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Dr. Olga Jafarova , Ph.D., Mr. Eugen Tarasov , MS,

Development of the System for Continuous Medical Rehabilitation for Patients with Post-Stroke and Spinal Cord Injury Motor Disorders. Dr. Olga Jafarova , Ph.D., Mr. Eugen Tarasov , MS,

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Dr. Olga Jafarova , Ph.D., Mr. Eugen Tarasov , MS,

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  1. Development of the System for Continuous Medical Rehabilitation for Patients with Post-Stroke and Spinal Cord Injury Motor Disorders Dr.Olga Jafarova, Ph.D., Mr. Eugen Tarasov, MS, Prof.Mark Shtark, MD, Ph.D.Institute for Molecular Biology and Biophysics of Russian Academy of Medical Sciences, Novosibirsk Dr.Ruslana Yu. Guk, MDCenterforNeurorehabilitationSiberian Clinical Centre FMBA of the Ministry of Health and Social Development, Krasnoyarsk

  2. The project is aimed to providea continuous course of medical rehabof the patients with motor disordersand limited physiological functioning(post-stroke, craniocerebral or spinal cord injury) • There are a lot of high-tech neuro-rehabilitation technologies which can be applied at hospitals and rehab centers: • Neuro-Robotics • Neural Prostheses • Virtual Rehabilitation What can be used at patient’s HOME?

  3. Point of Care Technologies Quality-of-Life Technologies Connected Health Technologies “Smart Home” - a home environment “equipped with automated devices specifically designed for remote health care” (Rialle et al., 2002) Telemonitoring - assess fall risk, control gait Telediagnosis - evaluation of health status or rehab outcome Telerehabilitation – inexpensive apparatus(Foot Mentor, Hand Mentor, Balance Trainer)

  4. The principal aspect, which should be ensured during in-home rehabilitation is providing a total safety of a patient and securing sufficient level of professional control of the training process Furthermore, it is necessary to provide the possibility of conducting rehabilitation sessions asynchronously, that is to separate in time: doctor’s recommendations for home training, fulfillment of these recommendations by a patient, analysis of results

  5. State-of-the-art rehabilitation technologies use feedback signals Biological feedback (BIOFEEDBACK) technologywhich considers a patient as anactive subjecttake central position in all rehab models

  6. Method The project “Network NeuroRehabilitation” (NNR) comprisesa complexof neuro-rehabilitation technologiesbased on the electro-myographic (EMG)biofeedback which can be used not onlyin hospitals, but at home. Thresholds BOSLAB system screenshotof EMG biofeedback training – if Integral EMG is abovethe threshold Audio feedback signal appears

  7. Multimedia and game-like sessions increase patient’s motivation for rehabilitation

  8. Screenshot of a game form of EMG biofeedback If EMG signal lies in the range between the thresholds in so called target zone a flower grows and blooms

  9. Structure of Network Rehabilitation In the clinic or rehab centrea patient masters the required program of rehabilitation and gets the necessary instructions to continue practicing at home At home the patient continues practicing rehab procedures, regularly sends out training reports and data, and gets more recommendations from the therapist

  10. System of continuous distant medical rehabilitation Interaction of Doctor and Patient Level 2 Network information processing Data & Reports https https http http Level 3 Level 1 Doctor Boslab Biofeedback System Patient Decision making by Rehab. Specialist Patient’s PC at Home Rehab procedures Training reports&data

  11. System in action Asynchronousaccess to portal In the proposed structure there is no need for rehab specialist and patient to conduct training sessions in teleconference regime, therefore the process can be organized with greater flexibility. 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… … 0101 10… 0101 10… 0101 10… 0101 10… 0101 10… On-line session 0101 10… 0101 10… Doctors Patients

  12. On-line session Patient Internet Doctor

  13. Local and Server Data Synchronization Raw Data Dynamics in Training Sessions • Pair Muscles Training (m. gastrocnemiusactivation by turns) • EMG Integral and Thresholds • Right • Left L R R L R L Labels: Tense Right, Relax, Tense Left Task: Tense Relax Tense Left Right Muscle Muscle Session statistics EMG averaged over periods activation/relaxation, mkV

  14. Experimental Group and Procedure Since 2007 theSiberian Clinical Centre FMBA (Krasnoyarsk) has been a clinical base of the project Experimental group: 73 patients who manifested severe motor disorders. Among them 30 post-stroke 43 SCI consequences Control group: 35 disabled in-patients of the Siberian Clinical Centre FMBA with motor disorders of the same origin who were examined in 2011-2012

  15. Experimental Group and Procedure At the first stage the patients underwent 5 to 10 sessions of EMG biofeedback at the hospital to get the required training skills. The choice of training type depended on the clinical picture of the disease Patients with high muscle tone underwent the treatment of excessive spasticity, mainly aimed at spastic muscles’ relaxation and the rest practiced increasing muscle strength (alternation of activation and relaxation) Later at home they continued practicing muscle activation and relaxation exercise 3 to 5 times a week during 2 to 4 months, depending on the severity of the cases and the level of affection, using distant network neuro-rehabilitation.

  16. Experimental Group and Procedure Testing was conducted at the end of staying in a rehabilitation center and after the distant rehabilitation, which usually coincided with the rehospitalization For the control group the testing was performed at the end of the period of staying in a rehabilitation center and before the next hospitalization We used the following scales: • Modified Ashworth Scale for Grading Spasticity • Barthel ADL Index • Motor and Sensory Examination of ISCSCI-92

  17. Dynamics of amplitude of hip joint movement(19 patients with SCI, group average) 5 Scores Before After Network NeuroRehabilitationOutcome: stable increase in EMG amplitude increase of muscle strength increase of limbs’ circumference and joint range of motions improvement of the superficial sensitivity reduction of anxiety and depression *** 4 *** * ** ** ** ** 3 2 1 0 Before After Unbending Bending Abduction Adduction Rotation outside Rotation inside

  18. Case study 1 PatientV. age: 50. Post-stroke Left side hemi paresis EMG Dynamics in m. Tibialis anterior,left 04.12.09 : EMG biofeedback training at Rehab center 17.12.09 : Beginning of distant rehabilitation 03.02.10 : after 2 month of distant rehabilitation 400 300 200 100 0 100 200 300 400 Dynamics in m.Bicepsfemoris, left side Dynamics in m. Gastrocnemius, left side 300 300 200 200 100 100 0 0 100 200 300 400 500 100 200 300 400 500

  19. Case study 2 Patient M, age: 21. Lower paraparesis. Dynamics in m.Biceps femoris, right side 500 400 18.08.09 Beginning training in Rehab center 02.12.09 Session of distant rehabilitation at home 300 200 100 0 100 200 300 400 500 EMG Dynamics in m. Gastrocnemius:left , right Beginning of distant rehabilitation 20.08.09 Session of distant rehabilitation 20.01.10 80 60 20 40 15 20 10 0 100 200 300 100 200 300 400 500

  20. Dynamics during Network Neuro-Rehabilitation courseLow Spasticity Subgroup NNR Group 195 80 1.5 85 ISCSCI-Sensory ISCSCI-Motor ADL Index Ashworth Scale (N=56) P=0.028 P=0.000 Control Group (N=27) 1 78 190 80 Before After 0.5 185 76 75 P=0.000 p – level of significance Wilcoxon matched pairs test 74 0 180 70 Before After Before Before After After

  21. Dynamics during Network Neuro-Rehabilitation courseHigh Spasticity Subgroup NNR Group 3.5 170 65 75 ISCSCI-Motor ADL Index ISCSCI-Sensory Ashworth Scale (N=17) Control Group (N=8) P=0.004 3 160 60 70 Before After 55 150 2.5 65 p – level of significance Wilcoxon matched pairs test 2 50 140 60 Before After Before Before After After

  22. Discussion The results of patients’ examination before and after distant rehab showed that for the patients with increased spasticity the efficiency of biofeedback training was less pronounced. This could be due to their low motivation related to the relaxation training, as these patients wanted to improve their movement ability and increase self-service, for which purpose they thought it was expedient to practice muscle activation, not relaxation. Therefore we believe that for patients with increased muscle tone the biofeedback relaxation training at home should be more exciting, with a sufficient motivational component

  23. Discussion In our study, during the relaxation training, the patient tried to relax muscles and increase the skin temperature, at the same time trying to keep the EMG signal on the monitor lower than the threshold set by the program. Upon reaching the required level of muscle relaxation a movie or slide show could be viewed without distortion, the flowers were growing, the mosaic pictures were opening

  24. The use of the immersive virtual/ augmented reality aiming to relax muscle is still a challenge

  25. http://www.wilddivine.com. http://www.wilddivine.com. The most famous training set to develop the skills of self-control, uses cardio intervals and skin conductance, but not muscle characteristics

  26. GAME BIOFEEDBACK Control parameter Heart Rate

  27. Functional Independence Assessmentwith and without Network Rehab 70 FIM(TM) score P=0,02 60 NNR Group (N=12) Control (N=23) 50 40 After Rehab 1 Before Rehab 2

  28. Acknowledgments: Network NeuroRehabilitationProject Team • Chernikova, L.A. • Shtark, M.B. • Sklyar, M.M. • Sokolov, A.V. • Tarasov, E.A. • Tarasevich, A.F. • Terleev A.A. • Tzirkin, G.M. • Voroninskiy, V.A. The project made it real to rehabilitate the patients with severe motor disorders on everyday basis and secured constant contact between patients and therapists

  29. Network NeuroRehabilitation Project members: • Research Institute for Molecular Biologyand Biophysics of the Russian Academy of Medical Sciences • Siberian Clinical Centre of Federal Medical Biological Agency • Biofeedback Computer Systems Ltd. • Non-commercial InternationalCharity Foundation “SM, Charity” • Neurology Scientific Centerof the Russian Academy of Medical Sciences

  30. THANK YOU!

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