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Development of the System for Continuous Medical Rehabilitation for Patients with Post-Stroke and Spinal Cord Injury Motor Disorders. Dr. Olga Jafarova , Ph.D., Mr. Eugen Tarasov , MS,

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slide1
Development of the System for Continuous Medical Rehabilitation for Patients with Post-Stroke and Spinal Cord Injury Motor Disorders

Dr.Olga Jafarova, Ph.D., Mr. Eugen Tarasov, MS,

Prof.Mark Shtark, MD, Ph.D.Institute for Molecular Biology and Biophysics of Russian Academy of Medical Sciences, Novosibirsk

Dr.Ruslana Yu. Guk, MDCenterforNeurorehabilitationSiberian Clinical Centre FMBA of the Ministry of Health and Social Development, Krasnoyarsk

slide2

The project is aimed to providea continuous course of medical rehabof the patients with motor disordersand limited physiological functioning(post-stroke, craniocerebral or spinal cord injury)

  • There are a lot of high-tech neuro-rehabilitation technologies which can be applied at hospitals and rehab centers:
              • Neuro-Robotics
              • Neural Prostheses
              • Virtual Rehabilitation

What can be used at patient’s HOME?

slide3

Point of Care Technologies

Quality-of-Life Technologies

Connected Health Technologies

“Smart Home” - a home environment “equipped with automated devices specifically designed for remote health care” (Rialle et al., 2002)

Telemonitoring - assess fall risk, control gait

Telediagnosis - evaluation of health status or rehab outcome

Telerehabilitation – inexpensive apparatus(Foot Mentor, Hand Mentor, Balance Trainer)

slide4

The principal aspect, which should be ensured during in-home rehabilitation is providing a total safety of a patient and securing sufficient level of professional control of the training process

Furthermore, it is necessary to provide the possibility of conducting rehabilitation sessions asynchronously, that is to separate in time:

doctor’s recommendations for home training,

fulfillment of these recommendations by a patient,

analysis of results

slide5

State-of-the-art rehabilitation technologies use feedback signals

Biological feedback (BIOFEEDBACK) technologywhich considers a patient as anactive subjecttake central position in all rehab models

slide6

Method

The project “Network NeuroRehabilitation” (NNR) comprisesa complexof neuro-rehabilitation technologiesbased on the electro-myographic (EMG)biofeedback which can be used not onlyin hospitals, but at home.

Thresholds

BOSLAB system screenshotof EMG biofeedback training – if Integral EMG is abovethe threshold Audio feedback signal appears

slide8

Screenshot of a game form of EMG biofeedback If EMG signal lies in the range between the thresholds in so called target zone a flower grows and blooms

slide9

Structure of Network Rehabilitation

In the clinic or rehab centrea patient masters the required program of rehabilitation and gets the necessary instructions to continue practicing at home

At home the patient continues practicing rehab procedures, regularly sends out training reports and data, and gets more recommendations from the therapist

slide10

System of continuous distant medical rehabilitation

Interaction of Doctor and Patient

Level 2

Network information processing

Data & Reports

https

https

http

http

Level 3

Level 1

Doctor

Boslab

Biofeedback

System

Patient

Decision

making by

Rehab.

Specialist

Patient’s PC at Home

Rehab procedures

Training reports&data

slide11

System in action

Asynchronousaccess to portal

In the proposed structure there is no need for rehab specialist and patient to conduct training sessions in teleconference regime, therefore the process can be organized with greater flexibility.

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On-line session

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Doctors

Patients

slide12

On-line session

Patient

Internet

Doctor

slide13

Local and Server

Data Synchronization

Raw Data Dynamics

in Training Sessions

  • Pair Muscles Training (m. gastrocnemiusactivation by turns)
  • EMG Integral and Thresholds
  • Right
  • Left

L R

R L R L

Labels: Tense Right, Relax, Tense Left

Task: Tense Relax Tense Left Right Muscle Muscle

Session statistics

EMG averaged over periods

activation/relaxation, mkV

experimental group and procedure
Experimental Group and Procedure

Since 2007 theSiberian Clinical Centre FMBA (Krasnoyarsk) has been a clinical base of the project

Experimental group: 73 patients who manifested severe motor disorders.

Among them 30 post-stroke 43 SCI consequences

Control group: 35 disabled in-patients of the Siberian Clinical Centre FMBA with motor disorders of the same origin who were examined in 2011-2012

slide15

Experimental Group and Procedure

At the first stage the patients underwent 5 to 10 sessions of EMG biofeedback at the hospital to get the required training skills. The choice of training type depended on the clinical picture of the disease

Patients with high muscle tone underwent the treatment of excessive spasticity, mainly aimed at spastic muscles’ relaxation and the rest practiced increasing muscle strength (alternation of activation and relaxation)

Later at home they continued practicing muscle activation and relaxation exercise 3 to 5 times a week during 2 to 4 months, depending on the severity of the cases and the level of affection, using distant network neuro-rehabilitation.

experimental group and procedure1
Experimental Group and Procedure

Testing was conducted at the end of staying in a rehabilitation center and after the distant rehabilitation, which usually coincided with the rehospitalization

For the control group the testing was performed at the end of the period of staying in a rehabilitation center and before the next hospitalization

We used the following scales:

  • Modified Ashworth Scale for Grading Spasticity
  • Barthel ADL Index
  • Motor and Sensory Examination of ISCSCI-92
slide17

Dynamics of amplitude of hip joint movement(19 patients with SCI, group average)

5 Scores

Before

After

Network NeuroRehabilitationOutcome:

stable increase in EMG amplitude

increase of muscle strength

increase of limbs’ circumference and joint range of motions

improvement of the superficial sensitivity

reduction of anxiety and depression

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4

***

*

**

**

**

**

3

2

1

0

Before

After

Unbending

Bending

Abduction

Adduction

Rotation outside

Rotation inside

slide18

Case study 1

PatientV. age: 50. Post-stroke Left side hemi paresis

EMG Dynamics in m. Tibialis anterior,left

04.12.09 : EMG biofeedback training at Rehab center

17.12.09 : Beginning of distant rehabilitation

03.02.10 : after 2 month of distant rehabilitation

400

300

200

100

0

100

200

300

400

Dynamics in m.Bicepsfemoris, left side

Dynamics in m. Gastrocnemius, left side

300

300

200

200

100

100

0

0

100

200

300

400

500

100

200

300

400

500

slide19

Case study 2

Patient M, age: 21. Lower paraparesis.

Dynamics in m.Biceps femoris, right side

500

400

18.08.09 Beginning training in Rehab center

02.12.09 Session of distant rehabilitation at home

300

200

100

0

100

200

300

400

500

EMG Dynamics in m. Gastrocnemius:left , right

Beginning of distant rehabilitation 20.08.09

Session of distant rehabilitation 20.01.10

80

60

20

40

15

20

10

0

100

200

300

100

200

300

400

500

dynamics during network neuro rehabilitation course low spasticity subgroup
Dynamics during Network Neuro-Rehabilitation courseLow Spasticity Subgroup

NNR Group

195

80

1.5

85

ISCSCI-Sensory

ISCSCI-Motor

ADL Index

Ashworth Scale

(N=56)

P=0.028

P=0.000

Control Group

(N=27)

1

78

190

80

Before

After

0.5

185

76

75

P=0.000

p – level of significance

Wilcoxon matched pairs test

74

0

180

70

Before

After

Before

Before

After

After

dynamics during network neuro rehabilitation course high spasticity subgroup
Dynamics during Network Neuro-Rehabilitation courseHigh Spasticity Subgroup

NNR Group

3.5

170

65

75

ISCSCI-Motor

ADL Index

ISCSCI-Sensory

Ashworth Scale

(N=17)

Control Group

(N=8)

P=0.004

3

160

60

70

Before

After

55

150

2.5

65

p – level of significance

Wilcoxon matched pairs test

2

50

140

60

Before

After

Before

Before

After

After

discussion
Discussion

The results of patients’ examination before and after distant rehab showed that for the patients with increased spasticity the efficiency of biofeedback training was less pronounced. This could be due to their low motivation related to the relaxation training, as these patients wanted to improve their movement ability and increase self-service, for which purpose they thought it was expedient to practice muscle activation, not relaxation.

Therefore we believe that for patients with increased muscle tone the biofeedback relaxation training at home should be more exciting, with a sufficient motivational component

discussion1
Discussion

In our study, during the relaxation training, the patient tried to relax muscles and increase the skin temperature, at the same time trying to keep the EMG signal on the monitor lower than the threshold set by the program. Upon reaching the required level of muscle relaxation a movie or slide show could be viewed without distortion, the flowers were growing, the mosaic pictures were opening

slide26

http://www.wilddivine.com.

http://www.wilddivine.com.

The most famous training set to develop the skills of self-control, uses cardio intervals and skin conductance, but not muscle characteristics

slide27

GAME BIOFEEDBACK

Control parameter Heart Rate

functional independence assessment with and without network rehab
Functional Independence Assessmentwith and without Network Rehab

70

FIM(TM) score

P=0,02

60

NNR Group

(N=12)

Control

(N=23)

50

40

After Rehab 1

Before Rehab 2

acknowledgments network neurorehabilitation project team
Acknowledgments: Network NeuroRehabilitationProject Team
  • Chernikova, L.A.
  • Shtark, M.B.
  • Sklyar, M.M.
  • Sokolov, A.V.
  • Tarasov, E.A.
  • Tarasevich, A.F.
  • Terleev A.A.
  • Tzirkin, G.M.
  • Voroninskiy, V.A.

The project made it real to rehabilitate the patients with severe motor disorders on everyday basis and secured constant contact between patients and therapists

network neurorehabilitation project members
Network NeuroRehabilitation Project members:
  • Research Institute for Molecular Biologyand Biophysics of the Russian Academy of Medical Sciences
  • Siberian Clinical Centre of Federal Medical Biological Agency
  • Biofeedback Computer Systems Ltd.
  • Non-commercial InternationalCharity Foundation “SM, Charity”
  • Neurology Scientific Centerof the Russian Academy of Medical Sciences
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