Predicting rehabilitation and walking performance post stroke

Writing in the Archives of Physical Medicine and Rehabilitation, 04/05/2013 Dr. Rose DK et al look at the predictive power of the results of Exercise Tolerance Testing and the 6MWT (six minute walk test). The group compare the scores to the number of physical therapy rehabilitation sessions – treadmill and overground Locomotor Training Program (LTP), needed to achieve 20 minutes stepping duration in these patients. ETT is a measure of cardiac performance where as 6MWT is more a measure of neurological impairment and muscular condition.

Exercise reduces disability and improve quality of life in persons with Parkinson disease (PD).

Parkinsons disease exercise

Reporting in Physical Therapy, Dr. Ellis and his team from the Department of Physical Therapy & Athletic Training, College of Health & Rehabilitation Sciences Boston University USA look at the barriers to exercise in people with Parkinson Disease (PD). Although exercise is known to reduce disability and improve quality of life in persons with Parkinson disease (PD).  The group conclude that low outcome expectation of exercise, lack of time to exercise, and fear of falling are important barriers to engaging in exercise among ambulatory, community dwelling persons with PD.

 

What is the The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) for Stroke

Upper extremity Rehabilitation

Dr Winstein and her colleagues working from several sites in the US present their protocol for a randomized controlled trial called an Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE).

Contributing to this study will be teams from the Division of Biokinesiology and Physical Therapy University of Southern California, Department of Neurology, Keck School of Medicine, USA MEDCOM WRAMC, Department of Rehabilitation Medicine, Emory University School of Medicine, Centre for Rehabilitation Medicine, Atlanta, National Rehabilitation Hospital, Washington, DC, Long Beach Memorial Medical Center, Long Beach, CA.

The interest in upper extremity rehabilitation is due to the fact that Residual disability after stroke being large with 65% of patients at 6 months unable to incorporate the impaired upper extremity into daily activities. There is an absence of any consensus on the essential elements or dose of task-specific training therefore the trial will set out to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles.

The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke initiative compares an Accelerated Skill Acquisition Program (ASAP) to control occupational and physical therapy of the upper extremity.    One of ASAP’s eight overlapping operating principles includes the fact that exercise practice needs to be challenging and meaningful practice and assure active patient involvement and opportunities for self-direction and drive task-specific self-confidence

Outcome measures include the Wolf motor function test (WMFT) and Stroke impact scale (SIS).

 

Paralysis From a Non-Physical Source?

Arriving at the University Medical Center in Salt Lake City all the way from South Africa, the helicopter carrying Jeremy Clark landed noisily. Jeremy, a 23 year old college graduate had been on a Mormon religious mission for just a few weeks when he woke one morning to find that his legs were completely paralyzed. Doctors in S.A. were unable to find anything wrong with him medically.

Also not speaking made his examination process in Utah more difficult. Doctors were determined to get to the bottom of the problem and arranged for various tests to be performed. It was necessary to rule out diseases such as multiple sclerosis (ms); myasthenia gravis, a neuromuscular autoimmune disease that causes varying degrees of muscle weakness; Guillain-Barré syndrome, an acute condition associated with progressive muscle weakness and paralysis and stroke. A lumbar puncture to collect fluid from around the brain and inside the spinal cord had to be done to rule out infection.  

Then a full medical examination was conducted. Jeremy was a healthy and physically fit young man and his heart, lungs, abdomen, neurological exam, muscle tone all acted in a normal fashion. He was able to move his head, neck and arms without a problem but his legs would not move at all. More surprising was the fact that tapping his legs with a rubber hammer showed that there was no damage to the nerve path between muscles and spinal cord.

A stroke was ruled out as that usually would have affected only one side of the body. A discussion with Jeremy’s parents ruled out drug use or mental health problems. A doctor involved in the case was wondering whether Jeremy was ”faking” his symptoms and finally the staff psychiatrist was called in for an evaluation.

After another neurological exam the psychiatrist came up with a diagnosis of ”conversion disorder”. He explained that conversion disorder is an unusual psychological state with symptoms that resemble a neurological disorder or another medical condition. It usually begins abruptly and begins with a mental conflict or emotional crisis. Then it “converts” to a physical problem that prevents the patient from being involved in the activity that was causing him stress. There are a relatively small number of cases reported per 100,000 people and it is more common in women. Beginning at almost any age it usually occurs between the ages of 11 and 35. Aside from paralysis it can also cause amnesia, blindness, motor tics and other ”symptoms”.Usually the disorder will disappear spontaneously after 2 weeks of hospitalization and in some cases a physical illness is discovered later.

Jeremy was told about his condition, reassured that there was no physical disability and that he would recover very soon. After further routine questioning Jeremy broke down and and stated that he could not continue with the mission he was sent on. He didn’t like talking about religion with people. He was reluctant to come home because he thought he would let his parents or God down . This caused him enormous stress. The doctor informed him that no one could force him to go back. The situation was explained to his parents who agreed to get involved in his therapy sessions and rehabilitation. Within days Jeremy was walking the halls and was discharged from the hospital after making a complete recovery from the paralysis.

When a disease or surgery causes an incomplete paralysis of a limb or joint the most effective physical therapy solution should be found. Fortunately, a recent innovation has created the TUTOR system of products known as the HANDTUTOR, ARMTUTOR, LEGTUTOR and 3DTUTOR. The TUTOR system was developed to allow intensive exercise practice to those who have incurred a stroke, brain/spinal cord injury, MS, CP, knee/hip surgery or other type of upper or lower limb disabling event.

The TUTORs consist of ergonomically comfortable gloves or braces that are strategically placed and contain sensors connected to sophisticated exercise game programs. Physical or occupational therapists record and monitor the progress made and then design a specific exercise regimen for that patient. The TUTOR system is now in use in leading U.S. and European hospitals and clinics. Fully certified by the FDA and CE they are available for use at home through telerehabilitation and can be used by adults and children from the age of 5 and up. See WWW.MEDITOUCH.CO.IL for further information.

Four Ways to Treat Apraxia

 

Generally speaking Apraxia is the loss of  ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements.

1. TREAT THE UNDERLYING DISORDER

When a brain tumor/lesion is the cause of apraxia, sometimes the apraxia can be diminished or cured   by treating the cause. Surgery, chemotherapy and radiation   are the standard courses of treatment for a brain tumor. Even after treatment, it’s common for some of the tumor to remain, but reducing it may help to treat symptoms of apraxia. Some rehabilitation therapy may still be needed to regain the ability to speak or perform everyday tasks.

2. RESTORE LOST MOVEMENTS WITH REHABILITATION

Occupational and physical therapists usually treat the patient where one or more body parts is affected . Physical therapists   teach the motor skills needed to perform  everyday tasks which is the purvue of occupational therapists.   Usually these two therapies complement each other but they can be used independently if the situation calls for it. For mild to moderate apraxia, these therapies usually are focused on restoring movements lost  resulting   a neurological event. This is usually accomplished with repetition of these movements and other drills.

3. COMPENSATE FOR LOST MOVEMENTS

The prognosis for severe apraxia is not as good, but therapy can  compensate for some of the lost movements in different ways. For example, a patient with severe apraxia that has limited ability to walk may be able to use a walker in rehabilitation therapy. Or a patient with apraxia of speech to the point of muteness can be taught to communicate with gestures or sign language. Experienced rehabilitation specialists can evaluate the patient to determine the best approach for therapy. Often compensation therapy is used if restorative therapy isn’t effective.

4. SPEECH AND LANGUAGE THERAPY FOR DEVELOPMENTAL APRAXIA OF SPEECH

Developmental apraxia of speech in children requires speech and language therapy for treatment. Unlike some cases of acquired apraxia of speech, developmental apraxia of speech does not resolve spontaneously. Speech therapy typically involves repetition of words and phrases, drills in front of a mirror and many other exercises. How the therapy is conducted is highly individualized. Parents are encouraged to continue exercises at home and provide a supportive environment. With adequate therapy, the prognosis for most children with developmental apraxia is good.

When children from the age of 5 and up as well as adults can benefit from intensive exercises for Apraxia-related limb disabilities the TUTOR system of physical therapy products is very useful. Specifically the HANDTUTOR, ARMTUTOR and LEGTUTOR provide

 a key system in neuromuscular rehabilitation and physical therapy for interactive rehabilitation exercise. These innovative devices implement an impairment based program with augmented feedback and encourage motor learning through intensive active exercises. These exercises are challenging and motivating and allow for repetitive training tailored to the patient’s performance by the occupational and physical therapist.This ensures that the patient stays motivated to do intensive repetitive manual therapy and exercise practice.

 The HANDTUTOR, LEGTUTOR, ARMTUTOR and 3DTUTOR are now  part of the rehabilitation program of leading U.S. and European hospitals and clinics. Home care patients can use the TUTORs through tele-rehabilitation. The TUTOR system is fully certified by the FDA and CE. See WWW.MEDITOUCH.CO.IL for more information.

 

Brain Stimulation Helps Parkinson’s Patients

There are several medications available to Parkinson’s patients to relieve their symptoms but when they aren’t effective a procedure called deep brain stimulation (DBS) is sometimes used. DBS consists of surgically implanting electrodes in deep brain structures that help control movement, and then delivering stimulation through the electrodes with a device very much like a pacemaker. One common target is the subthalamic nucleus (STN). The problem has been that although DBS can relieve movement problems it may incur problems in the patient’s cognition. Doctor’s do not fully understand the reasons for that.

A theory is being investigated by Dr. Joel Perlmutter, a professor of neurology and radiology at Washington University in St. Louis, Mo. to try to improve DBS and reduce its side effects. He has been targeting the stimulation to one particular site in the brain and avoiding another nearby site. Funding for the research is being provided from the National Institute of Neurological Disorders and Stroke through a recent congressional act called ARRA.

Studies show that stimulating the dorsal part (top) of the STN  can lead to desirable activity in the brain’s motor pathways, while stimulating the ventral part (bottom) can lead to negative activity in other brain pathways that are involved in cognition.

Dr. Perlmutter, together with his team, will examine Parkinson’s patients who have received DBS to the STN, and to try to pinpoint the location of the electrodes – which can possibly change after surgery. Their purpose is to  analyze how electrode location affects the  motor symptoms, cognitive function and cortical activity. In order to  locate the electrodes, the team instituted a method that involves reconstructing 2-D brain scans into 3-D maps, and then using landmarks in and around the STN for orientation.

From this research there should be a better understanding of how DBS works and improvements made in  treating Parkinson’s. This will include a better design and targeting of the electrodes. Besides that, the research is expected to yield insights into the function of the STN and how it is involved in other neurological disorders.

When Parkinson’s disease causes movement disorders physical therapy solutions become vital. The HANDTUTOR has been in the forefront of Parkinson’s patient exercise therapy for some time now. The HANDTUTOR consists of a safe comfortable glove with position and speed sensors that precisely record finger and wrist motion. Rehabilitation games allow the patient to exercise Range of Motion, speed and accuracy of movement opposition and pinch movement practice. The HANDTUTOR facilitates evaluation and treatment of isolated and combined finger/s and wrist joint.

Together with its sister devices (ARMTUTOR, LEGTUTOR, 3DTUTOR) the HANDTUTOR is currently in use in leading U.S. and European hospitals and rehabilitation clinics. They are fully certified by the FDA and CE and are available for use in the patient’s home through telerehabilitation.

See WWW.MEDITOUCH.CO.IL for further information.

Five Ways to Relieve Arthritis Pain

Arthritis has no known cure–just relief from pain. It’s called– exercise. Below are 5 exercises that are designed to bring joint relief, relieve stress and assist in weight loss. They can be fun too.

Doctors say that physical activity  is the best medicine  there is for arthritis pain relief, .

Patience White, M.D., chief public health officer of the Arthritis Foundation and professor of medicine and pediatrics at the George Washington University School of Medicine states that exercise can decrease pain, especially for people with osteoarthritis which is the most common type of arthritis.

 In the Cochrane Database of Systematic Reviews it was reported that exercise, such as walking, was  as effective  as drugs like Aleve or Advil in reducing knee pain.

By working out regularly it  may prevent sore joints and stop arthritis from getting worse.

Kevin Fontaine, Ph.D., assistant professor of medicine at the Center for Mind-Body Research at Johns Hopkins University School of Medicine in Baltimore states that  physically active people  have a higher quality of life and are less likely to become disabled or have days with lots of pain.

 Workouts also keep off the pounds. Obesity can increase the risk of arthritis and/or make its symptoms worse.

 Just 20 minutes three times a week or two 10 minute intervals is enough to make a difference according to Arthritis Today, the journal of the Atlanta-based Arthritis Foundation.

There are also new medications that can help relieve arthritis pain and swelling allowing patients to work out according to  Halsted Holman, M.D., professor emeritus of medicine and former director of the Stanford Multi-Purpose Arthritis Center at Stanford University’s School of Medicine.

Generally it is necessary to begin exercising only with a physician’s agreement.

A workout should be a challenging experience, but not painful enough to cause injury, Dr. Holman says.

 If you have sore joints or muscle pain that continues for even two hours after exercising or if the pain is worse the next day then the exercises were overdone. In that case the workout should be shortened or done more gently.

Here are 5 arthritis exercises that are sure to ease  arthritis symptoms:

1. Walking

 Walking is known to strengthen muscles, which in turn helps shift pressure away from the joints, and reduces pain.

 It also brings nourishing oxygen to the  joints by compressing and releasing cartilage in the knees.

 The Arthritis Foundation recommends walking 10 minutes at least 3-5 days a week to start.

As you progress, take longer walks and include short bursts of speed getting to a moderate pace until you are able to walk 3-4 miles an hour.

 People with serious hip or knee problems should first check with their doctor before beginning a walking program.

2. Water Exercise

How it helps: The University of Washington Department of Orthopedics and Sports Medicine recommends warm water – between 83˚ F and 90˚ F – to help relax  muscles and decrease pain.

Swimming and aerobics exercises in water are good for stiff, sore joints.

Water also supports the body as one moves. This reduces stress on the knees, hips  and spine, and offers resistance without any weights.

Water exercises are  ideal for people who need to relieve severe arthritis pain in knees and hips.

Arthritis Today quotes “Water provides 12 times the resistance of air, so one is  really strengthening and building muscle”.

When immersed in the water don’t pedal faster than 50-60 revolutions a minute. Add resistance  after a warm up period of  five minutes and don’t add more pedaling than you can handle.

3. Indoor Cycling

Matthew Goodemote, head physical therapist at Community Physical Therapy & Wellness in Gloversville, N.Y.  says that indoor cycling is one of the best ways to get a cardiovascular workout without stressing weight-bearing joints.

 Since there’s no need to lean the bike to turn a stationary bike is  a good option for people with balance issues – a common problem among some arthritis patients.

 When starting this arthritis exercise be sure that the seat height is at a position which allows the knee to be completely straight  when the pedal is at the lowest point, according to the University of Washington Department of Orthopedics and Sports Medicine.

One should not pedal faster than 50-60 revolutions per minute. A warm up period of five minutes should be allowed at first. Then patients should start 5 minute sessions 3 times a day. Then increase gradually to 7 and up to 20 minutes a day providing there is no pain.

 People with very painful knees should avoid indoor cycling, because it can aggravate the condition.

4. Yoga

 Steffany Haaz, MFA, a certified movement analyst, registered yoga teacher and research coordinator at Johns Hopkins Arthritis Center says that beginner yoga classes that have simple, gentle movements gradually build balance, strength  and flexibility  which are elements that can be  beneficial for people with arthritis.

Yoga  reduces inflammation, increases energy and, in general, allows for a more positive mental outlook, according to Psychosomatic Medicine, an Ohio State University study published in their journal.

To start, take a class at a  gym,  community center or yoga studio. You can find a certified teacher through the Yoga Alliance, the accrediting body for yoga instructors worldwide. It is important to tell the instructor before class about your  arthritis  so that they can  modify poses to accommodate your limited mobility.

For those that prefer doing Yoga at home,  there is a company called Gaiam that produces yoga videos and recently collaborated with the Mayo Clinic to produce a DVD entitled  “The Arthritis Wellness Solution” . It contains tips from specialists and a segment showing specific yoga for arthritis sufferers  and includes meditation exercises which are designed to enhance circulation and  relieve tension which helps relieve arthritis pain.

 Yoga should never hurt. If it does that means it’s overdone.

Straps, blankets and chairs can be used  to accommodate people with  limited range of motion, strength or balance.

5. Tai Chi

This traditional style of Chinese martial arts  goes back centuries and features slow, rhythmic movements to induce mental relaxation and enhance balance, flexibility and strength.

Tai chi is very valuable to arthritis patients because its movements are very slow and controlled. They put little force on the joints.

Some studies have shown that Tai Chi can improve life satisfaction, mental well-being  and perceptions of health, which oppose negative effects of  pain associated with arthritis.

The November 2009 issue of Arthritis Care & Research, a journal of the American College of Rheumatology has an article that describes Tai Chi as being beneficial for knee pain. Another research study by a Tufts University group found that Tai Chi was especially helpful for patients that were over 65 and had knee osteoarthritis.

According to another university’s Orthopedics and Sports Medicine department, Tai chi should preferably be done in the morning,  when there is  least pain and stiffness, when you’re not tired and when the arthritis medication is most effective.

Taking a warm shower is always a good idea before exercise if joints are stiff.

One of the most effective exercise programs for arthritis sufferers is by using the TUTOR system of physical therapy products. The HANDTUTOR, ARMTUTOR, LEGTUTOR and 3DTUTOR were originally designed to help patients that suffered a stroke, brain injury, Parkinson’s or other upper and lower limb disabilities. However much relief has been gained for arthritis patients as well  who would like a challenging and entertaining system of exercising arthritic joints. The TUTORs are ergonomically designed gloves and braces that contain sensors connected to sophisticated exercise games. The physical and occupational therapists monitor and record the progress made and design a customized exercise program for that patient.

Currently in use in leading U.S. and European hospitals and clinics the TUTORs are fully certified by the FDA and CE. They are also available in the home through the use of telerehabilitation and can be used by adults and children from the age of 5 and up.

See WWW.MEDITOUCH.CO.IL for further information.

Chocolate Eater Makes Medical History

A 52 year old woman, named Jan  Scheuermann, ate chocolate after a brain operation. So what? One might ask. However this simple act made history because Jan is paralyzed from the neck down

Originally diagnosed with a degenerative brain disorder 13 years prior  doctors implanted tiny electrodes in her brain which allowed her to operate a robotic  arm.

Jan’s ultimate wish was  to feed herself chocolate once the electrodes had been in place.

Doctors, led by Professor Andrew Schwartz of the University of Pittsburgh Medical Center, applauded her feat.

The arm is a  prosthetic controlled directly by the brain and  this achievement marked a major step for people who are unable to move their own arms.

“Our study has shown us that it is technically feasible to restore ability and gives patients hope for the future”, said Dr. Schwartz.

The two  microelectrodes were implanted into Jan’s left motor cortex. This is the part of the brain that initiates movement.

A scanning technique called ”functional magnetic resonance imaging” (fMRI) located the  part of the brain that lights up when the patient is asked to think about moving her paralyzed arms.

The electrodes were connected to the robotic hand through a computer which ran an  algorithm to translate the signals that imitates the way an unimpaired brain is able to control healthy limbs.

Decoding human motion has no limit now. It is quite complex when one works on parts like the hand for example, but  once the desired motion is tapped  how that motion will be effected has a wide range of possibilities according to the medical researchers.

For those brain injured patients that still have arm mobility the ARMTUTOR and HANDTUTOR offer an effective physical therapy solution.

The ARMTUTOR™ and HANDTUTOR systems have been developed to allow for functional rehabilitation of the upper extremity including the shoulder, elbow and wrist. The system consists of an ergonomic wearable glove and arm brace together with dedicated rehabilitation software. The ARMTUTOR™ and HANDTUTOR systems allow the physical and occupational therapist to report on and evaluate the patient’s functional rehabilitation progress. This allows the PT and OT to prescribe the correct customized and motivating intensive exercise practice to the manual rehabilitation therapy. Intensive repetition of movement is achieved through  challenging games set to the patient’s  ability. The system provides detailed exercise performance instructions and precise feedback on the patient’s efforts. Controlled exercise of multijoints within the normal movement pattern prevents the development of undesired and compensatory joint movement and ensures better performance of functional tasks. Telerehabilitation allows the recovering patient to continue his physical therapy at home. The system is used by many leading rehabilitation centers worldwide and has full FDA and CE certification.

See WWW.MEDITOUCH.CO.IL  for more information.

Post ACL Surgery Rehabilitation Study

Charles P. Vega, MD, FAAFP , Washington University School of Medicine authored a study of  anterior cruciate ligament (ACL) rehabilitation strategies after surgery. The study was posted on  October26, 2012.

The anterior  cruciate ligament (ACL) is  one of the four major ligaments of the human knee.

There are about 80,000 ACL  injuries in the United States each year, according to a review by Waters (J Orthop Sports Phys Ther. 2012). These injuries are quite common among basketball players, with female players more frequently injured than male players. Also, more than half of basketball players who undergo ACL reconstruction may suffer either a tear of the ACL graft or a tear of the ACL of the contralateral knee within 5 years.

Because of the widespread nature of ACL injuries and reconstructive surgery, understanding the best practice for rehabilitation of patients after ACL reconstruction is critical.

The cornerstone of postoperative ACL rehabilitation is Range-Of-Motion, strengthening, and functional exercises. Bracing following ACL reconstruction has been found to be neither necessary nor beneficial,  did not improve pain or knee laxity and just adds to the cost of the procedure.

It is crucial for ACL surgery patients  to begin physical therapy early and rigorously. Although it can be difficult at first, it’s worth it in terms of returning to sports as well as  other activities according to  Rick W. Wright, MD, also from the Department of Orthopedic Surgery, Washington University School of Medicine.

The following are some of the results of the study:

On the basis of limited research, immediate postoperative weight-bearing, range-of-motion exercises from 0° to 90° of flexion, and closed-chain strengthening exercises after ACL reconstruction appear safe.

Eccentric quadriceps strengthening and isokinetic hamstring strengthening at 3 weeks after ACL surgery may improve strength more rapidly.

Home rehabilitation regimens can be very effective even though  there are limited data to support this conclusion.

Vitamin C and E supplements do not appear effective in helping patients after ACL reconstruction.

Hyaluronic acid injections to the knee administered 8 weeks post surgery may improve ambulatory speed and muscle torque.

Single-leg cycling can improve cardiovascular fitness after ACL reconstruction.

For post operative limb surgery such as ACL repair the most effective physical therapy solution should be incorporated into the rehabilitation program.

The recently developed LEGTUTOR by MEDITOUCH is one such product. The LEGTUTOR consists of a safe comfortable leg brace with position and speed sensors that precisely record three dimensional hip and knee movements. The LEGTUTOR has a range motion limiter that can limit the dynamic range of knee extension and flexion. Rehabilitation games allow the patient to exercise Range Of Motion, speed and accuracy of movement. The LEGTUTOR facilitates evaluation and treatment of the lower extremity including isolated and combined hip and knee movements.

Currently in use in leading U.S. and European hospitals and clinics the LEGTUTOR together with its sister devices (HANDTUTOR, ARMTUTOR and 3DTUTOR) are fully certified by the FDA and CE and can be used at the patient’s home through telerehabilitation.

See WWW.MEDITOUCH.CO.IL for further information.

Telehealth Comes of Age

What do the following have in common?

Rural areas, medical insurance companies, 200,000 patients, cardiac patients, mental health patients, neurological telehealthdisease patients, suicide prevention and oncology follow-up care. An unlikely group of terms? Not if you consider that all of these derive a benefit or support from TELEHEALTH. In this age of high technology many medical procedures and benefits can be accomplished remotely and with as much expertise as with a face to face encounter with a professional.

Today, telehealth   is fast taking its place as a major aspect of healthcare and is understood more than ever before.

According to Jonathan Linkous, CEO of the American Telemedicine Association (ATA),  telemedicine is growing by leaps and bounds, and is due to double its current use in upcoming years.

More and more people and agencies of all kinds are joining the telehealth bandwagon.”

Telehealth used to be prevalent in rural areas mostly, where it is vital for care. However now, it is used in all parts of the country, Linkous said.

It has also attracted the interest of insurance payers. ”In the next few years,  major healthcare payers will be making interesting announcements” about telehealth, he said.

According to Linkous, tele monitoring is used by 200,000 patients nationwide. It is used to monitor one million cardiac patients a year alone, and provides 400,000 virtual visits  to mental health patients, via Skype.

The majority of patients being treated for neurological diseases are currently connected to a telesystem outside of a hospital. Nearly every major neurologic healthcare organization is using the system.

The Department of Veterans Affairs has recently begun to use telehealth to focus on mental healthcare. Beginning in July, the VA has used instant messaging in a suicide prevention program to help keep 6,000 vets online until assistance can arrive. The VA is also using telemedicine on oncology follow-up care.

When a physical therapy solution is needed and the patient lives too far from a rehabilitation facility or is back home after substantial recovery from a stroke or other limb disabling disease or surgery the TUTOR system is equipped with telerehabilitation to allow the patient to receive therapist monitored exercises.

The HANDTUTOR, ARMTUTOR, LEGTUTOR and 3DTUTOR are physical therapy products that consist of ergonomically designed gloves and braces with sensors connected to dedicated software. This software contains challenging games whereby the patient can use his own power to move a disabled limb or joint. The therapist then designs a specific exercise program for that patient based on his abilities.

The TUTOR system is currently in use in leading U.S. and European hospitals and clinics and is fully certified by the FDA and CE. See WWW.MEDITOUCH.CO.IL for further information.