Austrian innovators believe they may have cracked one of the great global challenges of post-stroke rehab. One-to-one therapy can be hugely effective in enabling patients to regain lost functions.
Yet personnel and resource shortages often mean the individual’s time in this setting is limited. Technology company Rewellio has developed a potential solution, combining EMG biofeedback and an app to help patients recover lost hand movement after stroke.
Its aim is to enable more therapy time and promote a faster, motivating and independent recovery process.
Founder and CEO Georg Teufl says: “Our initial idea was to work out how we could enable a stroke patient more therapy time. Hand rehabilitation is particularly tricky, especially in the early stages when quite often the muscle contractions are so weak that no visible movements can be seen. Therefore, the patient at home has no real feedback as to whether or not the exercises are being done correctly.”
Rewellio’s app is used with a compatible EMGbiofeedback device which can detect any minimal muscle activity in the affected limb.
Often these movements are too weak to move the hand, but provide a platform on which the patient can build.
The data is transmitted to the app and incorporated into the rehab session, giving patients instant feedback during their exercises.
This allows for a fully functional, virtual hand that shows users the real-time activity of their targeted muscles.
Teufl says: “The aim of this concept is to ‘trick’ the brain so that it relearns which signals produce the right outcome in movement. The repetition of these exercises helps the patient get back some functional use of the hand, which becomes the basis for other exercises, such as training for more precise movements of the hand and fingers.”
The system is designed to both assist therapists in clinical and rehabilitation settings, and to give the patient extra independent therapy time at home. It supports dozens of exercises for arm and hand rehab – encouraged through a series of interactive games. These are played via the app on a tablet or a virtual reality headset, with EMG biofeedback bracelets providing the real-time data.
As well as boosting exercise hours after stroke, Rewellio’s approach to rehab is also driven by the power of motor imagery; the mental practice of movement without physical movement.
Motor imagery, and also observation of actions, are shown in various studies to improve motor performance and upper limb function after a stroke. They are also commonly used to improve performance in elite-level sport.
Imagining and observing activates certain motor-related regions, such as the premotor cortex and inferior parietal lobule – the same areas in the brain used in the actual movement (Mizuguchi et al, 2017). Both motor imagery and action observation are connected to the mirror neuron system, defined as the network for understanding actions performed by others.
These neurons discharge either when the individual is performing a motor task or watching someone else perform a related action. Action observation and motor imagery use this mechanism for the recovery of motor impairment.
A number of studies describe the findings and knowledge of the mirror neuron system as a source of information to motor training after stroke (Garrison et al, 2010).
Research also shows that there is no difference in a healthy person’s functional magnetic resonance imaging (fMRI) when watching real or virtual hands. These findings bring virtual reality (VR) to the next level as a promising tool for neuro-rehab (Brihmat et al, 2018).
Teufl says: “Immersive VR in combination with hand tracking capabilities allows for very efficient therapy methods.”
This, he says, can be used to build on the traditional mirror therapy concept – in which a mirror is placed in the person’s midsagittal plane, thus reflecting movements of the nonparetic side as if it were the affected side.
“The sensors in the VR headset make it possible to capture the patient’s improvement precisely helping the therapist to recommend the best possible therapy modules at any given stage.”
Teufl founded Rewellio in 2017, bringing together his experiences as a stroke therapist and his “passion” for software development. The company is headquartered in Austria, with a US office in Los Angeles and plans underway to establish a presence in Australia.
It recently raised €800,000 in angel investment, part of which will fund clinical trials into the technology.
“There are so many research questions we have opened up with this technology. We want to work with as many research institutions as possible to increase the amount of evidence for what we are doing. We’re currently preparing for the trial and [enlisting] pilot customers.
“We’re keen to connect with pilot customers who want to try out the technology and get an understanding of how they can benefit from it.”
Professionals and patients interested in trialling the technology are encouraged to visit www.rewellio.com or email info@ rewellio.com.
New guidance for teachers on ABI children returning to school
UKABIF and the N-ABLES programme have joined forces to show education staff how to help children when they return to school after a brain injury.
Teachers and support staff already play an essential role in a child’s development, but their importance is increased tenfold when dealing with a child who has endured a brain injury.
Their return to school is one of the biggest steps of the rehabilitation process, so it is crucial this is done properly.
To make sure all education staff are properly trained in how to do this, the National Acquired Brain Injury in Learning and Education Syndicate (N-ABLES) have launched a new set of resources.
Created in partnership with The United Kingdom Acquired Brain Injury Forum (UKABIF), the information will be used to help children from ages four to 18.
From inclusion to understanding, the resources highlights a number of steps teachers can take to make sure these children are not left behind.
Dr Emily Bennett, consultant clinical psychologist at Nottingham Children’s Hospital, spoke on behalf of N-ABLES about why this information is so needed.
“A lot of the work that we’ve been doing is thinking about how we can upskill teachers,” she said. “They don’t have that background with ABI and what that leads to is a child coming back into school and the impact of that brain injury being missed.
“We also find that over time what happens is behaviours that might come as a result of the injury become misinterpreted or misattributed, so people are forgetting about the brain injury.
“I think the other reason that it matters is that there is this lack of pathways and there’s a lack of joined up thinking across health and education.
“What we found clinically is that it means the teachers feel that they’re left with a situation that they don’t believe they’ve got any expertise in.
“So the guidance really spells out who should be involved, what can they do to help and it’s aiming to get everybody working together and sharing this expertise
Through a set of posters, booklets and educational materials N-ABLED and UKABIF are looking to make sure the unique needs of children affected by ABI are met.
Their younger years are then most crucial for their development, which is why both groups feel this training for school staff is vital.
“Returning to school is absolutely crucial, there’s no doubt,” Dr Bennett said. “For many children schools are actually the biggest rehab provider that they have any contact with.
“We think that probably around 70 per cent of most children’s rehab will happen in school and it’s a place where they’re in this natural, experience rich environment.
“It’s somewhere that they relearn a lot of the skills that they may have lost, particularly with regards to things like cognition and social skills.
“But it’s also somewhere that they can learn to compensate for those acquired difficulties, they can learn new ways of trying to do things and with the right support around them that can be really successful.”
The resources are off the back of an independent inquiry from 2018 which outlined a number of recommendations for the government to undertake to better care around brain injury.
The Time to Change report also displayed some alarming statistics, such as traumatic brain injuries costing the NHS around £15 billion a year.
Furthermore it led to the formation of N-ABLES, which includes professionals from a range of backgrounds including head teachers and both educational and clinical psychologists.
The All-Party Parliamentary Group on Acquired Brain Injury (APPG on ABI) discussed the improvements, including allowing ABI to be classed as a special educational need.
However where UKABIF and N-ABLE’s are currently concerned is around making sure all education professionals have a minimum awareness and understanding of the condition.
The Department of Education has been heavily involved with this, but all organisations are aware that every child’s needs are different and they need to be empowered from this.
“The guidance was made off the back of that Time to Change report,” Dr Bennett said. “One of the recommendations in the education section was that we needed a clear pathway and support for returning to school after ABI.
“What we’re faced with is a situation where there’s a handful of pathways and processes around the country, but in most areas there’s a real lack of any coordinated or collaborative learning around this.
“We discussed clinical experience and thought about how we could produce a set of core principles to provide this effective support around a return to school.
“What we wanted to do was to make sure that the guidance was really focused on the child and young person, but then encouraged professionals to work together around a set of shared principles.”
More recently the UK has undergone some huge changes to its educational practices brought on by the pandemic, leading to a large-scale return to school effort after lockdown.
Dr Bennett says this has been a tough time for those affected by ABI.
“I think clinically our experience has been really mixed. From a rehab perspective, you lose a lot with home schooling, especially that experience rich environment.
“For those who have had an injury during COVID, it’s been really complicated as we’ve wanted to get them back into school and get them that natural rehab that they need.
“It has been more challenging and I think COVID hasn’t helped any of us, but it’s certainly not made life easy for young people with an acquired brain injury.”
Dr Bennett also said there has been a real positive reaction to this new approach from educational staff, with the resources set to be sent out to more schools in the coming weeks.
The guidelines were first announced at The Children’s Trust National Paediatric Brain Injury virtual conference, with that particular charity also recently publishing its own set of recommendations in this area.
50,000 call on government to fix broken dementia research promises
Alzheimer’s Research UK has pleaded with the UK government to invest in dementia studies, as it promised to do back in 2019.
More than 50,000 people have signed a petition to ask the UK government to double its funding for dementia research and keep the promises it made two years ago.
Boris Johnson initially said there would be £160 million invested into the sector in the 2019 Conservative manifesto, but there has been a lack of movement in this area since.
This has spurred the Alzheimer’s Research UK charity to launch the petition, calling on Number Ten to help fund possible treatments for dementia.
The pandemic has been particularly hard for those with the disease, with a quarter of COVID-related deaths coming from this group.
The charity feels the sector has been neglected in recent years with David Thomas, head of policy at Alzheimer’s Research UK, saying the funding is the best chance of curing the condition.
“Dementia research is an area of huge need,” he said. “There are a huge number of people affected by it and with an aging population that will only increase.
“There are currently no treatments in the UK for the disease so we think research is vitally important to tackling that.
“We’ve seen an historic underfunding for dementia research. When the Conservatives announced their manifesto and made a commitment to double dementia research funding we thought that would be a great step forward.”
An Alzheimer’s Research UK supporter has also made a personal plea with the government to change this.
Olive Munro lives with vascular dementia and this week she submitted a letter to the Prime Minister asking him to make sure future generations do not suffer the same fate as her.
“She supports our campaign,” David said. “Her letter set out the impact that her diagnosis has had on her life and ultimately she wants to ensure that her children and grandchildren don’t have to go through a similar terrible situation.”
“I think it’s a really powerful message Mrs Munro has sent.”
The pandemic has been a big player in regards to this underfunding, but its impact on those with dementia has only heightened these concerns.
As well as this a lack of finances have meant that a number of researchers across all sectors have been lost, only making the situation worse.
This is why the charity has chosen to call on the government now. With the crisis in its latter stages Alzheimer’s Research UK wants to see a similar success that has come about from the vaccination programme.
“We understand that COVID has played its part,” David said. “It has had a significant impact on government priorities and we’re very sensitive to the fact that since the promises were made we have been in this crisis.
“But with the pandemic moving into a different stage and the vaccine programme being such a big success, now feels like the right time to meet that commitment.
“COVID has had a devastating impact on people living with dementia, so we think the pandemic has made this more urgent not less urgent.”
There is support across parliament for this investment, with over 100 MPs across all major parties supporting the move.
The petition has also been signed by some famous names, including Dame Judi Dench, Julie Walters, Stephen Fry and Dame Harriet Walter.
If it were to progress and the government were to double dementia funding then it would have a profound impact on the sector.
“Ultimately what we hope that funding will lead to is new treatments in this space that will ultimately stop the progression of the disease, which we haven’t got at the moment.
“We also hope it will lead to improvements in detection and diagnosis of the disease as that is really important.
“One particular thing we think the additional funding could do is ensure that we don’t lose a generation of researchers and that we keep and expand that talent, because that’s the people who will be responsible for delivering those life changing treatments.”
Away from the UK there has been some progress in this area.
In America the first dementia treatment in over 20 years was approved recently, which is a landmark move.
David is hoping this can send a clear message to the UK government that progress for this really is possible.
Many in the research industry are hoping this will lead to the approval of further treatments, as well as more investment from big pharmaceutical companies.
There is certainly the appetite for these changes, as Alzheimer’s Research UK has shown, but it is now in the government’s hands to act upon this.
“We have over 50,000 people who have signed the petition and we are well aware that behind each one is a story around the impact dementia has had on them,” he said.
Headway and Centurion come together for Hard Hat Awareness Week
Construction sites are often danger zones when it comes to head injury, an issue which one charity and safety company are hoping to tackle.
Brain injury charity Headway has partnered with safety manufacturer Centurion in an effort to educate those in the construction industry around concussion and brain injuries.
Hard Hat Awareness Week runs from June 14th – 20th and is designed to make sure those in the building sector are following the best practices to avoid any potential head injuries.
As well as this both groups are using the event to help people spot the signs of concussion for both themselves and their coworkers through a series of educational media pieces.
Like Griggs, deputy chief executive at Headway, said campaigns like this are vital to showing people the serious nature of a head injury.
“We have been running our concussion awareness campaign for a while now,” he said. “But that has been primarily focused on the world of sport.
“With this what we are trying to do is to raise awareness and make people realise that concussion and head injuries are not just confined to sport.
“It can happen to anyone at any time, so we are gradually opening up the concussion awareness campaign to other facets.”
Ultimately the week is being used to remind workers of the importance of wearing a hard hat on site.
When operating heavy machinery and materials a blow to the head can have some life changing consequences, which is why Headway are pushing this message.
“It is absolutely crucial that we make people aware of the signs and symptoms,” Luke said. “People also need to be aware of the consequences, not only for themselves but for others around them.
“Construction sites are intrinsically risky places, despite the fact that the industry itself has improved so much in terms of its health and safety on site, head injuries still remain.
“We need to educate people on the importance of prevention, to make sure that they don’t see a hard hat as just something they’re forced to wear because you just never know when it might save your life.”
The charity has also pointed out the need for a societal shift in this industry, saying because it is a masculine sector people can often attempt to ignore a concussion.
Furthermore a lot of construction workers are either self-employed or contracted, meaning a lot of them can’t afford to miss a day’s work and won’t do so because of a headache.
“There’s still a degree of a kind of ‘macho’ culture in the construction industries,” Luke said. “Even though this is beginning to change it still has that element of not taking a minor head injury seriously.
“For many construction workers if they miss a day’s work they’re not necessarily going to be paid for it, they’re not going to be backed up by sick pay or any kind of protection in that respect.
“That is causing a serious concern and it is half the challenge here.”
Headway and Centurion ran the first Hard Hat Awareness Week back in September 2020, which came off the back of a survey run by the charity around construction site safety.
This produced some concerning results, saying 86 per cent of workers had suffered a blow to the head but only 52 per cent reported it.
More worryingly only 6 per cent sought medical attention, while a further 79 per cent didn’t take any time off after their injury.
“The survey backed up what our fears were,” Luke said. “It’s vital to rest and to not overdo it because otherwise you’re going to exacerbate injury, taking even more time to recover.
“The difficulty and some of the attitudinal issues we found with that survey were the reasons why people aren’t aren’t doing it, some of which we can challenge others that are proving to be more difficult.
“So there’s real work to be done now with the construction industry and we have tried to reach out to all the major construction players in this area, to actually help to educate people around concussion.”
Centurion are one of the biggest personal protection equipment companies in the UK and they are helping lead the way with this initiative.
One thing both organisations are also pushing throughout the week is the importance of properly mating hard hats and what role this can play in a person’s safety.
As important as it is to make sure people are wearing this safety equipment, if it is not properly looked after then the risk of injury increases.
Workers can still comply with regulations by wearing a hard hat, but if there is any defect in it then they are not sufficiently protected.
Through adverts on industry radio, educational posters and by working with the big companies in the industry Headway are hoping to minimise the short and long term effects of a head injury.
“It’s important to take this ‘if in doubt, sit it out’ approach, which is in everyone’s interest, including the individuals and their long term health, which could be affected if they don’t take it seriously.
“Every year Headway supports new people whose lives have been devastated by brain injury and the most tragic ones are always the ones which could have been prevented.”
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