whose visual and motor function have been compromised by neurological disease or traumatic injury

Video Example
Advantages
Current Best Evidence
Anderson, L., Cross, A., Wynthein, D., Schmidt, L., & Grutz, K. (2011). Effects of dynavision training as a preparatory intervention status postcerebrovascular accident: A case report. 
Occupational Therapy in Health Care,25
(4), 270-282.

67-year-old woman status post (R) CVA
3 Dynavision sessions per week for 6 weeks
Broad battery of assessments used pre- and posttest to assess progress
Improvements demonstrated in:
AROM
Functional activity tolerance
Awareness of neglected side
Performance skills
Perceived occupational performance
Perceived satisfaction with engagement
in occupation
Disadvantages
Basics of the Dynavision D2
Clinical Diagnoses
Driver Rehabilitation
CVA
TBI/ABI
Spinal Cord Injury
Visual field deficits or other visual impairments
Vestibular and balance disorders
UE and LE Amputations
Multiple Scerlosis
Orthopedic conditions involving shoulder and arm movement
Mode A
Targets remain lit indefinitely
Flash option

Mode B
Targets remain lit for predetermined time
Flash option + green lights

Mode C
Follow targets that change direction every 15 seconds

Reaction Time

Eye-hand coordination
Peripheral awareness
Ocular motor skills
Visual reaction time
Motor Planning
Muscular and physical endurance
Balance
UE ROM and coordination
Decision making under stress
Concentration while fatigued
Skill Deficits
Vesia, M., Esposito, J., Prime, S. L., & Klavora, P. (2008). Correlations of selected psychomotor and visuomotor tests with initial dynavision performance. Perceptual and Motor Skills, 107(1), 14-20.
36 men & 52 women (M age=20.5 years)
Investigated relationship between Dynavision scores and 6 conventional psychometric tests
Dynavision performance was significantly correlated with performance on the psychometric tests







Nintendo Wii
“Wii-habilitation”
Commercially available gaming system
Encourages players to use natural actions to play games

Video Example
Trunk balance
Standing balance
Upper extremity strengthening
Upper extremity range of motion
Gross motor coordination
Eye-hand coordination
Endurance
Visual-perceptual training
Cognitive training

Uses in OT
Fung, V., So, K., Park, E., Ho, A., Shaffer, J., Chan, E., & Gomez, M. (2010). The utility of a video game system in rehabilitation of burn and nonburn patients: a survey among occupational therapy and physiotherapy practitioners.
Journal of Burn Care & Research, 31
(5), 768-775.
Current Evidence
Investigated perceptions of occupational therapists and physical therapists on the use of Nintendo Wii™
OTs and PTs in a rehabilitation hospital trialed four Wii games that addressed physical movement, balance, coordination, and cognitive performance
Then, they completed an opinion survey on the utility of Wii in rehabilitation

Results
Participants reported:
Wii was easy to set up (71%), operate (68%), and safe to use (76%)
Useful in outpatient settings (76%) and inpatient settings (65%)
Improved treatment compliance (73%)
Believed skills learned were transferred to daily function (60%)

Conclusion
Overall, practitioners favored the use of Wii in rehabilitation as an adjunct to traditional therapy because it is therapeutic, engaging, and may increase patient participation in rehabilitation.

Mouawad, M., Doust, C., Max, M., & McNulty, P. (2011). Wii-based movement therapy to promote improved upper extremity function post-stroke: a pilot study.
Journal Of Rehabilitation Medicine, 43
(6), 527-533.
Seven patients (5 men, 2 women, aged 42–83 years; 1–38 months post-stroke, mean 15.3 months)
2 weeks of Wii based movement therapy performed 60 minutes per day


Functional ability improved for every patient.
The mean performance time significantly decreased per Wolf Motor Function Test task, Fugl-Meyer Assessment scores increased, and upper extremity range-of-motion increased significantly for passive and active movements, respectively.
Mean Motor Activity Log (Quality of Movement scale) scores increased reflecting a transfer of functional recovery to everyday activities.
Results
Conclusion
A 2-week protocol resulted in significant and clinically relevant improvements in functional motor ability post-stroke. These gains translated to improvement in activities of daily living.

Advantages
Low- cost commercially available gaming system
Reasonable prices allow for use of device at home for carryover of rehabilitation
Encourages players to use natural actions
Variety of uses
Increases patient motivation

Summary
Disadvantages
Not specifically designed for rehabilitation
Motions and actions required are not focused on rehabilitation outcomes (e.g. increasing range of motion or muscle strength)
Game difficulty is calibrated to healthy players making many games unplayable or too challenging for patients with physical disabilities
The game scores or progress measurements that are often provided are too generic, making them insufficient for tracking patient progress

Other Options
Large, height adjustable light board

Password-protected computer system

User info is stored, viewed and graphed, making patient progress easy to track

Can be used with a variety of diagnoses, deficits, characteristics, etc.

Fun and motivating!
Cost (> $14,500)
Limited research in rehabilitation setting
Lack of norms



Anderson, L., Cross, A., Wynthein, D., Schmidt, L., & Grutz, K. (2011). Effects of dynavision training as a preparatory intervention status postcerebrovascular accident: A case report. Occupational Therapy in Health Care,25(4), 270-282.

Baltimore Therapeutic Equipment. (2012). PrimusRS. Retrieved January 29, 2014, from BTE website: http://www.btetech.com/primusrs.htm

Bradshaw, J. (2005, August). A powerful tool. Advance for Directors in Rehabilitation.

Colomer, C., Baldovi, A. Torrome, S., Navarrow, M. D., Moliner, B., Ferri, J., & Noe, E. (2013). Efficacy of ArmeoSpring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia, 28(5), 261-267.

Dynavision D2 vision training system. (n.d.). Retrieved January 28, 2014, from Bioness website: http://www.bioness.com/Healthcare_Professionals/Dynavision_D2_Visuomotor_System.php

Dynavision d2 [Fact sheet]. (2010, April 23). Retrieved January 28, 2014, from Bioness website: http://www.bioness.com/Documents/RehabCtrProducts/dynavsn_trfld.pdf
Ellyson, T. (2013). Virtual therapy. Washington, DC: McClatchy Tribune Business News.


Fung, V., So, K., Park, E., Ho, A., Shaffer, J., Chan, E., & Gomez, M. (2010). The utility of a video game system in rehabilitation of burn and nonburn patients: a survey among occupational therapy and physiotherapy practitioners. Journal of Burn Care & Research, 31(5), 768-775.

Mouawad, M., Doust, C., Max, M., & McNulty, P. (2011). Wii-based movement therapy to promote improved upper extremity function post-stroke: a pilot study. Journal Of Rehabilitation Medicine, 43(6), 527-533.

Performance Enterprises. (2010). Dynavision d2 operators manual, rev1:0:5 [Brochure]. Ontario, Canada: Dynavision.

Rehabilitation. (n.d.). Retrieved January 28, 2014, from Dynavision International website: http://dynavisioninternational.com/resources/medical/rehabilitation/

Shechtman, O., Davenport, R., Malcolm, M., & Nabavi, D. (2003). Reliability and validity of the BTE-Primus grip tool. Journal of Hand Therapy, 16(1), 36-42.

Shechtman, O., Hope, L., & Sindhu, B. (2007). Evaluation of the torque-velocity test of the BTE-Primus as a measure of sincerity of effort of grip strength. Journal Of Hand Therapy, 20(4), 326-335.

Staubli P., Nef, T., Klamroth-Marganska V., & Riener R. (2009). Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: Four single cases. Journal of Neurological Rehabilitation, 6(46).

Turolla, A., Dam, M., Ventura, L., Tonin, P., Agostini, M., Zucconi, C., Kiper, P., Cagnin, A., & Piron, L. (2013). Virtual reality for the rehabilitation of the upper limb motor function after stroke: A prospective controlled trial. Journal of Neuro Rehabilitation, 10(85). Doi:10.1186/1743-0003-10-85

Vesia, M., Esposito, J., Prime, S. L., & Klavora, P. (2008). Correlations of selected psychomotor and visuomotor tests with initial dynavision performance. Perceptual and Motor Skills, 107(1), 14-20.
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