Ottobock is big news in Germany. When the company celebrated its centenary earlier this year, German Chancellor Angela Merkel addressed 350 distinguished guests from politics, industry and academia at its Lower Saxony HQ.
On the world stage too, it is a dominant force, with a team of over 7,300 and an array of mobility-boosting products available across the globe.
The company exhibited at this year’s European Neuro Convention in Birmingham; and NR Times took the opportunity to explore its newest offerings.
Among them is latest version of C-Brace, billed as ‘the world’s only stance and swing phase controlled orthosis’. For users affected by partial or total paralysis of the knee extensors, this means being able to walk more naturally.
In neuro-rehab terms, this might be required for example, after stroke, brain injury or polio. In the past, paralysis orthoses were limited to locking and unlocking the knee joint, leading to abrupt movements – for example when sitting down.
The C-Brace, however, is able to respond rapidly and intelligently to the user’s immediate situation, including to tripping situations.
An integrated microprocessor controls the stance and swing phase of the leg, and therefore the entire gait cycle. The result is that users no longer need to pay attention to every step and can navigate stairs, uneven ground and slopes more naturally.
The new generation of C-Brace comes with a few useful additions. The sensor technology has been stepped up to make it more dynamic and sensitive than previous versions.
A clever introduction is the Cockpit smartphone app that enables users to adjust their joint and switch into different modes such as ‘cycling’. It is also supported by the Setup app, designed for the orthotist’s use.
An additional advancement is that it is smaller, so can be worn under clothing; it is also lighter, meaning less effort is needed to walk.
Jana Middlebrook (pictured above), Orthotic Academy clinician at Ottobock UK, says: “Everything we do is aimed at improving the patient’s life and reducing the impact their disability has on them. With other braces on the market, it can be easy to accidently unlock the knee, particularly on stairs or slopes.
“The C-Brace will lockout to prevent the patient from falling. This computer controlled brace enables the user to walk step over step and to have a controlled sit. Often if people have weakness in their quad muscles, they end up throwing themselves down when they sit. This prevents that.”
Also relatively new to Ottobock’s product portfolio, meanwhile, is the Bioness L300 Go. Created by Californian-based Bioness, this is a functional electrical stimulation (FES) system designed for patients with foot drop, for example in MS or after a stroke.
FES involves the application of small electrical charges to a muscle that has become paralysed or weakened, due to brain or spinal cord damage. The electrical charge stimulates the muscle to make its usual movement.
With foot drop, disruptions in the nerve pathways between the legs and the brain prevent the foot from being lifted to the correct angle when walking. FES can help to change this.
Ottobock has been the exclusive distributor of the new FES generation and a strategic partner of Bioness since September 2017. This latest product was introduced to the UK last year.
As well as electric stimulation, it provides support for instability of the knee and can be used for both children and adults. It is available as an independent lower leg system (L300 Go), a combined lower leg and thigh system (L300 Go and L300 Go Plus Upgrade) and as an independent thigh system that uses a foot sensor (L300 Go Plus Stand Alone).
Features include 3D motion detection, multichannel stimulation, Bluetooth programming and a user app for mobile devices.
Middlebrook says: “Importantly, it doesn’t have wires so the patient can just pop it on and off and it doesn’t require the fishing of electrodes, which is quite a complicated technique required to make sure the correct nerves are stimulated.
“The technology works on gyroscopes on three planes so, rather than just being able to walk in a straight line, users can walk diagonally and backwards, and it will still work to lift the foot clear of the ground. With the upgraded version, you can also control the knee.
“If there is a much higher level of weakness, you can stimulate the quads or the hamstring muscles to control knee hyperextension or knee flexion.”
L300 Go is supported by a ‘learning algorithm’ that adapts to changes in gait dynamics and deploys stimulation within 0.01 seconds. The device controls dorsiflexion (movement of the foot upwards) and inversion/eversion (tilting the sole of the foot inward and outward) with a single electrode pad – plus acceleration sensors which monitor movement patterns on three planes.
Other features include an optional foot sensor and remote control and an app that allows users to monitor their own therapy progress.
For more information on this and other Ottobock products visit: www.ottobock.co.uk.
Top tech and devices for at-home stroke rehab
While COVID-19 lockdown continues to play havoc with people’s plans and appointments, with many going into isolation during this time, rehabilitation in its traditional setting is not always possible…
However, for stroke patients, there are many options available to help sustain their recovery at home, several of which make use of the very latest in cutting-edge technology.
The Stroke Awareness Foundation is vocal in its promotion of the adoption of the latest tech, which often also enables users to make vital progress they may not have done without their usual specialist rehab.
Here, NR Times looks at a few of the options out there:
A high-tech project for cognitive rehabilitation after stroke, Cogwatch is a behaviour tracking system which will help patients who struggle with basic day-to-day activities. The system uses intelligent objects like a mug or kettle and the Kinect motion tracker to monitor the patient as they perform a task, such as making a cup of tea.
It will use behaviour prediction algorithms to detect when a person makes an error and will prompt them to correct their mistake.
The technique is based on methods used by occupational therapists as part of rehabilitation and can allow patients to access therapy practice in their own homes without the need for a therapist to be present – particularly important in the present climate where many people are self-isolating. Cogwatch is currently developing technology to assist with other daily tasks, such as preparing food and getting dressed, to help with regaining independence.
The smart glove, developed by Neofect, is a high-tech stroke rehab product for the hand which follows motions, measuring even the slightest movements with sensors while performing gamified exercises.
The glove builds on the benefits traditionally delivered by using hand putty, introducing a way of achieving therapy at home with the use of cutting-edge technology. The smart glove ensures a user completes their exercises correctly and gives instant feedback.
FitMi interactive therapy
The FitMi home therapy system helps users to accomplish the high repetition of exercise necessary to achieve results. The product, developed by Flint Rehab, has been proven to deliver benefits to leg, arm and hand mobility. It can adapt to a user’s level of mobility, even if that is minimal, and offers the motivation to continue via a computer.
The system is used in over 300 therapy centres worldwide and a fast-increasing total of 10,000 homes, with FitMi proving to be a rehabilitation option for stroke patients during isolation.
While a relatively simple device, its effects can be significant and is a low-tech option for users who are less confident in using technology.
The benefits of mirror therapy have been proven over several years and delivers benefits to stroke patients struggling with hand paralysis or clenched hands after stroke. The mirror box works by placing a mirror over the affected hand and uses its reflection to ‘trick’ the brain, retraining it to move the hand over time.
As part of rehabilitation at home, gaming can play an important role. Motion-controlled consoles like the Xbox Kinect or Nintendo Wii offer games which can motivate independent movement as a form of physiotherapy. The Able-X system comes with an adapted handset to allow patients with greater levels of paralysis to use their more able arm to help coordinate movements of the affected side.
Software developer Roke has also created a programme which links with the Kinect to track the movements of a person’s fingers, which can support the rehabilitation of the hand following a stroke.
There are increasing numbers of apps emerging for use by stroke patients as part of their recovery. Medical News Today points to the breadth and efficacy of apps on the market, including those which allow a patient or their loved ones to track appointments and medications, provide language therapy, train the brain, and even lower some risk factors for future strokes.
Among the selection include Cozi, a family organiser app which can help keep track of appointments through a colour coded calendar, and shopping and to-do lists can be shared with loved ones and updated in real time. Medisafe is another app which is recommended for enabling patients to keep up with their medication and dosage.
On the more physical side, the 7 Minute Workout Challenge app is a research-backed exercise programme which enables people to tailor their own programme depending on their stage of rehabilitation.
The developers of the app have put together 12 exercises to perform for 30 seconds each, and is built on research published in Neurology journal which claims exercising three to five times a week reduces the likelihood of a recurrent stroke by five-fold.
Virtual reality (VR)
Research has shown the effects of VR on stroke patients, both in immersive and non-immersive formats. In immersive VR, the person becomes fully ‘immersed’ in their environment through use of a VR headset, or non-immersive is delivered through a computer screen.
The user can control what is happening in both versions of VR by use of a joystick, mouse or sensor, and can experience welcome distraction in their immersive environment.
VR is said to play an important role in helping rehabilitation of the upper and lower limbs of stroke patients, as they recover motor skills and the brain forms new neural connections.
Users have reported an increase in confidence and a greater likelihood of using their affected limb spontaneously.
VR equipment can be used in a rehabilitation setting or at home, with the latter proving to be an enjoyable option for many people during isolation.
Arm training wheel
A more basic option than those which rely on technology, the arm training wheel can be an effective home rehabilitation option.
A weighted wheel, such as the Rolyan Pronation and Supination wheel, allows a user to strap their hand into the device and perform rotations on a tabletop.
The device has been credited for helping stroke patients who have suffered arm and hand paralysis or mobility problems, enabling them to exercise their hand even when the shoulder and arm muscles do not move at all.
Users have reported increased sensation and functionality in areas of their body which previously had little to none.
A 20-year adventure in rehab robotics
Tech pioneer Hocoma has long been pushing the boundaries of innovation in rehab. Now marking its 20th anniversary, it plans to step up its ability to drive better patient outcomes, as Deborah Johnson reports.
Back in 2000, the world was a very different place, particularly in terms of technology.
Many of the high-tech innovations we now accept as standard were not yet launched and healthcare remained one of the most traditional markets around.
Yet into this climate, Hocoma launched the prototype of its pioneering Lokomat, a robotic medical device which provides repetitive and highly physiological gait training to patients, enabling even some of the most impaired to learn to walk again.
While it has gone on to become one of the world’s leading robotic medical devices, in 2000, it was a significant and controversial disruption into a long- established and relatively low-tech rehab scene.
Clemens Muller, global head of clinical and scientific affairs at Hocoma, says: “Twenty years ago, gait rehabilitation was completely different.
Therapists had to physically move patients’ legs – a manual task that can be very tiring and requires huge effort, particularly when you are doing it many times a day.”
Gery Colombo, a trained electrical engineer with an interest in neural rehabilitation, founded Hocoma alongside Peter Hostettler, an economist, and Matthias Jörg, a biomedical engineer.
“The founders realised the need for a change to this way of doing things and to find a better solution,” says Clemens.
“They wanted to establish a venture which could use their specialist knowledge and go in a particular direction, with a purpose and intention.
“The goal was to change rehab as it was known. This was absolutely new; in fact so new and innovative that the world of healthcare rehabilitation wasn’t really ready for it.
“This was a challenging phase but one in which Hocoma needed to be really entrepreneurial with a very clear vision and focus and to keep on going.
“It did take a little while until it was accepted and it was a long journey for the founders.”
Despite the initial challenges of launching such a high- tech product, over the past two decades, the Lokomat has become one of the most widely used gait rehabilitation devices in the world.
It has helped to set an industry standard in rehab products for people with brain injury, stroke and other neurological disorders.
Hocoma recently installed its 1,000th Lokomat.
But it has also built on the success of its flagship product by launching an array of other devices.
Among its product portfolio is the Erigo, which assists with patient mobilisation in the earliest stages of rehabilitation; its Armeo range, which supports the recovery of arm and hand function; and its Valedo products that targets back pain.
The business is headquartered in Switzerland but works in 27 countries worldwide – and believes it is changing the lives of people in clinics across the globe.
Clemens says: “I think there are three drivers behind innovation in healthcare – social aspect, which includes demographic changes and the shift from using products which are based on evidence rather than just experience; the technology changes in the world as a whole; and the clinical changes, which are moving on quickly and have changed dramatically to encompass robotics and exploit the previously unused potential of this way of therapy.
“These drivers have changed, and continue to change, the landscape of the world in which we work. Hocoma has always been at the front pushing the boundaries and helping to change the resistance there was at the beginning of our journey.
“When you went to a rehab conference 15 or 20 years ago, there was only one tech provider there, which was us.
“But if you compare that to now, there can be anything up to 20 companies at an event, including start-ups that are working in technology fields like robotics or sensor-based equipment, offering products for inpatients and outpatients, for acute needs. So there is a huge selection now available.
“There is also the demand from the market to integrate technology. The key for us has always been how to integrate this technology into a routine of therapy to use it to its full potential.
“It is about not only being engineering-driven but understanding how to use that to make a bridge to the rehab world and understand the link to the human world – bringing the know-how and capability and opening that up for the needs of patients.
“As a market, we do need to do more homework in that area.
“Lots of clinics already have integrated the technology they are using very successfully, and with our products it makes us proud to see how the patient is being supported to the highest level.
“I have seen this happening in many clinics around the world and it gives me goosebumps to see how happy patients are with how it is working for them. It also makes a huge difference to the work and demands placed on the therapist, and that is something that also makes us so proud.”
Now celebrating its 20th anniversary, Hocoma’s ambition for the future is to continue changing lives and reaching out to millions more around the world.
A strategic move in achieving this came in 2017 when Hocoma joined its now-parent company DIH – bringing it under the same roof as other rehab technology developers including Motek.
“We have always been a pioneer since we were established so we will continue this with new and better solutions to benefit people’s lives.
“Our focus is on bringing solutions which are innovative, high quality, effective and efficient.
“The future for us will of course be affected by the healthcare market in general. We are seeing a rapid demographic change around the world and this will mean a change in the healthcare approach.
“There will be a search for solutions.
“With the huge move towards digitalisation through the Industrial Revolution 4.0, there will be a greater role played by artificial intelligence and virtual reality.
We will continue to develop as a business so we can continue to be at the front of what is happening.
“Traditionally, we have come up with a new innovation every year, which could be a new product launch, or else new features or a new version of an existing product, but we are always developing what we have to make it the best it can be.
“We are always learning by doing and have a network of research and academic partners all over the world and this enables us to come up with great products which deliver solutions.
“We are planning heavily in our development team and are continuing to develop our launch plan and product road map.
“We hope the global coronavirus outbreak and the shutdown we are seeing around the world does not affect our plans too much in the short-term, but we will have to see how that develops and adapt to that as we need to.”
As a business which has helped to change traditional practices and approaches in rehab globally, one area in which Hocoma would like to push for further change is in widening patient access to its own products, and other high-tech solutions.
“At the moment, it is not a given that all patients and all clinics will have access to our products. Of course technology has its price, but we need to address that at some point.
“We need to work with clinics and insurance companies to try and find a solution here and to shape the future of rehabilitation.
“It is important to find optimal solutions which increase access to technology, to improve the quality of rehab, while looking at the cost effectiveness of such products.
“Over the next five to 10 years, there are going to be more stroke, cerebral palsy and traumatic brain injury patients who are needing innovative solutions and our goal is to develop more solutions which will benefit them and the therapists.
“When money and costs are involved it can often be a long journey, but we believe if all stakeholders got together to find a way of best dealing with this, together we could deliver the best rehab to patients, and this is something we would like to be involved in delivering.”
An uprising in rehabilitation
The rise of online content services has revolutionised TV viewing and music consumption in recent years. And in neuro-rehab too, it is changing approaches and patient interactions.
Leading the way in this new world order is NeuronUP – an online platform which is helping rehabilitation professionals across the globe to drive better outcomes from their patients.
The tool features more than 10,000 activities, classified into 40+ different cognitive processes and areas of occupation; with new materials released every fortnight.
CEO and founder Iñigo Fernández de Piérola set up the company based on his experiences as a neuropsychologist and his work with patients with neuro-deficits, including those caused by brain injury. In the years preceding its 2011 launch, recognition had grown of the need to carry out more ecological neuropsychological assessment (Tirapu, 2017).
There was a movement towards more “ecological, motivational and personalised content in the process of cognitive stimulation and rehabilitation”, allowing clinicians to better assess the accurate functional condition of individuals, NeuronUP states.
Cognitive functions are interrelated, and interdependent on a functional and anatomical level, the company explains.
When daily tasks are carried out, neural combinations that recruit specific neuropsychological processes to perform it are put into play.
NeuronUP’s goal is to identify these processes and design useful and relevant activities for neuropsychological rehabilitation, occupational therapy and speech language therapy.
An initial collection of materials was released in 2012, which has since evolved into a multi-faceted tool used by professionals across the globe to help patients with cognitive deficits.
But in a world where brain training ranges from mainstream fad to seriously researched approaches, Fernández de Piérola cautions that the platform is nothing without professional input.
“The material by itself does nothing. The patient is not going to improve his memory in six weeks, pressing a button on a tablet for example, he or she needs to be guided by a professional.
“If the professional is bad, the platform isn ́t going to do magic.”
Ongoing work continues among professionals using the platform, exploring the cognitive processes within specific conditions, such as MS, acquired brain injury, Parkinson’s and forms of dementia.
This research will then shape future content.
The platform, says Fernández de Piérola, is used in many different ways by professionals – often influenced by varying country-to-country approaches.
“Here in Spain we can’t tell someone in Australia how to work with their patient.
“Professionals have the ability to adapt the materials of the platform to their interventions in many different ways, always according to the needs of each specific patient.
“The platform can either be used in the clinic, or the patient can log into it from home and work through a session the professional has created ahead of time, via its ‘NeuronUP2GO’ option.
“So, there is a lot of variety in terms of how that professional wants to work and there is really no set way to use it.
“It really depends on the individual’s needs and we help to make the professional ́s job easier.”
User-friendliness is crucial in enabling patients to access intense therapy at home, whether they can do it themselves or with the assistance of family members.
“It’s created with the idea that they can log in and the materials are ready to go and they can work through that intense therapy.”
Common feedback from professionals is that the platform saves them time, enables them to better plan sessions and increases patient motivation.
“Our focus will continue to be on creating new materials. Just like Netflix is a platform for video content, we want to continue being a source for good neuro-rehab and cognitive stimulation materials. Also, we want to add extra features to compliment the platform.”
Surprisingly for an online service, these features include paper resources which many professionals still prefer to use.
But there are also advanced technical additions planned, including virtual and augmented reality content.
The company is also developing a series of content focused on the link between neuropsychology and emotion – “an underdeveloped aspect of neuropsychology,” according to Fernández de Piérola.
“It’s early days but we’re currently working on a social cognition part of this, looking at how we can move from that to something that helps people with social challenges.”
But the company says its most significant development in coming years will be implementing greater use of the 150 million+ pieces of data it has related to neuro-rehab interventions.
“We are currently analysing this data and aim to put it to use in modelling future content. We want to be able to predict cases and develop content that could help professionals to do so too.”
NeuronUP’s content is increasingly being used in research projects around the world.
Among them was a study by the University Hospital of Tenerife, presented at the European Congress of Neurology in 2018.
MS patients received 24 sessions of “computer assisted” cognitive treatment through NeuronUp. Significant improvements in verbal memory, delayed visual memory, working memory and semantic fluency were noted.
Also, MRI analysis showed a 0.7 per cent increase in the global grey matter volume in most patients.
There was also a decrease in certain problems within learning and memory processes, suggesting that cognitive therapy improves cognitive performance; and may induce structural and functional changes in the brains of MS patients (Plata-Belle et al, 2018).
The platform is currently used in over 25 countries spanning 1,000+ facilities and 4,000 professionals.
Around 40,000 patients have now had access to its content. Part of its overriding appeal, says Fernández de Piérola, is its personalised approach.
“It’s important that the content is relevant to the patient. Something that motivates them. So, we have over 10,000 activities and a lot of these can be personalised.
“For example, in a word search you could add in the name of a patient’s favourite football player, or the name of their grandchildren.
“This personalised approach extends to the provision of one-to-one webinars for professionals using the platform. It gives the client the possibility to interact with the NeuronUP team at almost any time.
“We love it when our clients interact with us. We want them to check out the new content and tell us how it is affecting their clients.
“We love to get suggestions as well, if we can create something that will be useful in your practice, we ́ll do it!”
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