Physiotherapy for the severely paretic arm and hand in patients with acquired brain injury - Virtual reality combined with task specific practice

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1 Physiotherapy for the severely paretic arm and hand in patients with acquired brain injury - Virtual reality combined with task specific practice Christian Gunge Riberholt, PT MR

2 Nakayama et al, 1994 (Copenhagen Stroke Study)

3 Nakayama et al, 1994 (Copenhagen Stroke Study)

4 Nakayama et al, 1994 (Copenhagen Stroke Study)

5 Barriers After stroke, patients and physical therapists are concerned about ambulation It is cheaper (for society) if the patient can walk and transfer himself Physical therapists lack skill, equipment, time or interest

6 3-6 month window for regaining function Wade DT, Wood VA, Hewer RL. Recovery after stroke-the first 3 months. J Neurol Neurosurg and Psychiatry 1985;48:7-13. Olsen TS. Arm and leg paresis as outcome predictors in stroke rehabilitation. Stroke 1990;21: Is this true? Chronic stroke ( years after stroke) Klamroth-Marganska V et al, 2014 Lo AC et al, 2010

7 So why does robot and intensive therapy still show an effect years after injury?

8 Motor recovery Repetitions Active participation Variation Feedback 8

9 Birkenmeier et al. 2010

10 Active participation is important! Perez et al 2004

11 Variation Practice at its simplest is just performing the same movement repeatedly. Although this may be the most effective way to improve performance during the training session itself, it is not optimal for retaining learning over time. Krakauer Hanlon et al. 1996

12 Augmented Feedback Immediate effects More interested, work harder, persist longer Gives guidance (or right/wrong) High frequency of feedback (100%) better results on performance Long term effects (learning) High frequency of feedback (100%) lower transfer effect Salmoni et al

13 UE function and daily use Overall goal Timing in rehabilitation efforts Patient preferences End of rehabilitation

14

15 Rand D & Eng JJ, 2015

16 Rand D & Eng JJ, 2015

17 Homework based exercise booklet Severe, moderate, mild n=53 n=50 Harris JE et al, 2009

18 Department of Neurorehabilitation / TBI unit Not a classical stroke unit setting Patients primarily admitted with low consciousness GCS < 9 Severe cognitive deficits and paresis

19 Planning the intervention Who gets to decide what to do? Goals determine the intervention Goals should be guided by the team

20 Severe UE paresis Individual PT Individual OT Class practice Other staff members Neuroeducator Nurses Robot as ekstra PT and OT sessions

21 L1 Flaccid MMT 0-1 L2 Paresis, hypertonia MMT 2-3 L3 low dexterity, stamina, strength MMT 4-5 ICF Body function and structure Body function and structure Body function and structure / Activity level Primary purpose Facilitate activity / Induce plastic changes Induce plastic changes Improve dexterity, stamina, strength, dual-task etc. Interv. Sensory stimulation FES Mental practice Mirror therapy Task specific practice Robot Task specific practice Robot Wii Laptop CIMT Task specific practice Activities Cognitive challenging Strengthening exercise Using PC as feedback tool

22 L1 Flaccid MMT 0-1 L2 Paresis, hypertonia MMT 2-3 L3 low dexterity, stamina, strength MMT 4-5 ICF Body function and structure Body function and structure Body function and structure / Activity level Primary purpose Facilitate activity / Induce plastic changes Induce plastic changes Improve dexterity, stamina, strength, dual-task etc. Interv. Sensory stimulation FES Mental practice Mirror therapy Task specific practice Robot Task specific practice Robot Wii Laptop CIMT Task specific practice Activities Cognitive challenging Strengthening exercise Using PC as feedback tool

23 Robot technology and virtual reality

24 Summary Challenge for patients with severely impaired UE to get better. Challenge for therapists Increasing intensity Getting the timing right Choosing the intervention Threshold for daily use activity

25 Additionally, robots do not get tired, can generate more repetitions then can a therapist in the same time, offer accurate feedback about patients performance, and can be fun to use. Kwakkel & Meskers, 2014

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