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Stroke

Rehab device enables stroke survivors with arm disabilities to do more training

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A rehabilitation device can increase the amount of arm exercises stroke patients do without professional supervision, according to a new study.

Over five million people in the UK live with arm weakness, with stroke damage accounting for one million people of those people.

The only intervention shown to improve arm function is repetitive, task-specific exercise but this is limited by the cost and availability of occupational therapists and physiotherapists.

The GripAble device, created by researchers at Imperial College London and clinicians at Imperial College Healthcare NHS Trust, consists of a lightweight electronic handgrip that interacts wirelessly with a standard PC tablet to enable the user to play arm-training games.

To use it, patients squeeze, turn, or lift the handgrip, and it vibrates in response to their performance whilst playing. The device uses a novel mechanism, which can detect the tiny flicker movements of severely paralysed patients and channel them into controlling a computer game.

In a clinical trial of 30 patients, researchers from Imperial College London, the University of Southampton and Imperial College Healthcare NHS Trust found that the device enabled on average 104 upper limbs (UL) repetitions per day whereas conventional therapy achieved 15 UL repetitions per day.

Michelle Broderick, lead author of the study and clinical research therapist in stroke at Imperial College Healthcare NHS Trust, said: “Stroke is a major cause of arm weakness in the UK. It can significantly impact survivors’ lives, making it hard for them to do routine daily tasks, limiting their independence.

“Previous studies have shown that repetitive exercise is vital for improving arm weakness, but this can be difficult due to resource constraints within healthcare settings, as well as the range of challenges faced by stroke survivors during their recovery, which can limit their ability to initiate or engage in independent exercise or rehabilitation activities.

“This study is the first to show that a rehabilitation device – GripAble – can achieve significant increases in the amount of exercise patients do compared to supervised therapy.

“Our findings suggest that a significant proportion of stroke survivors may potentially benefit from GripAble alongside conventional therapy. This could improve patient outcomes as well as easing pressure for the NHS in terms of infrastructure and resources.

“The next steps to fully determine GripAble’s impact is to assess the technology across a wider section of the population over a longer period of time.”

Dr Paul Bentley, co-author of the study and clinical director of the Imperial College Network of Excellence in Rehabilitation Technology at Imperial College London, added: “The findings from this clinical trial provide evidence that GripAble can be adopted to help further support stroke patients with severe arm weakness with their rehabilitation unsupervised.

“This could have big implications for the NHS, given that recovery from stroke is strongly influenced by exercise intensity. Our technology can be used by patients to continue with their physiotherapy outside of standard treatment and help with their recovery.

“The long-term aim of GripAble is that patients can use it outside of a clinical setting such as in their homes and communities and we are now working to further assess the device?s impact on clinical outcomes.”

UL impairment is the most common physical side effect of stroke, with 60 per cent of stroke survivors experiencing persistent UL weakness. Repetitive task-directed exercise improves long-term UL recovery, making this a key component of occupational therapy and physiotherapy following a stroke. However, this is limited by cost and availability of therapists.

In recent years, a growing number of rehabilitation technologies have emerged that boost the potential to provide cost-effective, intensive UL exercise.

However, studies of rehabilitation technologies to date have typically focused on high-functioning cohorts of patients, which limits the applicability of their findings. The researchers wanted to see whether the GripAble device could be used to increase exercise dose of inpatient stroke survivors.

The team recruited 30 patients with UL weakness as a result of stroke from Charing Cross Hospital, part of Imperial College Healthcare NHS Trust, between September and December 2019. All participants were provided with the GripAble device and taught to use it in a single training session. The participants were then left to use the device without any supervision over eight days.

The researchers then compared the number of UL repetitions patients did as a result of the device with conventional therapy at the hospital. They found that 26 patients were able to use the device meaningfully with their affected UL. The device enabled 104 UL repetitions per day, whereas conventional therapy achieved 15 UL repetitions per day.

They also found that on average patients used the device for 26 minutes per day to do their UL exercises, in addition to 25 minutes daily conventional UL therapy, therefore doubling total exercise duration to 51 minutes, which is significantly greater than standard care.

After surveying the participants, they also found that 57 per cent found the device easy to use and understand and 63 per cent felt that the device promoted UL recovery.

The team will now conduct a further study to access the impact of GripAble on clinical outcomes.

The study was funded by NIHR Imperial Biomedical Research Centre (BRC).

News

Sexual trauma ‘could lead to neurological conditions’

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Traumatic experiences, including sexual violence, could be linked to dementia, stroke and other brain disorders in women, new research has indicated.

Links between such trauma and poor mental and cardiovascular health are already established – but a new study suggests they could also be linked to indicators of cerebrovascular risk that may be a precursor to neurological conditions. 

To date, little research has been done to examine the relationship between traumatic experiences, including sexual assault, and indicators of small vessel disease in the brain. 

But a new study from the University of Pittsburgh specifically investigated whether traumatic experiences were associated with white matter hyperintensities (WMHs), which are markers of brain small vessel disease. 

WMHs can be detected decades before the onset of dementia, stroke, and other neurological risk and can serve as early markers. 

Of the nearly 150 mid-life women involved in the study, 68 per cent reported having at least one trauma, with the most common trauma being sexual assault (23 per cent of the women). 

After evaluating the data, researchers concluded that women with trauma exposure had greater WMH volume than women without trauma. The particular trauma significantly associated with WMH was sexual assault.

Associations between sexual assault and WMHs persisted even after adjusting for depressive or post-traumatic stress symptoms, suggesting that sexual assault may put women at greater risk for poor brain health.

“The results of this study are noteworthy in that sexual assault is an unfortunate, yet all-too-common, experience for women; national data indicates that, on average, up to a third of women have had this experience,” says Dr Rebecca Thurston from the University of Pittsburgh and lead author of the study.

“This distressing experience is not only important for women’s mental health, but also their brain health. This work is a major step toward identifying a novel risk factor for stroke and dementia among women. 

“Not only do these results underscore the need for greater prevention of sexual assault, but also provide healthcare professionals with another indicator of who may be at most risk for stroke and dementia later in life.”

“Identifying early warning signs of stroke and dementia are critical to providing effective intervention,” says Dr. Stephanie Faubion, North American Menopause Society (NAMS) medical director. 

“Studies like this one provide important information about the long-term effects of traumatic experiences on a woman’s overall well-being and mental health.”

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Stroke

Preventing strokes through AF detection

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With 1 in 4 people over the age of 40 likely to develop a heart rhythm disorder like atrial fibrillation (AF) in their lifetime, the risk of experiencing an AF-related stroke has never been higher. NR Times learns more about Fibricheck, a fast-growing international solution which can detect irregularities and deliver actionable life-saving results

 

Undetected and untreated AF is responsible for 20 to 30 per cent of all strokes, making it the single most important risk predictor for suffering a fatal or debilitating stroke.

Studies estimate that someone suffers an AF-related stroke every 15 seconds. One of these stroke cases was the father of FibriCheck co-founder and CEO, Lars Grieten.

Since the majority of these strokes are preventable with timely diagnosis and treatment, the idea for FibriCheck was simple – develop something that is easy to use, by anyone, at anytime, anywhere, and doesn’t require a costly device or a trip to the doctor.

Having started as a clinical research project in a Belgian academic teaching hospital in 2014, FibriCheck has gone from community bedside to the international stage with their clinically-validated and compliant smartphone app that enables people to remotely monitor their heart at home, whenever they choose over a selectable duration.

In as little as 60 seconds, users have validated real-time results and actionable findings they can share with their provider, improving timely detection and intervention for better health outcomes.

Now a CE-certified class lla medical device in Europe and the UK, with regulatory approvals from the FDA (US), TGA (Australia), Singapore’s HSA and the UAE’s Ministry of Health & Prevention, FibriCheck has garnered adoption worldwide since the pandemic through its ability to overcome many of the traditional access to care barriers – saving travel and appointment times for patients, redcuing diagnostic waitlists and backlogs and providing a scalable approach to population health management and continuity of usual care.

“The intermitten nature of AF, especially in the early stages makes it difficult to capture during scheduled appointments and annual checks,” says Felicia Vaz, who leads market access and business partnerships at FibriCheck to understand the company’s current global impact and how they’re working to transform care.

“This results in a lot of repeat visits, and to the frustration of patients and clinicians alike, yielding not a lot of evidence to explain what’s going on or how to proceed.

“While simple to undertake, routine testing for AF is not generally done before 65 owing to resource intensity, scarcity of diagnostic devices and long appointment waits.

“Despite knowing AF doesn’t discriminate, causing strokes and heart problems in people as young as 40, this balancing act of who and when to check and who should be prioritised is naturally challenging for the health system and providers, as many patients present with palpitation complaints year over year, without data or results to inform decision making.

“This ‘wait and see’ approach means patients often have to get worse before they can get better.”

FibriCheck’s first demonstration of its disruptive potential was proven in 2018 when the company screened approximately 65,000 people in a week, simply by placing a QR code in the local newspaper.

In addition to proving a tripling in detection rate by monitoring over the course of a week, compared to a single spot-check, the results also highlighted the significant impact large-scale detection programmes can have on population health outcomes improvement.

Importantly, the project also confirmed the feasibility and potential cost-effectiveness of supervised digital screening at scale.

The company is currently working with health system funders, clinical leaders and industry partners to implement targeted case-finding projects across the care continuum in countries around the world.

“Part of what motivates us at the company is the fact that our work helps empower and bring peace of mind to people,” says Felicia.

“More than the ‘thank yous’ we receive from our users that the solution helped save their life, it’s the feedback that the reports helped support a discussion with their provider, or the validation they feel when something is detected and the reassurance of knowing everything is ok when there isn’t.

“Likewise, we receive a lot of provider feedback that the application has helped to triage worried-well patients from serious ones, reducing appointment bookings and provider demand – freeing up more time for those that need it most. Or that they’ve been able to engage more of their hard to reach, at-risk patients with an at-home alternative to coming in.

“It’s the shared understanding that comes from both parties having been involved in the process. Ultimately leading to better medication adherence, treatment compliance and overall better outcomes.

“It’s user stories like this and knowing our work has an impact on people’s lives that pushes us to do what we do.

“For me personally, it’s about health system transformation, engaging people in their care and making things better for patients and providers, regardless of geography so that nobody, along with their loved ones, have to suffer through an unnecessary stroke and all that goes with a life-altering event.”

Prevention and health literacy hits especially close to home for Felicia, having watched her dad come back from a near-fatal and debilitating stroke at the age of 14.   

“People don’t realise how much life changes, not just for the individual and how they see themselves, but their family, their community, and society more broadly – impacts like exit and re-entry to the workforce, returning to routine activities like driving and new features of daily life like regular specialist and doctor appointments,” says Felicia.

“Not to mention the costs associated with rehabilitation, modifications to your home to support temporary or permanent disability. The reminder is always there. The issue is so much broader than the event itself. That’s what makes stroke prevention so important.

“It’s more than just a company mission statement for us, we’re driven to remove the barriers around accessible stroke prevention and transform the way care is delivered.”

The app itself was designed by and continues to be informed by users and clinicians to ensure it is fit for purpose and continues to evolve with care needs.

“Unlike a lot of tech developers who build solutions – often in a vacuum – to answer a problem, I’d like to think we put our users at the heart of everything we do because you can’t bring about lasting change without bringing people along,” says Felicia.

“And for that we have an amazing team whose unique lenses bring diversity to our work as widespread as our customers”

Having partnered with both Fitbit and Samsung pre-pandemic to help make its technology accessible to mass consumer audiences, the trend in people self-monitoring and managing their health via apps only continues to grow. Since Fibricheck’s first appearance in the UK in late 2019 through its partnership with Fitbit, it has seen adoption by over 30 NHS organisations, and over 150,000 patient users nationally, since March 2020.

And ith the rise of digital health during the past 18 months, Fibricheck’s adoption is ongoing.

”Digital health’s impact is better realise when we stop looking at health as a seperate thing, but rather embeded in daily life the way online banking or the shared economy has evolved,” says Felicia.

“It’s really exciting to be apart of the movement that is advancing and transforming the way we operate as a society.”

Pre-COVID, the company’s focus was primarily around case finding and detection. While remote monitoring post-treatment intervention was always a feature of solution, the prevalence of face-to-face consultations never necessitated a need by providers.

However, once COVID hit, the demand for FibriCheck grew exponentially, with the company being part of the physician-initiated and led TeleCheck-AF, which enabled thousands of people to access cardiac care at home.

Onboarding 40 leading hospitals and centres of excellence across 14 European countries in less than two months at the start of the pandemic, FibriCheck enabled remote AF management post-intervention via specialist prescription.

Telecheck-AF quickly became a pan-European response to the crisis, breaking new ground in the monitoring and provision of care continuity. And as the return to business as usual remains in flux, many clinics involved in Telecheck-AF are now adopting remote monitoring as standard practice, despite the return of face-to-face appointments.

“Through TeleCheck-AF, clinicans were able to replace 95 per cent of face to face visits,” says Felicia.

“We know AF detection rates dropped last year as non-COVID related care took a back seat with redeployment efforts and resources strained at the front lines.

“People were told not come in and consequently continue to be apprehensive about engaging with the system. Unsurprisingly, many high-risk and at-risk individuals continue to fall between the cracks while the system tries to recover and deal with the backlog of missed appointments and procedures, causing delays in life saving intervention.

“There are so many digital pathways that were created, and continue to be created. By working to deliver these things together, we can streamline and simplify the process for patients and providers.”

Felicia is a big proponent that the conversation needs to shift from digital inclusion/exclusion to digitally enabled/ supported if health equity is to be meaningfully achieved.

“In one of our recent implementations where FibriCheck was aligned to vaccine delivery, replacing annual in-practice pulse checks, our oldest female patient was 92 and our oldest male 83, which goes to show using technology isn’t hard, it’s just about making it easy for people and supporting them to do so,” she says.

“Many older people prefer using our app to attending appointments in person; as it supports their independence and reduces reliance on caregivers and family to facilitate their care. It also provides them with a sense of security by not having to go into the hospital.

“People are quick to say older generations can’t use technology and end the conversation there. This viewpoint is both ageist and limiting. Not only have more people embraced mobile technology during the pandemic, but for many it was their only connection to the outside world and their family and friends during lockdown.

“Reaching people where they are is one of the biggest advantages of digital health and where it can bring the most value to the system in engaging and informing the people they’re trying to help.”

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Inpatient rehab

‘The outdoors makes you feel alive and gives you an appreciation for life’

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A stroke survivor is drawing on his own personal experience to help others recover from life-changing injuries at the UK’s first brain injury rehabilitation centre focusing on outdoor activities.

Rob Morris’ life changed forever eight years ago when he had a stroke, aged just 29.

“I was putting my shoes on ready to step out the door, when I fell over a couple of times,” explains Rob, who was working as a lead instructor of outdoor activities at a centre in Cambridgeshire at the time.

“I knew instantly that something wasn’t right. I was dazed and a bit muffled. Luckily my girlfriend was around to call 999. 

“I displayed all the classic symptoms of a stroke, one sided weakness, facial palsy and speech difficulty.

“I was hospitalised for five days. For a couple of days, I was unable to talk. I was also unable to walk or move my right arm or hand.”

While Rob made a good physical recovery and returned to work, the longer-term effects were more subtle and took longer to present. 

Four years after his stroke, in 2016, Rob took on a new challenge, moving to the Lake District and joining the Calvert Trust as an outdoor activity instructor working with people who have disabilities.

“At the time it seemed like the perfect job,” he says.  “But with hindsight I was taking on too much.”

Rob found that working evenings and weekends was impacting on his health.

“I was giving everything to my job as I loved it, but I had nothing left at the end of the week.  

“Fatigue was a constant companion. Realising my own limitations, reluctantly I decided to step away from the career I loved.”

Recognising Rob’s talent and passion, The Lake District Calvert Trust offered him a new role as a development officer at Calvert Reconnections – its new residential neurorehabilitation centre for people with post-acute, acquired brain injury.  

The fully accessible centre is based within an adapted Grade ll listed building in Keswick and combines traditional clinical therapies with rehabilitation through the specialist use of outdoor activities. 

It is the first time this approach has been used in the UK.

Rob joined in Calvert Reconnections 2019 while the centre was under development. In June this year, the service opened its doors.

“I now have a set working pattern and a more focused office role, utilising many of the skills I developed over my outdoors career but applying them in a new way,” says Rob.

“I feel that I’ve got a unique insight into what we are trying to do at Reconnections. Although I don’t have a clinical background, what I do have is bags of enthusiasm, ideas and empathy for our participants.”

Calvert Reconnections actively seeks to incorporate a wide range of outdoor activities into each participant’s rehabilitation programme.

This may range from reflective activities such as fishing, bird watching or a nature walk to higher adventure activities such as horse riding, canoeing, rock-climbing and abseiling – all closely assessed and graded to a person’s interests and functional abilities. 

The centre’s highly skilled team includes neuro-rehab coaches, neuro-occupational therapists, a neuro-physiotherapist, neuro-psychologist and speech and language therapist.

“I would have jumped at the chance to do my own rehab in an outdoor setting,” says Rob. 

“The outdoors has so many benefits and you can already see the progress that is being made by our very first participants. 

“Extensive research shows that it can help individuals in their recovery from brain injury. It’s very exciting to be involved.”

Settled into his new role and happily married, Rob is now feeling positive about his future.

“My stroke hasn’t defined who I am, but it has certainly had an impact,” he continues.

“Fatigue is still the number one factor that I have to live with and plan my life around. I am able to do days that require a lot of energy but have to plan recovery time into my routine.”

Rob also retains his love of the great outdoors.

“The outdoor lifestyle has given me so many rewarding experiences,” he concludes.  

“From my first days working with kids on grass sledges on a hill to canoeing with three essential wheelchair users in the Lake District, I always find time to get outdoors and go and do something adventurous. 

“It’s these experiences that make you feel alive and give you an appreciation for life.”

Calvert Reconnections is now open and taking referrals. For further information. visit www.calvertreconnections.org.uk

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