ABI  and  Upper  Limb  Rehabilita4on  

Computer  Based  Therapy  Devices  &  Constraint  Induced  Therapy  

an  alternate  therapy  to  increase  upper  limb  func;on  

Vicki  Abraham  Managing  Director/Occupa;onal  Therapist  Abraham  OT  Services  Pty  Ltd  

 Agenda  !    Introduc;on  

!    Explana;on  of  Vicki’s  Fellowship  Experience  &      Research  Conducted    

!    Brief  background  on  ABI  !  CI  Therapy  !    Computer  /  Robo;c  Based  Therapy  

!  Client  Case  Studies  

 Fellowship  Informa4on  ISS Institute:

•  is an independent, not-for-profit, national organisation providing opportunities for Australians to gain enhanced skills and experience in traditional trades, professions and leading-edge technologies, through overseas applied research Fellowships.

The George Alexander Foundation International Fellowship 2013

 Fellowship  Informa4on  Fellowship Aims

• To gain a comprehensive understanding relating to the underlying processes of CI Therapy.

• To determine best practice related to the use of Robotic/Computer assisted devices throughout upper limb rehabilitation

• To establish techniques to tie these treatment techniques with functional goals

 Fellowship  Informa4on  Overseas Program • The Taub Clinic at the University of Alabama, • Birmingham, to be trained in CI Therapy

• Germany – robotic/computer based devices • and modified CI Therapy

• Austria – robotic/computer based devices

• Israel – robotic/computer based devices

 ABI  refers  to  any  damage  to  the  brain  that  occurred  aLer  birth.  

 Causes  include  accidents  (trauma;c  brain  injuries),  stroke,  lack  of  oxygen,  brain  bleeds,  ruptured  blood  vessels  in  the  brain,  degenera;ve  neurological  disease  

 Can  affect  cogni;ve,  physical,  emo;onal  and  level  of  independence  

Acquired  Brain  Injury  

6  

Within  Australia      

!  1  in  45  Australians  have  suffered  an  ABI  resul;ng  in  a  limita;on  of  ac;vity  

!  This  equates  to  432,700  people  

!  Almost  ¾  of  this  number  were  aged  under  65  

!  About  20,000  children  under  15  years  of  age  had  an  ABI  

BACKGROUND  

7  (Australian Bureau of Statistics 2003)

Within  Australia      !  27,300  people  under  65  reported  ABI  as  being  their  main  disabling  condi;on  !  For  55%  of  these  people  the  main  cause  for  their  ABI  was  a  road  traffic  accident  !  2004-­‐2005  there  were  almost  21,800  hospital  stays  related  to  TBI  !  2004-­‐2005  almost  12,000  people  with  an  ABI  received  a  disability  pension  

BACKGROUND  

8  (Australian Government, Australian Institute of Health and Welfare, 2007)

!   Stroke  is  a  major  cause  of  chronic  impaired  arm  func;on  

 aLer  stroke  more  than  two-­‐thirds  of  all  pa;ents  have  reduced  upper  extremity  func;on  

!   four  out  of  five  pa;ents  leave  rehabilita;on  with  restricted  arm  func;on  

Stroke  

9  (Mehrholz et. al. 2012)

There is still an urgent need for rehabilitation strategies that match the specific patient needs

Within  Australia      

!  Someone  suffers  a  stroke  every  10  minutes  !  That  is  almost  1,000  cases  in  1  week  !  In  2014  it  is  es;mated  that  over  51,000  people  will  experience  a  stroke  !  It  is  es;mated  that  in  2014  

!   nearly  12,000  people  will  die    from  a  stroke    !   2/3  of  those  who  survive  will  be  disabled  !   The  vast  majority  of  stroke  survivors  live  with  needs  which  are  not  being  met  

         STROKE  BACKGROUND  

10  (Stroke Foundation, 2014)

 Severe  Arm  Paresis  •  90 % of patients have a weakened arm after a

stroke. •  30% – 40 % of these patients have weakness that

is so severe that the limb cannot be used functionally at all.

•  Some patients regain shoulder and elbow movement, the hand usually remains paralysed

•  Increasing function in an upper limb is not an important aspect of rehabilitation

 S.  Hesse,  C.  Werner,  A.  Bardeleben:  Der  schwer  betroffene  Arm  ohne  distale  Willkürak;vität  –  ein  »Sorgenkind«  der  Rehabilita;on  nach  Schlaganfall?!  In:  Neurol  Rehabil  2004;  10  (3):  120-­‐126  (The  severely  affected  arm  without  distal  voluntary  ac;vity  -­‐  a  "  problem  child  "  of  rehabilita;on  aLer  stroke)  

 Severe  Arm  Paresis  ABI vs Stroke

Why is it that, arm paresis following an ABI is not treated with the same clinical

guidelines that it is post stroke?

Upper  Limb  Ac4vity  

   Stroke  Clinical  Guidelines  

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 NEUROPLASTICITY  “Neuroplas;city  is  the  ability  for  the  brain  to  adapt  in  func;on  and  morphology  to  environmental  

influences  such  as  new  experiences  (learning)  and  

compensa;on  aLer  damage”    

Barry  Winkler,  25-­‐28  February  2014,  Level  Two  Training  in  Acquired  Brain  Injury,  Presented  by  Monash  University  Department  of  Occupa;onal  Therapy,  Victoria,  Australia  

INCREASING  FUNCTION  VIA  PLASTICITY  

Rearrangement:  change  of  exis;ng  connec;on    (increased  efficiency)  

Regrowth:  new  connec;ons  (increased  synap;c  density)  

(Dr  Pinter,  Department  of  Neurology,  Graz  University,  2014)  

What  is  Constraint  Induced    Movement  Therapy?  

“Constraint  Induced  Therapy  is  a  rehabilita>on  treatment  approach  that  improves  more-­‐affected  extremity  use  following  a  stroke,  especially  in  life  situa>ons,  by  restric>ng  

movement  of  unaffected  arm.”    

D.  M.  Morris,  E.  Taub,  V.  W.  Mark.  Constraint-­‐induced  movement  therapy:  characterizing  interven;on  protocol  

16  

Research  Background  

17  

During the 1970’s, at the forefront of this research, Dr. Taub in collaboration with A. J. & H. Knapp.

• Animal studies • Human studies

“overcoming learned non-use” of the affected limb

“Massive use-dependent brain reorganization”

CI  Therapy  

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•  Based  on  the  theory  that  an  affected  limb  is  not  being  func;onally  used  due  to  learned  non-­‐use  

•  This  is  believed  to  occur  because  mainstream  rehabilita;on  has  limited  4me  to  focus  on  intensive  upper  limb  rehabilita;on  

•  Intensive  therapy  aimed  to  make  substan;al  improvement  in  func;on  of  the  affected  upper  extremity  

CI  Therapy  

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•  Also  aimed  at  overcoming  perceived  barriers  to  why  a  task  is  not  completed  with  the  affected  upper  extremity  

•  Therapy  con;nues  at  home  by  comple;ng  func4onal  tasks  in  order  to  ensure  that  the  client  con;nues  to  use  their  affected  limb  aLer  therapy  has  ceased  

Based  on  the  theory  of  Neuroplas4city  

CI  Therapy  Protocol  

20  

Adherent-­‐enhancing  behavioral  strategies  (Transfer  package)  

•  Motor  Ac;vity  Log  (daily  administra;on)  

•  Home  diary  

•  Problem  solving  to  see  more-­‐affected  upper  extremity  in  real  world  situa;ons  

•  Behavioral  contract  and  caregiver  contract  

•  Home  skills    assignment  

•  Home  prac;ce    

•  Daily    schedule  

Repe44ve,  task  oriented  training  

•  Shaping    

•  Task  training  

Constraining  use  of  the  less-­‐affected  upper  extremity    

•  Miw  restraint  

•  Any  method  to  con;nually  remind  the  par;cipant  to    use  the  more-­‐affected  upper  extreme  

Inclusion  Criteria  

21  

CIT  Upper  Limb  Protocol    

•  Intensive  Training  Program  

•  Shaping  of  tasks  

•  Transfer  package  

•  Constraining/restraining  the  non-­‐affected  arm  

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Computer  Based  Therapy  Devices  for  Upper  Limb  Rehab  

DEVICE  REQUIREMENTS  !   Assessments  !   Increased  exposure  to  the  desired  movements  

!   Extensive  repe;;on  of  these  movements  

!   Clients  need  to  remain  mo;vated  

!   Internal  vs  External  focus  

!   Immediate  feedback  is  required  

!   Passive  /  Ac;ve  movements  

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DEVICE  REQUIREMENTS  !   Progression  across  devices  !   Recording  of  data  

!   Carry  over  to  func;onal  ac;vi;es  

!   Ease  of  changing  from  leL  to  right  hand  

!   Ability  to  remain  in  wheelchair  

!   Training  requirements  for  therapists  

!   Ease  of  use  by  therapists  

!   Servicing  costs,  upgrades  to  soLware  25  

Tyrosolu;on  :  CBR  

!   AMADEO® !  PABLO® SYSTEM !   TYMO® !  DIEGO®

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!  Pool  of  rehabilita;on  devices  based  on  research  background  

!    Associated  devices  for  upper  extremity  and  occupa;onal  therapy      

!  Addresses  upper  limb  func;on  as  well  as  cogni;ve  func;on  

SOFTWARE  

ASSESSMENTS  

27  

SOFTWARE  INTERACTIVE  THERAPIES  

28  

SOFTWARE  

DOCUMENTATION  &  REPORTING  

29  

AMADEO®  !  simulation of natural gripping movement !  individual finger movement !  adjustable for individual application !  for all phases of rehabilitation:

!  passive (CPM therapy) - assistive - active therapy

!  measurements: !   isometric forces !  range of movement (ROM)

!  integrated real time bio-feedback !  measure progress

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DIEGO®  

!  ac;ve  gravity  compensa;on  !  uni  &  bilateral  and  symmetric  therapies !  individual application !  no  restric;ons  to  the  range  of  movement !  for all phases of rehabilitation:

!  passive – assistive - active therapy

!  full  3D-­‐tracking  !  integrated real time bio-feedback  !  measure progress

31  

PABLO®  

!  sensor  handle  for  ac;ve  therapy  !  integrated real time bio-feedback  !  suitable  for  in-­‐pa;ent,  out-­‐pa;ent,  and  home  therapy !  measure grip forces and range of movement (ROM)  !  make the progress visible

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TYMO®  !  portable  therapy  plate  with  integrated real time bio-feedback  !  suitable  for  in-­‐pa;ent,  out-­‐pa;ent,  and  home  therapy !  applica;on  !  various  star;ng  posi;ons  !  sta;c  and  dynamic  measurements  

!  measure progress  

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HELPING  RECOVER  ABILITIES  !  generate and

modulate muscle force !  develop muscular

endurance !  coordinate muscle

activity !  modulate and control

speed !  respond to external

disturbances !  reach a wide range of

target spaces

!  achieve appropriate forms of dexterity

!  process and integrate sensory information

!  psychological and cognitive function

!  develop cardiovascular and aerobic capacity

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 CBR:  Advantages  !    One  complete  system  for  upper  limb  rehabilita;on  

!    Rehabilita;on  with  evidence,  concept  based  on  RCS    !    One  common  soLware,  easy  to  use  for  therapists  and  pa;ents  

!  Therapy  with  fun,  mo;va;ng    

for  pa;ents  

Case  Study  1  

•  26  years  old  male   Fell  off  a  3-­‐4  meter  balcony  

Medical  Background    ABI  post  fall  in  October  2011  resul;ng  in  

 LeL  Hemiparesis   Right  PCA  Infarct   Cogni;ve  Deficits  

Case  Study  1  

Issues/concerns  on  ini4al  assessment   Upper  limb  retraining   Reduced  sensa;on/propriocep;on  of  leL  hand   LeL  shoulder  fixa;on  with  internal  rota;on  upon  func;onal  use  

 Reduced  lower  trunk  stability  –  affec;ng  balance  reac;on  

 Ataxic  movement  of  leL  arm   LeL  shoulder/neck  ;ghtness  affec;ng  movement  quality  

Case  Study  1  Results  from  ini4al  assessment  

 NHPT  –  0  pegs  in  60  seconds   B&B  –  17  blocks  in  60  seconds   Tymo  &  Amadeo  assessments  were  also  completed  

*  Lower  trunk  control  *  Propriocep;on  in  leL  hand  

 Func;onal  task  goals  *  Holding  a  glass  of  water  *  Typing  *  Doing  up  buwons    *  Using  cutlery  

Case  Study  1  Treatment  strategies  using  Computer  Based  Therapy  

 Increase  propriocep;on  in  leL  hand  *  Pablo  *Home  exercise  program  

 Increasing  strength  in  leL  fingers  •  Pablo  *  Home  exercise  program  

 Increase  lower  trunk  control  *  Tymo  in  si|ng  and  standing  *  Pablo  strapped  to  torso  while  si|ng  on  physio  ball  *  Home  exercise  program  

Case  Study  1  

•  NHPT  –  9  pegs  in  60  seconds  •  B&B  –  33  in  60  seconds  •  Tymo  balance  assessment  –  client  balance  for  17  seconds  on  leL  (affected  leg)  as  opposed  to  6  seconds  in  original  assessment.  

Results  from  reassessment  aWer  5  weeks  of  therapy  

•  Func;onal  task      *client  can  hold  glass  in  leL  hand  and  pour  it  with  increased  precision.            *  Buwon  his  right  cuff  on  shirt  –  use  of  buwon  hook  

 *Use  knife  and  fork  comfortably  to  cut  up  food  

Case  Study  2    55  year  old  male  

Motorbike  Accident  

Medical  Background   TBI  post  MBA  in  2008  resul;ng  in  *Global  brain  damage  *Right  sided  weakness  *Right  Orbital  Fracture  *Fractures  to  UL  *Cogni;ve  Deficits    *Mobilises  with  a  power  wheelchair  

Case  Study  2  

Issues/concerns  on  ini4al  assessment   RHD  but  does  not  use  right  UL  ac;vely   Right  sided  weakness   Reduced  awareness/inclusion  of  right  arm   Poor  propriocep;on  in  both  UL   Poor  quality  of  movement  in  right  arm   Limited  wrist  movement,  pain     High  tone  in  flexor  tendons  of  right  hand  

Case  Study  2  Results  from  ini4al  assessment  

 Ac;ve  Range  of  Movement  was  assessed  using  Pablo    

 Func;onal  task  goals   To  use  right  hand  more  func;onally  

  Ea;ng  &  drinking    Personal  care  

 To  work  with  both  hands  together  in  daily  tasks  

Case  Study  2  Treatment  strategies  incorporated:  

 1  hour  session  weekly  (7  weeks)   Ac;ve  ac;vi;es   Passive  stretching   Computer  Based  Therapy  

 Massage   Homework  tasks  to  be  completed  with  carer  assistance  

Case  Study  2  Treatment  strategies  using  Computer  Based  Therapy  

  Increase  elbow  flex/ex,  pro/sup,  external  rota;on  of  shoulder   Pablo  using  the  Mul;board  to  incorporate  bilateral  movements   Home  exercise  program  

  Increase  wrist  pro/sup,  flex/ext   Pablo   Home  exercise  program  

  Increasing  movement  in  fingers   Amadeo   Home  exercise  program  

Case  Study  2  

•  Increased    ac;ve  &  passive  ROM  

•  Increased  strength  in  hand  and  grasp  •  Increased  awareness  of  right  arm  

•  Improved  control  of  movement  •  Improvement  in  propriocep;on  in  both  UL  

•  Reduced  tone  flexor  tendons  in  right  hand  •  Func;onal  task    

•  Increased  use  of  right  arm  in  everyday  tasks  with  carer  encouragement  

•  Ea;ng  sandwiches,  drinking  with  2  handled  mug,  dressing  

Results  from  reassessment  aWer  7  weeks  of  therapy  

Case  Study  3    41  year  old  male  

Mountain  Bike  Accident  

Medical  Background   Severe  ABI  post  accident  in  2006  resul;ng  in  

 LeL  sided  hemiplegia   Spas;city  and  pain  in  leL  UL   Cogni;ve  Deficits   Perceptual  Deficits  –  leL  sided  neglect   Mobilises  with  a  power  wheelchair  

Case  Study  3  

Issues/concerns  on  ini4al  assessment   LeL  sided  hemiplegia  

 Significant  leL  neglect   No  ac;ve  movement  in  elbow,  wrist,  fingers   Flickers  in  shoulder  girdle  –  but  tends  to  compensate  with  trunk  

Case  Study  3  

Results  from  ini4al  assessment   No  assessment  was  completed  due  to  no  ac;ve  movement  

 Func;onal  task  goals   Was  leL  hand  dominant  prior  to  accident  

 Wants  to  be  able  to  use  leL  arm  again  

Case  Study  3  Treatment  strategies  incorporated:  

 1.5  hour  sessions  twice  weekly     Computer  based  therapy   Passive  stretching   Ac;ve  prac;se   Homework  tasks  to  be  completed  with  carer  assistance  

Case  Study  3  Treatment  strategies  using  Computer  Based  Therapy  

 Pablo  •  Using  Mul;board  to  allow  bilateral  movement    •  Focus  on  scanning  to  leL  side  •  Focus  on  concentra;on  &  awen;on   Amadeo  •  Passive  range  of  movement  •  Provide  s;mula;on  to  nerves   Diego  •  Gravity  assisted  movement  of  shoulder  and  elbow   Tymo  •  While  seated  •  Prac;ce  weight  shiL  from  right  to  leL  side  

Case  Study  3  

 Client  can  elicit  flickers    •  in  middle  and  ring  fingers  

•  of  elbow  extension  with  gravity  removed  •  of  shoulder  extension  from  a  flexed  posi;on  with  gravity  removed  

  Awen;on  to  leL  side  is  improved  

•  This  client  has  a  very  suppor;ve  family  &  carers  who  complete  home  exercise  tasks  with  him  every  day  

Results  aWer  7  months  of  therapy  

Case  Study  3  

  Increase  in  finger  flickers  &  at  ;mes  some  ac;ve  movement  

 Wrist  movement  has  begun   Finger  strength  beginning  to  show  –  grip  when  shaking  

someone’s  hand  

 PROM  has  increased  &  less  resistance  from  the  shoulder   Awen;on  to  leL  side  has  improved  further  –  not  needing  to  

provide  verbal  prompts  

•  More  mo;vated  with  these  changes  

Results  aWer  10  months  of  therapy  

Case  Study  4  •  55  year  old  woman  (was  27  when  incident  occurred)  •  Suffered  an  Arteriovenous  Malforma;on  at  the  age  of  28  

•  1/3  of  primary  motor  cortex  was  removed  •  Against  all  odds,  survived  •  Result  of  surgery  was  leL  sided  hemiparesis  

•  Inability  to  use  leL  wrist,  fingers  &  thumb  •  Unable  to  control  elbow  extension  •  Reduced  shoulder  movement  •  Increased  tone  in  fingers  

Case  Study  4  Treatment  strategies  using  Computer  Based  Therapy  

  Increase  shoulder  movement  *Diego  *Pablo  in  si|ng  and  standing  *Home  exercise  program  

 Controlled  elbow  movement  *Pablo  *Diego  *Home  exercise  program  

 Decreasing  tone  in  fingers  /  increasing  finger  movement   Amadeo   Home  exercise  program  

  Increase  wrist  movement   Pablo  in  si|ng  and  

standing   Home  exercise  program  

Case  Study  4  Results  6  months  of  weekly  therapy  sessions  

•  Shoulder  moves  more  freely  

•  Able  to  liL  shoulder  against  gravity  •  Able  to  ac;vely  flex/extend  elbow  smoothly  •  Able  to  ac;vely  flex  and  extend  fingers  •  Feels  less  self  conscious  about  leL  arm  •  Is  extremely  mo;vated  to  con;nue    

with  therapy  in  order  to  reach  her  maximum    func;onal  level  

Case  Study  4  Addi4onal  Results  aWer  10  months  of  weekly  

therapy  sessions  •  Reduced  compensatory  movements  in  leL  side  of  trunk  and  shoulder  

•  Wrist  devia;on  reduced  significantly  

•  Wrist  can  move  more  freely  •  Propriocep;on  has  improved  –  now  knows  what  her  arm  is  doing  and  can  elicit  the  movements  she  wants  

•  Has  bewer  control  of  her  arm  movements  •  Can  sustain  a  posi;on  longer  (even  at  end  of  range)  

What  does  this  mean?   CBTD  are  being  used  overseas  with  clients  with  an  ABI     Results  have  shown  an  increase  in  UL  movement  and  func;on  

 CI  Therapy  is  now  being  used  with  clients  with  an  ABI  

 Results  have  shown  an  increase  in  UL  movement  

and  func;on    63  

What  does  this  mean?  Within  the  Australian  Community  

• New evidence based treatment techniques need to be embraced • Clients should be provided with information regarding alternatives to their traditional therapy options. • Technology is a growing industry and a part of everyone’s daily life, this needs to be extended to therapy. • For many clients, even a minimum improvement in movement will lead to greater independence and quality of life.

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What  does  this  mean?  Within  the  Australian  Community  

• Limited time within a hospital setting to provide intensive therapy required so therapy should be continued when client returns home, not stopped. • NDIS now allows clients to decide whether they would like to use their funding on therapies such as these  

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WHAT  WE  HAVE  LEARNED  •  The  brain  can  keep  forming  new  pathways  no  mawer  how  long  aLer  the  incident  and  no  mawer  the  age  of  the  client  

•  Early  interven;on  is  required  in  order  to  maximise  long  term  func;onal  outcomes  

•  Repe;;on  assists  with  these  pathways  being  formed  •  Clients  need  to  be  mo;vated  in  order  to  perform  the  task  at  hand  •  External  focus  assists  with  the  client  performing  the  required  movements    

•  Technology  is  the  way  of  the  future  so  it  should  be  embraced  as  part  of  therapy  

EVERYONE  NEEDS  HOPE  

THANK  YOU  

 AOTS  -­‐  CBRA  

AOTS  Clinic  

Computer  Based  Rehabilita4on  Australia      Unit  16  

   26-­‐28  Roberna  St  

   Moorabbin,  3189  

   Ph:  (03)  9555  0303  

   www.aots.com.au