Telerehabilitation for addressing executive dysfunction after traumatic brain injury

Telerehabilitation allows for the delivery of cognitive training post traumatic brain injury. Writing in Brain Injury, 05/01/2013 Ng EMW et al. from Toronto Rehabilitation Institute, University Health Network , Toronto, ON look at the delivery of the Cognitive Orientation to daily Occupational Performance approach (CO-OP) in a telerehabilitation format. Using the Outcome measures included the Canadian Occupational Performance Measure, the Mayo-Portland Adaptability Inventory-4 Participation Index, and the Dysexecutive Questionnaire the group conclude that Telerehabilitation can be used for addressing executive dysfunction after traumatic brain injury and may help promote community integration of individuals living with TBI.

Web-based telemedicine provides specialty care at home for Parkinson Disease (PD)

Published in JAMA Neurol. 2013 Mar Dr. Ray Dorsey, Associate Professor of Neurology, Director of the Movement Disorders Center, Johns Hopkins University concludes that web-based videoconferencing and telemedicine for the provision of specialty care at home is feasible, effective and provides value to patients, and may offer similar clinical benefit to that of in-person care in  Parkinson Disease (PD). This indicates that telemedicine is feasible for other movement Disorders and neurodegenerative Diseases.

The HandTutor, ArmTutor and LegTutor is used at home by Parkinsons disease patients and is supported by telerehabilitation.

Licensure Portability for occupational and physical therapists in Telerehabilitation in the USA

What are the models of PT and OT licensure portability in the USA

1. Mutual Recognition Compacts — This model is similar to being able to use a driver’s license issued in one’s own state in other states that have a legal agreement with this state.

2. Expedited License— This is a uniform application and credential verification that is stored and sent to the state that the license is required for.

3. Limited License— this will grant a license to an OT or PT in each state that will be limited in scope to the practice of telehealth across state lines.

4. National License— The OT and PT profession will be administered at the national level and based on a universal standard.

5. Federal Pre-emption— the federal government will grant licensure for inter-state practice of telerehabilitation.

Telerehabilitation for all

Telemedicine is described as the delivery of healthcare services – diagnosis, consultation or treatment, through the use of interactive audio, video or other electronic media. Ready access to telecommunications technology is therefore transforming the delivery of care. This is why the following US states are planning to in introduce legislation that will make tele rehabilitation reimbursed:

The District of Columbia – legislation filed by Council woman Mary Chehwill require private health insurers and Medicaid to cover healthcare services including physical and occupational therepy via telemedicine.

Connecticut, State – Sen. Joseph Crisco Jr. bill will require health insurers to cover services provider through “telecommunications technology.”

Florida – State Rep. Mia Jones bill will require insurers, including Medicaid, to provide coverage for telemedicine and homecare services. The bill will allow the provision of telemedicine to be given by practitioners and professionals in other states.

Mississippi – State Sen. Terry Burton bill will also require insurers to cover telemedicine

New Mexico – State Rep. Stephen Easley and State Sen. Gerald Ortiz y Pino bills require insurers to cover healthcare services provided via telemedicine.

South Carolina – State Sens. Raymond Cleary III, Bradley Hutto and Greg Hembree bill will require individual or group health maintenance organizations to cover telemedicine services.

Indiana – State Sen. Vaneta Becker bill will require Medicaid to reimburse certified home health agencies, federally qualified health centers and rural health clinics for telehealth services.

Nebraska – State Sens. Amanda McGill, Brad Ashford and Annette Dubas bill will authorize telehealth services for public school students.

Telerehabilitation in the UK a solution for timely access to physiotherapy

Writing in the January edition of the BMJ  Dr Salisbury – professor of primary healthcare and his colleagues Dr. Hall – lead for outpatient physiotherapy and Dr.Foster – professor of musculoskeletal health in primary care show that telephone assessment and advice services for patients with musculoskeletal problems is as clinically effective as usual care and provides faster access to physiotherapy. Therefore tele rehabilitation has the potential of providing timely access to physiotherapy (a problem in the National Health Service (NHS). In the UK General practitioners refer about 1.23 million patients for physiotherapy each year in the U.K. The referrals are mostly for lower limb, back, upper limb and cervical pain, respectively.

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.

Multiple Sclerosis Symptom Guidelines

People who develop Multiple Sclerosis (MS) are usually between 20 and 40 and display at least two symptoms before being seen by the doctor.

Blurred or double vision

Weakness in one or more limbs

Cognitive difficulties

Sudden onset of paralysis

Slurred speech

Lack of coordination

 Early symptoms of MS include:

Tingling

Loss of balance

Numbness

Later, as the disease progresses, other symptoms may appear such as fatigue, muscle spasms, sensitivity to heat, sexual disturbances and changes in thinking or perception.

Fatigue is typically present in the afternoon and may include increased muscle weakness,  mental fatigue, or sleepiness.  Many patients with MS complain of  fatigue even after a good night’s sleep.

Heat sensitivity which can worsen symptoms  occurs in most people with MS.

Spasticity. Muscle spasms are a common  symptom of MS. Spasticity  affects the muscles of the legs and arms, and may interfere with being able to move those muscles freely.

Dizziness. A feeling of “off balance” or lightheadedness or that the surroundings are spinning is common; this is called vertigo. These symptoms are due to damage in the complex nerve pathways that coordinate vision and  are needed to maintain balance.

Impaired thinking  occurs in about half of the people with MS. This can manifest itself by slowed thinking, decreased concentration, or decreased memory.  10% of people with the disease have it so severe  that they cannot carry out  tasks of daily living.

Vision problems can include blurring or graying of vision or blindness in one eye.

Abnormal sensations. Many  MS patients experience  sensations such as numbness, “pins and needles,”  burning, itching,  stabbing, or tearing pains. Even though these symptoms are aggravating, they are not life-threatening and can be  treated.

Speech and swallowing problems in people with MS are caused by damaged nerves that normally would aid in performing these tasks.

Tremors are fairly common in people with MS and can be debilitating and difficult to treat.

Difficulty walking is among the most common symptoms of MS.  This  is related to muscle weakness and/or spasticity.   Balance problems or numbness in the  feet can also make walking difficult.

There are other rare symptoms which include breathing problems and seizures.

 The symptoms can be divided into three categories: primary, secondary, and tertiary.

Primary symptoms are a result of the  impairment of the transmission of electrical signals to muscles  and the organs of the body.  These symptoms include: tremors, weakness,  tingling, paralysis, loss of balance, numbness, vision impairment and bladder or bowel problems. These can be kept under control through the use of medication and rehabilitation.

Secondary symptoms are a result of primary symptoms. For example, paralysis  can lead to bedsores  and bladder or urinary incontinence  can cause frequent urinary tract infections. Although these symptoms can be treated,  the ideal goal is to  treat the primary symptoms.

Tertiary symptoms include psychological, social,  and vocational complications that are associated with the primary and secondary symptoms. Depression can be a common problem for those  with MS.

Deterioration of the protective sheath (known as Demyelination) that surrounds nerve fibers, can occur anywhere in the brain or spinal cord.  Demyelination in the nerves that communicate with the muscles causes problems with movement (called motor symptoms) and demyelination along the nerves that carry  messages to the brain causes disturbances in sensation.

Multiple sclerosis is a varied and unpredictable disease. For many people, it starts with a single symptom, followed by months or longer without any progression of symptoms. In others, the symptoms can become worse within weeks or months.

There are many symptoms, as stated above, but it is important to know that a given individual may only experience some of the symptoms and not others. With some the symptom may occur and then disappear. It is not wise to compare one MS patient with another.

When the symptoms reach a level where physical rehabilitation can be helpful the most effective solutions should be incorporated into the patient rehabilitation treatment program. Such solutions would include the TUTORs. The HANDTUTOR, ARMTUTOR, LEGTUTOR and 3DTUTOR are ergonomic wearable devices together with powerful dedicated rehabilitation software. The system is indicated for patients in rehabilitation centers,, private clinics and the home supported by telerehabilitation. The TUTORs have been used to create an intensive exercise program for patients who have had MS or stroke, Parkinson’s disease, head or brain injuries, CP and other upper and lower limb disabilities.

Currently in use in leading U..S. and European rehab facilities the TUTORs are fully certified by the FDA and CE.

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