ot 6, otd, otr/l - gillette children's specialty healthcare · virtual reality creates...
TRANSCRIPT
OT Evening SeriesNovember 6, 2014
Kristin Ries, OTD, OTR/L
Review motor learning principles related to intensive upper extremity treatment options
Understand use of the ArmeoSpring, including indications/contraindications, episodes of care, and outcomes
Describe a case study
Motor learning: Motor control principles put into practice in order to teach movement for retention during occupational performance (Obrien & Lewin, 2009)
Practice Feedback Active Involvement Novelty Verbal Instruction Modeling and demonstration Mental rehearsal
“Therapies first focus on preserving the remaining areas of motor control, and then later refine motor control…”
Two of the most well‐supported therapies used in stroke and CP include CIMT and robot‐assisted movement practice
(Delgado, 2013)
RestorationRestoration RecruitmentRecruitment RetrainingRetraining
Task Specific Training: practice context‐specific motor tasks and receive some sort of feedback TST as a core element of several interventions which may include equipment or virtual environments Focus on training of functional tasks rather than only on the impairment(s) Promotes neural plasticity Repetition PLUS specific skill learning (Delgado,
2013)
Repetition and consistent practice Repetition plays a role in promoting and maintaining brain changes
Specific motor training fMRI has shown that TST, in comparison to traditional stroke rehab, results in long‐lasting cortical reorganization Increased intensity alone does not account for the differences between traditional and task‐specific training (Delgado, 2013)
Upper extremity
Functional Intensive Training/therapy
Includes: Armeo CIMT Intensive Bimanual therapies
Adjunctive therapies Aquatic therapy NMES FES cycle Kinesiotape Splinting
Improved awareness Visual Attention Sensory awareness
Skill Acquisition Strengthening and improved range of motion Facilitation of new motions through sustained attention and effort
Functional, Everyday Practice and Success Participation in functional activities first in virtual reality environment
Generalization of new skills to ADLs, play, school…
Minimal size requirements for Armeo
Baseline strength Consider targeted skill Dexterity? Bimanual assist? Frequency of use? Severity of spasticity? Etc.
If too high functioning…
If too low functioning…
Specialized arm orthosis that provides support for the arm as it moves against gravity No robotic component
As a user moves, the exoskeleton measures arm movement and hand grasp as the patient interacts with computer games
Passive
Gravity‐A
ssisted
Armeo
Spring
Armeo
Spring
Robo
tic
11
Initial set up Adjust length of upper arm and forearm orthoses
Adjust gravity compensation of upper arm and forearm
Set up workspace Choose therapy plan activities
Facilitate participation Adjust workspace and/or difficulty level
Tactile cueing or gentle restraint to non‐affected arm
Decrease gravity compensation
Increase time of participation
Work towards improved speed and accuracy in virtual reality activities
Decrease gravity compensation
Increase workspace to encourage increased range of motion
MAY BE INDICATED FOR PATIENTS WHO
Have at least minimal voluntary control of upper extremity muscles
Can be fit in the upper arm and forearm orthoses
Would benefit from intensive therapies to improve upper extremity range of motion, strength and/or functional use Increased repetitions and
training for longer duration
BENEFITS OF USE
Motivation from virtual reality environment Increased repetitions
Intensive nature of treatment Reinforcement and
refinement of movement combined with functional therapy activities
Contraindications Unable to meet size requirements
Upper extremity fractures, osteoporosis
Pronounced, fixed contractures Open skin lesions Paraesthesia Shoulder joint subluxation/instability
Severe spontaneous (uncontrolled) movements
Precautions Significant upper extremity spasticity
Cognitive deficits Limited cause/effect level cognition
Aggressive or self harming behaviors
Recently healed incisions
Diagnoses Cerebral Palsy Acquired brain injury
▪ Anoxic, CVA, traumatic
Spinal cord injury ▪ Incomplete
Transverse myelitis Brachial plexus injury Guillain‐Barre Syndrome
Inpatients and outpatients
Ages 4‐15 years old
Internal referrals Therapist and physician
Evaluation and baseline assessment
• Outcome Measures
Armeo Treatment
• Intensive treatment
Re‐evaluate• Transition to traditional OT
• Continue Armeo• Discharge
Body structure and function Range of motion Strength testing Active Movement Scale Observe participation in activity of daily living
Length of forearm and upper arm
Activities and participation Visual and cognitive screen Pediatric Motor Activity Log
(PMAL) Canadian Occupational
Performance Measure (COPM) for goal setting
MACS classification tool Child Hand Use Experience
Questionnaire (CHEQ) Participation and
Environment Measure for Children and Youth (PEM‐CY)
Gravity supported arm exercise using the ArmeoSpring can improve arm movement after severe hemiparesis
(Housman et al., 2009)
3‐D weight support, instant visual feedback, and virtual reality software are associated with sustained gains at 6‐months when compared with conventional approach
Virtual reality creates environment for high intensity practice and positive feedback.
A virtual reality program improved quality of reaching in children with CP, especially in children with normal cognition and good cooperation.
Training effects were generally retained for longer after the intervention
(Galvin et al., 2011)
(Chen et al., 2007)
Cerebral Palsy (Fluet et al., 2010) Massed practice interventions based on motor learning principles emphasize the repetitive practice of goal‐oriented tasks as a more effective approach for children with CP vs. a traditional neuro‐developmental approach.
Chronic Stroke (Colomer et al., 2012)
Robotic systems, such as ArmeoSpring®, promote the active, systematic, and intensive repetition of specific movements
Armeo®Spring is an effective tool for rehabilitating the affected arm in patients with hemiparesis secondary to stroke, even in the chronic stage.
Improvements remained stable 4 months after intervention
Spinal Cord Injury (Zariffa et al., 2012)
Most studies have focused on use of the Armeo in post‐stroke patient populations
This pilot study showed few functional benefits in the limbs receiving Armeo training compared with the limbs not receiving robotic training
For patients with some hand function at baseline, significant improvements were noted in strength and sensibility
ArmeoSpring® is one option for an intensive therapeutic modality to improve upper extremity strength, range of motion and functional use Armeo should be used in combination with traditional therapies
15 year old male status post CVA PMH positive for ADHD and Asperger Syndrome Inpatient rehab at Gillette from 2/25/10‐4/9/10
Several episodes of outpatient OT care Splinting, upper extremity FES cycle, Bioness, traditional OT, ArmeoSpring ®
ArmeoSpring ® Episode of care 7/29/13‐9/27/13
OT Treatment: total of 16 sessions 3x/week for 5.5 weeks for 60 minute sessions
Average time on Armeo= 38 minutes
Home exercise program and functional activity
Continued with Bioness and splinting outside of therapy
EVALUATION
COPM Performance score 10/4=2.5 Satisfaction score 0/4=0
MMT Wrist flexion 3/5 Wrist extension 2‐/5
AROM Lacking full active shoulder
flexion, abduction, external rotation, elbow flexion, wrist extension/flexion
DISCHARGE
COPM Performance score 28/4=7 Satisfaction score 25/4=6.25
MMT Wrist flexion 4‐/5 Wrist extension 3/5
AROM Shoulder abduction improved
from 35 to 145 degrees Elbow flexion improved from
42 to 125 degrees Full wrist flexion and extension
Questions?
Kristin [email protected]
Chen, Y., Kang, L., Chuang T., Doong, J., Lee, S., Tsai, M.,…Sung, W. (2007). Use of virtual reality to improve upper‐extremity control in children with cerebral palsy: A single‐subject design. Physical Therapy, 87(11): 1441‐1457.
Colomer, C., Baldovi, A., Torrome, S., Navarro, M. Moliner, B., Ferri, J., Noe, E. (2012). Use ofArmeoSpring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia, 28(5): 261‐267.
Delgado, M. (2013, October). Task specific training based on neural capacity ofpatients with spastic CP. Pediatric Neurorehabilitation Symposium. Lectureconducted from Rehabilitation Institute of Chicago, Chicago, IL.
Fluet, G., Qiu, Q., Kelly, D., Parikh. H., Ramirez, D., Saleh, S., & Adamovich, S. (2010). Interfacing a haptic robotic system with complex virtual environments to treat impaired upper extremity motor function in children with cerebral palsy. Developmental Neurorehabiitation, 13(5), 335‐345.
Galvin, J., McDonald, R., Catroppa, C., & Anderson, V. (2011). Doesintervention using virtual reality improve upper limb function in childrenwith neurological impairment: A systematic review of the evidence. BrainInjury, 25(5), 435‐442.
Housman, S.J., Scott, K.M., & Reinkensmeyer, D.J. (2009). A randomized controlled trial of gravity‐support, computer‐enhanced arm exercise for individuals with severe hemiparesis. Neurorehabilitation and Neural Repair, 23(5), 505‐514.
O’brien, J. & Lewin, J. (2009). Translating motor control and motor learning theory into occupational therapy practice for children and youth. OT Practice, 14(1), CE1‐CE8.
Zariffa, J., Kapadia, N., Kramer, J., Taylor, P., Alizadeh‐Meghrazi, M., Zivanovic, V.,…Steeves, J. (2012). Spinal Cord, 50(3), 220‐226.