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Technology in rehabilitation: what’s out there and how does it stack up?

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In today’s digital world, technology has a new role to play in increasing the efficiency of healthcare and reducing costs whilst at the same time ensuring that standards of care are continually being maintained and improved. Whilst innovation is core to healthcare, the field of rehabilitation is lagging behind, with its human and patient centricity making it more challenging to innovate.

But engaging equipment that can track outcomes remotely can support the self-management of rehabilitation and help people reach their rehab goals. Dr Paul Rinne is CEO and co-founder of GripAble, a smart mobile assessment and training device that connects to an app, to help people with upper limb impairment train hand and arm movements.

He explores technology in the rehabilitation landscape, including the opportunities and challenges it brings to patients and therapists alike, and explains how GripAble was developed with the user at front and centre.

The place of technology in rehab

For years, therapists have struggled to find the appropriate tools that can engage their patients in rehab, allow for greater efficiency in their workflow, and track outcomes remotely. As a neuroscientist carrying out my PhD at Imperial College London working closely with therapy teams on stroke wards, the need for an accessible mobile opportunity for patients undergoing physical and occupational therapy became clear.

We wanted to improve the translation of technology developed by the university into the real world. We were mindful that technology should complement traditional therapy rather than create a new clinical experience. Undeniably, tech needed to provide a continuation of the gold standard of care delivered by trained, expert therapists.

But it was apparent that traditional therapy equipment – like foams, cones and putty – wasn’t cutting it and couldn’t provide real-time motivation, feedback or data for tracking progress, leading patients to become disengaged in their rehab regimes once unsupervised.

Technology has the capacity to facilitate a level of self-management whilst assisting and supporting movement, allowing for high repetition therapy to engage and encourage a patient and thus increasing the amount of time they are engaging with their therapy programme. Not only this, but tech can facilitate gamification to motivate and challenge the user and provide real time feedback, and supports therapists in their roles by improving outcome recording and allowing for remote interaction – particularly important in today’s COVID era.

Barriers to tech adoption

Yet, despite the many advantages of technology, there is often a lack of true understanding of how it fits within the clinical pathway, with factors such as scalability, accessibility, cost – for therapist, patients and providers – and the fact a lot of tech does not allow for truly independent home use, all being potential barriers to adoption.

Developing technology without considering delivery and adoption hinders the hospital to home transition for people undergoing rehab, making it less likely to ‘stick’ and give them the agency they need to enable them to reach their goals as independently as possible.

Crucially, in order to succeed in supporting rehab and drive impact and adoption, tech should aim to be highly accessible, able to be used independently without the barriers of high cost, complexity and supervision, and have mass adoption potential.

The rehab device spectrum

Through exploration of the various rehab tools in use and weighing up their pros and cons, it is clear that cost and complexity does not necessarily imply impact. Indeed, it seems that the tech focused on accessibility, simplicity and delivery has the ability to bring the most long-term benefits to the largest number of patients.

The vast array of rehab devices includes conventional tools such as foams and putty, mobile touchscreen apps, sensor-based mobile systems, motion capture and virtual reality (VR) technologies, sensorised workstations and robots and exoskeletons. Of course, these tools aren’t accessible to everyone, with some robots and exoskeletons costing up to £1m, only facilitated by a specialist hospital or clinic environment (and not at home) and highly complex to set up and use.
Whilst motion capture and VR offer the ability to combine a lot of different types of movement in one system, including functional tasks, they are also complex in the sense that they require a level of computer literacy and may not be specifically tailored to rehab needs, with cognitive impairments of patients often being a consideration.

Mobile and sensor-based systems can be more accessible in terms of cost and patient reach, with advantages including the ability for the user to use them at home and to work on distal and finer motor control, but they do not provide active assistance, can be limited in the number of movements available to users, as well as in sensitivity and wide condition applicability, and can present challenges for home distribution.

Apps are perhaps the most accessible to the patient population with minimal cost involved and the potential to access and support millions of users. Though rehab apps can assist with finer motor control, the fact they are touch screen means there is limited range of movement, no proximal movement training ability and no strength assessment for users or their therapists to track.

Developing GripAble

GripAble is a smart mobile assessment and training device that connects to an app, to help people to work on their hand and arm movement and grip strength. Unique in the way it provides people of all ages, and their therapists, the ability and transparency to track and assess activity, GripAble is handheld and connects to a mobile app to play games to train core hand and arm movements. The results are measurable both for home-based users – and as a handy assessment tool for healthcare professionals.
Over 700 GripAble devices have been deployed since July 2020 with 3000 unique users added onto the system. But this has involved several years of development and testing of the GripAble prototype in partnership with thousands of occupational and physical therapists and patients across multiple clinical conditions, twelve different countries and leading academic institutions including Imperial College London and within Imperial Healthcare NHS Trust.

The initial feasibility studies for GripAble were driven by the idea of accessibility to ensure that the majority of patients could interact with it, including those with cognitive difficulties, when compared with other systems, and that the transition from bench to bedside was as smooth as possible. Through one study, we showed that 93 percent of patients with upper limb disability were able to interact and track their progress with GripAble. * The social aspect of GripAble was also key to engaging patients in their therapy, with collaborative training using a GripAble resulting in a 40 percent increase in engagement in rehab** whilst ensuring patients weren’t losing the human aspect that technology sometimes removes.

Innovating for the future

Alongside putting the fun into rehab, GripAble was developed with remote rehab at its heart, and can be delivered within 24 hours, with full set-up and support delivered remotely. For home-based rehab, it offers the added advantage of allowing people to train and track hand movements and grip strength from the comfort of their own home, so they can still achieve their rehab goals despite restrictions such as lockdown, and therapists can still support and help people who are shielding or self-isolating.

GripAble has the unique opportunity to be used by every single person coming into contact with the healthcare system globally, measuring and recording strength from early childhood until end-of-life care, giving us the ability to not only change the face of physical rehabilitation, but also of healthcare in general.

References
*Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke? https://pubmed.ncbi.nlm.nih.gov/27706248/
**Balancing the playing field: collaborative gaming for physical training: https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-017-0319-x

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“I wouldn’t wish it on anyone, but I’m glad my brain tumour happened in a way”

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Helen and Megan have both experienced cancer in different forms

After Helen Bulbeck’s daughter Megan was diagnosed with a brain tumour, the whole family was left isolated with little to no support. Now she is using this experience, plus her own journey with cancer, to help run the UK’s leading brain tumour support charity Brainstrust.

“It was at the time when Rohypnol was doing the rounds in the local pub, so I just thought maybe her drink had been spiked.”

This was Helen Bulbeck’s initial reaction to her daughter, Megan, collapsing after a night out and being omitted to A&E in 2006.

She later realised that it was the start of a lengthy battle, as MRI scans revealed Megan had a brain tumour.

To complicate matters, surgeons opted not to operate unless the tumour showed signs of developing.

And so began Megan’s monthly brain scans, all while she was completing a History of Art degree.

“University was where Megan’s priorities were,” Helen tells NR Times. “The main focus at that point was to get her epileptic episodes under control.

“We weren’t referred to a neurosurgeon until the following January – that’s six months after her first episode.

“We were completely out of our depth; we had no idea what was going on. We had been told in October that she had a brain tumour, but that was it.”

It was the lack of available support that really concerned and surprised Helen.

“There was nothing,” she says, when asked about the help they received after Megan’s diagnosis. “We were just left in a vacuum.

“That’s what I couldn’t understand, because if you’re diagnosed with breast cancer, you’re assigned a clinical nurse specialist. We didn’t have that.

“I spent a long time on the internet trying to find where the support and information was and I desperately needed to talk to somebody about the impact that this diagnosis had, but there was nobody.”

Helen was left on her own in search of a solution for Megan, spending countless hours learning more about brain tumours and possible treatments.

This led her to discover neurosurgeon Peter Black from Boston, who agreed to operate on the tumour after a consultation.

The severity of brain tumours is graded from one to four. Black was the first surgeon to tell Megan she had a grade two tumour, but it could transform into a higher grade within five years, with the consequences being potentially fatal.

With that in mind Megan decided she would have the tumour removed. Because of the risks involved with the surgery, however, the procedure was delayed until after she had finished her studies.

Through all this Helen was fighting her own battle after being told she had head and neck cancer.

She quickly underwent radiotherapy and surgery, knowing she needed to stay strong for her daughter.

“I was just focused on getting fit so that I could go with Meg to America for the surgery.”

Helen was able to make a full recovery, but then faced the challenge of funding Megan’s £30,000 surgery.

Megan’s group of friends were desperate to help and agreed to do some fundraising, eventually smashing their target and generating £70,000.

After this, things finally started to run smoothly. Megan was able to finish her degree and successfully underwent surgery in 2007 which saw her tumour removed.

“We had such a good story and we’d learned so much,” Helen says. “We thought we’ve got one of two options; we can either go back to our lives as they were and donate what we’ve got left to another charity. Or we can use those funds to set up a charity which was going to close the gap in the marketplace.

“Who do you turn to the day you’re told you have a brain tumour? There’s nobody out there and we didn’t want people to feel as lost as we did.”

From this Brainstrust was born.

Starting off simply as a helpline, the charity has evolved into a support trust with UK-wide reach, developing communities to reduce isolation, build resilience and enable people to live the life they want.

It focuses on providing evidence based information around brain tumours and its support specialists can point people to the correct resources, without forcing anything upon them.

“The only other charities that existed at that time were all to do with lab-based research, there was no charity out there where you could pick up the phone and ask for help.

“Because we have that experience, we knew what the information was that people would want to hear.

“Meg and I knew what it meant to be both a patient and a caregiver, so we used that 360 degree perspective to support others.”

Since then Brainstrust has gone on to support thousands of patients and their families.

The vast majority (93 per cent) of those that contacted the charity reported a positive outcome, with nearly 1,000 new patients engaging with it in 2019.

Since its founding in 2006, care around brain tumours has drastically improved.

It is the most common form of cancer that affects those under 40 and it is one that is rising at the fastest rate in over 65s.

Discussing how attitudes to brain tumours have changed, Helen says that new technologies can lead the way to better outcomes.

“Your first line treatment with a brain tumour should always be, where possible, neurosurgery. That was what saved our daughter’s life.

“I think the technology is absolutely key and probably until the last five years, that’s been hugely ignored, but it is catching up.

“In terms of the actual therapies, I think with radiotherapy we’ve made huge advances.”

Despite this progress, Helen says there are still huge differences between the treatment of brain tumour patients and those with other cancers and conditions.

She draws on the example of post-stroke rehab and the general care stroke survivors receive.

“Stroke patients get a wonderful wraparound reablement service and I’d love to see brain cancer having a parity.

“I find that some of the attitudes are a bit nihilistic, as in if you’re diagnosed with a glioblastoma people tend to see this as life limiting with a poor prognosis so it’s not worth investing in. I think it absolutely is.

“That’s the one thing I would love to be able to transform, the day somebody has a brain tumour,
they immediately get that same wraparound care.”

Megan is currently living a happy and healthy life since her surgery, being able to get married and gifting Helen with two granddaughters.

She still undergoes regular brain scans and, after becoming a qualified coach with Brainstrust, she is now training to become a psychodynamic psychotherapist (a discipline involving the interpretation of mental and emotional processes rather than focusing on behaviour).

Reflecting on her journey Helen describes her pride in the work they had done so far, but admits there is still much work to be done.

“It’s been a highly emotional rollercoaster at times, we get very tired but it’s not a job it’s a vocation.

“It’s important not to forget that before we’re patients, we’re people and I think the more we can get clinicians to recognise that sitting in front of them is a person not a patient, then that person is going to be much more resilient.

“Just hearing the testimonials of the impact that our work has had is what keeps us going.

“I will always remember Meg saying to me ‘I would never wish a brain tumour on anybody, but in a way I’m glad this has happened because of what we’ve achieved.’”

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Loneliness in lockdown – how have survivors been impacted?

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Loneliness in lockdown among brain injury survivors is the subject of a new research study which hopes to shine a light on the ongoing issue of isolation. 

While loneliness for the wider population was something rarely previously experienced prior to the COVID-19 pandemic, for those living with a brain injury, the everyday reality is often very different. 

And through this new study, researchers hope to discover the true effect the pandemic and its necessity for survivors to stay at home – and in some instances shield for several months – has had and how their protective factors have impacted on that. 

The project, by the University of Sunderland in conjunction with Headway, is currently gathering participants for its pioneering research, which will compare the experiences of people living with brain injury to those without. 

Led by Dr Stephen Dunne, who has a long-standing research interest in social factors which affect brain injury and stroke survivors, he hopes it will both raise awareness of the ongoing issue of loneliness many people face, as well as helping to inspire action.  

“There is a dual focus to this project – loneliness is something known to the masses now more than ever before; it’s not just something felt by a particular part of the population. For a neurotypical individual, I think it has shown what life can be like to be lonely in ways they may never have known previously. 

“An important point of our research is to try and understand how, for people with brain injury, their loneliness and their perceptions of loneliness have been affected during the pandemic – has this been heightened over the past year and been exacerbated by lockdown? 

“Or have they actually felt less lonely than neurotypical individuals, as they have had the experience pre-pandemic of adapting to life like this, and already have the support strategies in place?

“But crucially, the future of this project isn’t to define loneliness, understand its impact, then drop it – we want to understand it so that we can facilitate the removal of barriers so we can bring about strategic improvements to the wellbeing of people living with brain injury.” 

Dr Dunne and his team are seeking brain injury survivors nationally to take part in the research, which will be done by a survey: https://sunduni.eu.qualtrics.com/jfe/form/SV_czH5B8R5kieDgQR and an optional additional interview with the team remotely via Microsoft Teams. 

“We’re at a crucial stage now where we appear to be coming out of restrictions, but the experiences of the past year are still very real for so many people,” adds Dr Dunne. 

“We want to do this at the right time, before reintegration into society starts to happen and we are looking retrospectively, so we’re keen to hear the experiences of as many people as possible.

“We want to better understand loneliness and its impact, so we can help to bring about change for the future. Understanding the journey of brain injury survivors over the past year is a key part of us being able to do that.” 

For further information about the research study, or to share experiences through an interview with the research team, contact Stephen.Dunne@sunderland.ac.uk

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Temporary concussion substitutes ‘must be introduced by June 1’

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Temporary concussion substitutes must be included in the current trials underway in the Premier League to safeguard the safety of players, players’ unions said today. 

FIFPRO and the PFA have called for the introduction of temporary substitutes no later than June 1, and for the scope of the 18-month trial – which enables a team to replace a player who has sustained concussion, but on a permanent basis – be extended to include parallel trials for temporary substitutions. 

In an open letter to IFAB, football’s lawmakers, FIFPRO – which represents over 65,000 professional footballers worldwide – and the PFA highlighted the cases of West Ham United’s Issa Diop and Sheffield United’s George Baldock in making their case. 

“Player safety and welfare is paramount, and should be the only priority,” they say in their letter. 

While both bodies were supportive of the permanent concussion trials when introduced, such incidents – added to the new FIFPRO poll, which shows 83 per cent of 96 professional football club doctors at top-flight European club believe temporary substitutes should form part of future protocol – have shown that action needs to be taken. 

“In England, since the trial began, we are aware of two incidents where a temporary substitution option would have better protected players,” states the letter. 

“In each case, the players suffered from a head injury but, following an initial on-field assessment, continued to play. They were subsequently removed when it emerged their head injury was worse than first thought.

“These cases underline our concern that permanent substitutions do not give medical teams the appropriate environment to assess a player with a potentially serious head injury.

“The reality of the in-game situation is loaded with pressure. Medical teams can be presented with a situation where a globally broadcast match is on hold, awaiting their assessment. They have to make a potentially game-altering decision in a multi-billion-pound industry.

“We have no doubt medical teams act in the sole interests of the players. However, the rules do not do enough to support medical personnel. Pressure on them will be amplified with the return of crowds.”

The letter states that the inclusion of temporary concussion substitutions, which they propose should be tested in parallel with the current trial, will:

  • Provide medical teams with additional assessment time
  • Allow for the assessment to take place in an appropriate environment
  • Permit a match to restart with neither side numerically disadvantaged
  • Reduce pressure on players and medical staff to make quick decisions.

“In December 2020, we welcomed the decision by IFAB to invite competitions to trial permanent concussion substitutions,” FIFPRO and the PFA state.

“At the same time, we have remained in favour of testing temporary concussion substitutions. This has been our position for many years.

“Since the beginning of IFAB’s permanent concussion substitute trial, we have seen several incidents where the new laws of the game have fallen short of their objective and jeopardised player health and safety.”

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