Provided Prior to Workshop:
Clinical Needs and Barriers
Gaps in Knowledge
Emerging Rehab Technologies
During Workshop: [DRAFT - Participants, please edit, add to!]
Summarized Comments based on notes (Upper Breakout)
Clinical Needs and Barriers
Better ways to integrate new technologies with conventional treatment programs. [NH]
Consistency in the choice and administration of clinical scales. Present “standardized” scales are, in our experience, rarely administered to a reliable standard. [NH]
A clear relation between standard clinical instruments and technology-based measurements. Correlations won’t do; we need structure—details of why measure X is (or is not) related to which (sub-)score of clinical instrument Y. [NH]
Better biological assessment tools. For example, lesion territory is very poorly quantified using CAT or even MR imaging, yet it almost certainly has a profound influence on response to treatment and ultimate recovery. Brain chemistry is probably even more important but even fewer assay tools are available. [NH]
A means to enable incremental progress. Clinicians (for compelling reasons) usually focus on the overall goal of functional recovery but because function is complex, that turns out to be an ill-defined technical goal. Though admittedly difficult to achieve, a clearer “road-map” from impairment reduction to functional recovery is essential. [NH]
Means to assess key measures of functional status in a timely manner from outside of the clinic (e.g., locations with high ecological validity such as the home). Such information is a necessary condition for optimizing therapeutic interventions (e.g., movement therapy, drug delivery) over the continuum of care. [JW]
As a more consumer-centered model for healthcare emerges, most therapy needs to be delivered to (and through) the home. The current clinic-centered inpatient-outpatient-home model yields a sub-optimal continuum of therapeutic interventions. [JW]
Lack of training materials for allied health professionals in technology-assisted assessment and therapy techniques, including telehealth tools. [JW]
How can technology be effectively incorporated in a time-pressured, cost-conscious, inertial, therapy environment? [DR]
Encouraging and increasing the rate of the adoption of mechatronic devices and information technology to assist clinicians in facilitating and streamlining patient care. [MVdL]
Leveraging current industrial and consumer information technology for application in the rehabilitation and home-care environments. [MVdL]
Developing engineering and information-handling tools to make the home a more viable environment for the delivery of rehabilitation care to off-load higher-priced clinical environments and yet no downgrade the quality of care. [MVdL]
Given our current challenging clinical environment, a most pressing need is to demonstrate effectiveness of those rehabilitation treatments we already use. [CK]
Another is to develop new interventions that are more effective than we can now imagine. Randomized clinical controlled trials are needed, however, with limited resources, we need to be especially precise in not only measuring functional outcome, but in targeting those impairments (or functional limitation or disability) that are particularly critical to overall function. Advances in neurorehabilitative assessment can help us meet these goals. [CK]
What is the rational basis for physical medicine (and other key therapies for that matter, such as OT and speech)? [ZR]
What is the role of neural plasticity in restoration of function ? Is it the primary source of recovery of function in chronic injury.? It follows that we need to know the origins of factors controlling plasticity [ZR]
There is a need to design rational evidence-based therapies [ZR]
There is also a major concern about clinician acceptance of new technologies- therapists are inherently conservative, and they receive little training in technology applications. [ZR]
Limited health care resources (shorter lengths of stay, need for increased therapist productivity) [SF]
Traditional treatment techniques continue to be taught in therapy education programs and used in clinical practice without empirical support of their effectiveness. [SF]
Recent studies in stroke have demonstrated that repetitive, task specific training can contribute to improved cortical reorganization and motor performance. However, repetitive practice of daily tasks (e.g. reaching for items on a shelf) is contrived, and does not allow the patient to engage in the intensity of practice that has been shown necessary to produce significant motor effects. [SF]
Generally, clinicians do not have a strong understanding of how technology may be used to enhance clinical practice and patient outcomes [SF]
We need to develop customized treatment programs that integrate technological tools with clinician guidance/intervention to enhance functional motor outcomes (i.e. avoid “cookbook” interventions). [SF]
There is a time-delay between the gathering of evidence from stroke rehabilitation research and changes in clinical practice (i.e. evidence-based practice is not widely implemented) [SF]
Continued reductions in the amount of therapy patients receive due mostly to a lack of convincing scientific evidence for the effectiveness of current treatments in terms of outcomes and mechanisms [PL]
New assessment tools can help evaluate the effectiveness of treatments with more precision than clinical scales and can lend insight into mechanisms [PL]
New movement therapies can have an effect on outcomes by allowing patients to receive more movement therapy without increasing one-on-one time with therapists [PL]
Need: Methods to promote faster, more complete upper limb motor recovery following stroke. [CB]
Barriers: Incomplete scientific understanding of mechanisms of motor impairment and recovery; current reliance by rehab clinicians on dogma when formulating treatment plans; Impending rehab prospective payment system. [CB]
Potential of robot-assisted movement: [CB]
provides objective measure of assistive/resistive forces during reproducible movements performed over time as recovery of functions occurs,
can be coupled with other measures (e.g. EMG) to identify contributions of voluntary and passive forces.
facilitates practice of accurate, repetitive movements,
has potential to increase the rate and extent of functional CNS reorganization,
when performed bimanually, provides an opportunity to study interlimb coordination and, possibly, to promote functional adaptations of both contra- and ipsilateral pathways.
We need therapeutic devices (robots, etc.) that allow complex motions such as activities of daily living. ("task-oriented" is the big buzzword) [JP]
Complex, 3d, robotic technology is difficult to implement. Complex, 3d, robotic technology can be less safe because more things can go wrong. Complex, 3d, robotic technology can be intimidating to the patient and to the clinician administering it. [JP]
Complex motions such as activities of daily living are often not manageable scientifically. [JP]
I believe that an important barrier which needs to be overcome for improving patient outcomes is the interaction between engineers and scientists with clinicians and therapists. Clinicians and therapists who work with patients on a daily basis are exposed to pathological behaviors (e.g. cause and effect-> apply more hip extension in gait training, get better hip flexion) which, if properly investigated, could lead to a better understanding of the motor control system. On the other hand, engineers have a strong grasp on emerging technologies which could be used effectively in the clinics, IF we design with intention. Thus I propose the following: [JH]
o Educate therapists on new technologies that may be useful in treating patients
o Teach clinicians and therapists to look for these causal->resultant relationships that could be investigated in the lab
o Have engineers shadow therapists and observe effective therapeutic paradigms…can these be replicated and advanced using robotic devices?
o Establish a set of standards for assessing patient outcomes. As it currently stands, there are too many clinical scales used which may hinder true therapeutic comparisons and conclusions
o Problem solve neurorehab in a similar approach successful businesses do…assemble a diverse team including engineers, therapists, clinicians, and PATIENTS.
From a narrow perspective of vision rehabilitation within the broader field of rehab: [KK]
Unlike language disorders which are often easily detected, visual disorders tend to be underdiagnosed and may masquerade as dysfunction of attention, cognition, balance, perceptual speed, or may be mistaken for malingering or psychological disorders.
Visual-motor and visual-perceptual components of dysfunction in the neurologically affected person are frequently neglected in rehabilitation.
There are only a small number of professionals with expertise in neuro-optometric rehabilitation.
Cost of providing services that may be time intensive to a large number of patients.
Quantifiable high-resolution data of patient's functional abilities. This provides much needed evidence for the positive effect of various interventions both physical and pharmacological. [JD]
Need for novel science based interventions as opposed to empirically based techniques. [JD]
Prevailing view in the clinic of a lack of time. A frequently heard remark is that the pressure to see as many patients as possible doesn't permit to use engineering based approaches in the clinic. [JD]
Computer illiteracy is a problem especially with older clinicians. Fear of technology. [JD]
Gaps in Knowledge
The biology of how neurological injury gives rise to impairment and how impairment gives rise to disability. [NH]
The biology of how therapy of all kinds (including pharmacological as well as sensory and/or motor treatments) contribute to neuro-recovery. [NH]
Whether recovery of different musculo-skeletal subsystems (e.g., joints, limbs) may be treated separately or must be treated simultaneously. If the former, does sequence matter? To illustrate, is it effective to treat the hand without the rest of the arm? or vice versa? If so, does it matter which is treated first? [NH]
Whether sensory or motor stimulus is more important for recovery or whether both must be present. [NH]
What are the optimal therapy techniques, and especially the role of mechanical assistance in facilitating movement recovery? [DR]
How should therapy be optimized for different lesion types? [DR]
What is the optimal dosage pattern for movement therapy? [DR]
Understanding of spasticity and dysfunctional co-activation/synergy patterns for multi-muscle/multi-articular systems, e.g. as a function of lesion/pathology. Functionally relevant indices based on sensor-based measures (e.g., EMG, movement) from strategic tasks. Especially needed for developing recovery/rehabilitative strategies that combine drug therapy (e.g., Botox, baclofen, ...) with movement therapy (and orthotics, assistive technologies) over time. [JW]
Understanding the dynamics of neural tissue/cell recovery, both spontaneous and through rehabilitative interventions. (We have a much better understanding of skeletal and connective tissue healing/recovery mechanisms, and often reimbursement schemes seem to use the known temporal dynamics for orthopedic rehab recovery to set neurorehab practices, resulting in poor outcomes that make neurotherapy seem ineffective.) [JW]
From an engineering perspective, a better understanding of the neural mechanisms for sensory input and motion control will lead to the development of more appropriate and powerful devices and strategies for effective therapy. [MVdL]
From a user interface perspective, a better understanding of the role of psychological, social and communication factors in the effectiveness of therapy can lead to better integration of services, features, instruction and patient feedback in the information and therapy devices used in rehabilitation. [MVdL]
Our poor understanding of the relationships between disease, impairment, functional limitation and disability. With limited clinical resources, we may not be able to treat every impairment. In some cases we may not even want to treat an impairment that may actually be a compensatory consequence of a functional limitation, disability or yet another impairment. I believe we should give high priority to current and future scientific work that includes as a goal, improving our understanding of these complex relationships. [CK]
Although we’ve gained knowledge of the kinematic and force variables that constitute motor impairment after stroke –how do these variables relate to functional performance – how can this information help us to bridge the gap between recovery (cortical and motor) and motor function? [SF]
Although precise and objective measures of cortical reorganization and motor performance are important for our understanding of how motor recovery occurs after stroke, how can these exact measures be clinically useful – how well do they predict one’s ability to use the hemiparetic limb in the context of daily life? [SF]
If more intensive, task-specific training is substantially more effective than traditional methods in improving motor function, how can technology-based therapy best deliver this training? What forms of technologically driven therapy (e.g. functionally based, repetitive practice, strength vs. sensorimotor training etc.) yield the most promising outcomes? What patients benefit more from one form of intervention vs. another – both in terms of cortical reorganization and motor outcomes (a long-standing question that I think can be better addressed by technological advances in measurement and rehab)? [SF]
Relative contributions of motor unit recruitment and rate modulation, sensory changes, hyertonia, hyperreflexia, muscle weakness, incoordination, and soft tissue stiffness to the loss of motor function following stroke. [CB]
New clinical protocols that address specific impairment mechanisms. [CB]
Incomplete understanding of the mechanisms of motor impairment following neurologic injury [PL]
Lack of scientific evidence for the effectiveness of current treatments in terms of outcomes and mechanisms [PL]
What should we train? Forces, torques, kinematics or muscle "synergies"? [ZR]
What is the mechanisms for behaviorally mediated modification of brain function (ie plasticity) [ZR]
What are the relative contribution of structural changes in connectivity, versus compensatory contributions from other sources [ZR]
Learning of motor tasks [DK]
Promotion of motor relearning [DK]
What potential types of therapy can a robot implement that a human could not? [JP]
What fundamental therapy strategies can be challenged scientifically using rehabilitation technologies? [JP]
What joints (degrees of freedom) would be best focus for therapy in the stroke patient? [JP]
A much better understanding of the brain mechanisms and the psychosocial factors that underlie the capacity for late brain reorganization is needed. Methods of obtaining objective, quantified evidence of results with rehabilitation methods. [PByR]
It is clear that we still have a primitive understanding of the central mechanisms underlying motor control. To advance our knowledge, we can: [JH]
o Utilize imaging technologies to tracking patient behavior and outcomes, ONLY after we establish better correlations between image information and motor behavior. This may be done using transcranial magnetic stimulation.
o Establish better mathematic models of neuromuscular pathways, taking advantage of emerging animal data.
From a narrow perspective of vision rehabilitation within the broader field of rehab: [KK]
The discrepancy between the traditional view of the visual system (limited concept of the visual system comprised of the primary visual pathways and some eye movement controllers in the brainstem) and the actual neurophysiology of vision (the visual system is represented in every major lobe of the brain, as well as the midbrain and brainstem) has created an unfortunate treatment gap. Because the visual system is represented so widely in the brain, neurological compromise (whether acquired, congenital or degenerative) frequently affects the visual system.
Both developmental and rehabilitation professionals often take a wait-and-see attitude regarding treating vision dysfunction, even though research in other rehabilitation disciplines indicates that early and intensive therapeutic interventions often yield rewards.
Neuro-optometric rehabilitation can often relieve symptoms which interfere with other general rehabilitation activities. Great gains in knowledge have occurred in this field over the past several years—more must be done.
Most clinical rehab interventions are based on empirical approaches; there is a great need for science-based interventions. Example: Mechanisms of movement disorders both in neurologically and orthopedically impaired individuals. [JD]
Emerging Rehab Technologies
Generally, I think that technologies that can automate existing therapy techniques, or that can apply new techniques in a quantifiable way, hold substantial promise for filling the gaps in knowledge listed above. [DR]
Robotics: Highly promising. The devices deployed clinically to date are merely an initial “proof-of-concept” yet have shown remarkable results. More effective systems will almost certainly emerge. [NH]
Web-based tele-robotics: Tele-robots promise to extend clinical-quality treatment far beyond the confines of a clinic. The technical challenges are substantial but laboratory demonstrations of feasibility have been accomplished. [NH]
Neuro-active pharmacology: A combination of robotic and pharmacological therapies promises to be more effective than either alone. Animal studies have shown a positive interaction between neuro-active drugs (e.g. amphetamines, nerve growth factors) and sensory and motor experience. [NH]
Sensate garments: Advances in “wearable computing” will permit unobtrusive but precise monitoring of functional sensory and motor ability, patterns of limb use, effects of therapy, etc. [NH]
Active (actuated) garments: The technical challenges are vast but advances in micro- and nano-engineering may yield materials and fabrics that are also actuators (motors). They may enable unobtrusive delivery of sensory-motor therapy without the use of external (e.g., robotic) devices. [NH]
Everything Neville says (above), only squared. However, all of these require well-designed mobile electronic health records (EHRs) that are actually used by therapists. The rehab field is near/at the bottom of the medical profession in terms of EHR penetration. Until this changes, technology-assisted therapy will be a fringe element without much potential to become an integrated part of healthcare management. [JW]
Innovative rehab technologies that are integrated into mass-market input interfaces (e.g., mouse pointer, joystick, game pads, touch screens) and programming environments (e.g., XBox), thus allowing lower-cost solutions that also provide the client and practitioner with access to mass-market gaming software and Internet Messenger/Web communication interfaces. [JW]
Any emerging rehabilitation technology that improves impairment, functional limitation and/or disability is exciting. I don't want to prioritize here as I think the current number of emerging rehabilitation technologies is low. On the other hand, I am particularly excited about increasing this number via translating technologies (and brainpower) from other fields outside of medicine. [CK]
Technology that provides exercise training (haptic experiences) for improving distal hand use – to address the question – does early distal training lead to better cortical reorganization and motor function? [SF]
Technological tools that evaluate motor performance during a variety of motor tasks and environments – to gain objective and reliable measures of motor impairment and recovery and how contextual variables may influence performance. It’s important that these measurement tools can be used in conjunction with cortical imaging to enhance our scientific knowledge of rehabilitation effectiveness. [SF]
Technological tools that are flexible in their integration into clinical practice, and within the context of one’s daily life tasks (e.g. technology that can help a person use his/her hemiparetic arm during the performance of functional tasks). [SF]
Technological tools that can be easily used in a variety of environments (clinic, home etc) and provide the patient with direct feedback about motor performance (including perhaps, transitional information that can help the person can improve his movement during the next repetition). [SF]
Robot-assisted retraining of voluntary movement and coordination coupled with stem cell or neuroprotective therapy. Systems capable of tailoring therapeutic exercise regimens in real-time based on performance. [CB]
Neural engineering -direct or indirect recordings from the nervous system to drive actuators, or to develop direct connections from sensors at the periphery [ZR]
Virtual reality for training to prepare for standard environments [ZR]
Novel materials and device development allowing direct device attachment to bone [ZR]
The technologies that are the most exciting are devices that: [PL]
provide unsupervised movement therapy that can be used in acute and subacute patients
“smart” devices that can automatically guide the patient in terms of movement type, difficulty and repetitions
can be loaned or leased to patients to be used at home
Obviously, stem cell research could lead to major advances in enabling repair of tissue damage. The continued improvements in materials and semiconductor devices should permit the development of exoskeletons to assist movement when repair is not possible. It is telling that many amputees have greater function than individuals with intact limbs. [DK]
Passive systems (Masuoka's work, cobots, or curl force fields) [JP]
Nervous tissue implants integrated with intensive therapy [JP]
Rented rehab robots you take home with you [JP]
Communal robotics (multiple robot users working together on a collective goal) [JP]
Rehabilitation will become more scientifically-based. Timing and organization will reflect both the brain's requirements for effective reorganization, and society's ability to pay for it; this means that cost-effective rehabilitation must reflect the patient to client to student continuum, where the medical model is involved in acute, and the first stages of late rehabilitation, but the person who has had a stroke ceases to be a patient and continued functional recovery is obtained within an educational model. both institutional (e.g., Community Colleges) and home programs will be developed. Rehabilitation engineering will concentrate on cost-effective systems with very widespread applications. [PByR]
Certainly robotic technology has the potential to be extremely useful in the neurorehab community. However engineers must be careful not to design blindly, but should work closely with clinicians and therapists for optimizing design specifications. These devices can obviously be used for therapeutic interventions, and also tracking patient recovery. [JH]
It would be nice to combine drug studies (e.g. amphetamines, barbiturates,…) with clinical trials using such devices to investigate the effectiveness of such treatments. But at the very core, we need to better understand the central workings of the system first, otherwise the system will remain a “black-box”. [JH]
The use of robotics and cobotics in the field of rehabilitation. [JD]
The use of tele-rehab [JD]
From a narrow perspective of vision rehabilitation within the broader field of rehab: [KK]
Functional Magnetic Resonance Imaging—for further research to support current clinical practice in neuro-optometric rehabilitation as well as gain insight for future breakthroughs.
Human performance assessment tools (gait analysis,etc.)--for evaluating patient’s responses to different lenses affecting posture.
Telehealth
Notes From Workshop ("Upper" Breakout):
We need to evaluate the therapy in the home environment. Psychosocial factors are very important. Too many projects are engineering driven, not user driven. Need to have much more focus on human factors. [PbyR]
Clinicians are frustrated at our lack of capitalizing on patients’ experience. We do not listen enough. We need to have more consumer-group driven technology development. [JWer]
Involve disabled in research team. We can learn from how the disabled interact with the devices. [PbyR]
The end user must be an absolutely integral part of the research team. [many]
How do we train rehabilitation engineers? Dialog (communication) between the engineers and clinicians. Both the therapists and the patients are the end users. [CB]
Providing numbers can be dangerous in this healthcare environment. Insurance groups can abuse them… (What does this mean?) [JWer]
Patients are more motivated by functional improvement, not just improving “numbers”. [SF]
The numbers are dependent on the measure used. [JP]
Worried about how numbers will be used. Clinicians may not want new numbers. [ZR]
What are our goals? Is it to do netter than the therapists? Or to do at least as good as? There is a mind-set barrier. User interface issue? [JD]
Death-knell: engineering toy adapted for the clinic. [ZR]
Clinicians are very time-pressured. If we present data that enhances efficiency and efficacy, you may not have such a hard sell. [CB]
User-centered design principles are being broadly adopted by mass-market telecommunications/computer companies. The human-technology interface is commonly called "the future" (e.g., by Bill Gates), with many companies having usability labs. There is a need for research that includes both human factors and neuroscience. [JWin]
The human touch is very important. Technology does not have the ability to adapt therapy to psychological factors. CPM is an example of technology very well accepted. [JWer]
CPM offloads boredom issues, and a painful therapy onto a machine. So that is why it may be more accepted. [CB]
Robotic devices may allow therapists to focus on more desirable therapies. Leverage the therapist’s time.
The patients’ desires are to “walk”. The therapists work with the patients to establish goals that are appropriate. Therapists apply judgment, but robot apply the therapy. [SF]
Hands-on upper extremity rehabilitation is the desirable thing in the clinical setting. Robotic therapy would be less well accepted. [JWer]
Patients want to regain mobility. It is easy to sell them on tasks that get them to this goal. More patients achieve walking as inpatients over upper limb function, perhaps due to physiological mechanisms. They may come back three months later asking to work on upper limb, but problems may have already arisen. Third party payers will not buy it. [CB]
Can we convince therapists to buy into the robotic therapies? Yes, if the technologies can be proven to do as good or better than manual therapeutic techniques. [CB]
Using quantitative approaches really do make a difference and can be repeated to have evidence-based therapy. [JD]
Rehab therapy has to date been driven by FIM scores. You can improve FIM by compensating. We can not replace therapists with technology, but we must augment therapists. Perhaps patients need 6 hrs of therapy rather than what is currently provided. We want to get better identifying which patients show most potential and then we can titrate therapies accordingly.
Wants to challenge clinicians to help guide us to develop tech-based therapies. What sort of measures are important? [PL]
It is task dependent. Concert pianists need a fine scale, whereas carrying groceries could utilize a coarser scale. [J ]
Communicating “real improvement” via the use of statistics is a challenge. [Example provided: "before-after" video clip of subject using [CB]
Why couldn’t video of observational outcome be included in patient record? It also can be scored, similar to the scheme used by the RERC on Ergonomic Solutions at the Univ of Michigan for work tasks. [JWin]
Need: Automated image recognition to capture the expertise of the therapist to assess patient to provide objective assessment. [DR]
Closing summary: Devices that provide quantifiable measures are great, but unless we prove therapeutic efficacy the devices may not be accepted. [ZR]
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Needs/Gaps/Tech