Tele-Neurorehabilitation

Primary Category

Digital Neurology

P-Category

Secondary Category

S-Category

Authors:

Shehzeen Fatima Memon MBBS,
Junaid Kalia MD

Introduction

Tele-neurorehabilitation refers to the use of physical, communicative, or cognitive rehabilitation assessment tools and training through digital platforms

These digital platforms involve the use of video/telephone calls and sensors with virtual reality for assessing, diagnosing, treating, monitoring, and educating the patient

The need for constant supervision in patients with neurodegenerative and neuropsychiatric diseases during the pandemic period increased the demand of tele-neurorehabilitation

The perception of the patient as well as doctors about technology is a major challenge for its use.

Benefits of Tele-neurorehabilitation

A cost and time-saving technique

Helps the patients to access medical care in far-off places where reaching the hospital is difficult

Helps in educating and training the patients’ families

Improves patient comfort and lifestyle

Tele-motor Rehabilitation

Method of providing physiotherapy and occupational therapy at home without the need for the physical presence of therapists

An integrated program has been effective in preventing falls in elderly with a higher risk of falling and with chronic diseases

Parkinson’s disease is a common neurological disorder treated via tele-motor rehabilitation

According to studies, a reduction in falls, and improved balance and mobility are seen in the patients, as a result

Studies have shown tele-motor rehabilitation to be beneficial for stroke patients using virtual reality if started 6 months after the attack.

Hemi-neglect syndrome is also treated via rehabilitation by using wheelchair mobility.

This approach involves computer technology to simulate wheelchair manipulation and includes the perceptual aspects required to safely mobilize using a wheelchair.

GAME-PAD System

Carpinella et al. developed a bio-feedback system called GAME-PAD (GAM Experience in Parkinson’s Disease) aimed at balance and gait rehabilitation

They used sensors on the upper and lower trunk and lower limbs.

Each patient had exercise calibrated according to their needs

Visual and auditory feedback was provided to the patients regarding their activity with a scoring system between 1 and 10.

VR Software Types for Limb Motility and Falls

Various devices by the name of TheraDrive, Bilateral arm training, Java Therapy, etc. utilize force-feedback joysticks and steering wheels in a virtual reality software

This software includes games for therapy and remote assessment of the impaired limb online

An example of rehabilitation software for upper limb function is given in the figure below

Figure 1: Motor Exercises in the Virtual Environment.

VRRS® Khymeia Group, Ltd. Noventa Padovana. Italy) represent two scenarios: A) a simple reaching movement: the patient has to raise the red glass and place it among the blue glasses on the shelf, according to a pre-recorded path (yellow line); B) a complex movement of increasing difficulty: the patient has to move the blue ball through the orange circles. The green box represents the start zone, while the yellow box represents the end zone to reach, following the circular-like displayed path.

A handful of studies have shown that Tai Chi, an aerobic exercise considerably improves the ability to balance and prevents falls in elderly people

An effort is still needed on the patient’s part to gather the physical and mental strength to undergo virtual rehabilitation

Tele-cognitive Rehabilitation

Psychological rehabilitation improves cognitive functions to provide complete autonomy to the patient

Cognition rehabilitation software is based on the adaptability level of patients to different exercises

This system helps strengthen the previously learned patterns of behavior, establish new patterns of cognitive activity or provide compensatory mechanisms for impaired neurological systems

These mechanisms revolve around specific cognitive domains, like attention, problem-solving, working memory, praxis, and speed of processing any information

Use of cognitive rehabilitation in multiple sclerosis

Multiple sclerosis is one such disease where gradual cognition deterioration is noted with around 40-60% of people being affected.

It negatively affects the patient’s employability, social interactions, and quality of life.

These patients undergo deficits in several aspects of cognitive function, including attention, information processing, memory and learning, executive function, and visuospatial skills.

A growing interest has emerged in the diagnosis and management of cognitive impairment in this disease

BTS-N System

Maggio et al. performed a randomized clinical trial using the ‘BTS-N system’ which consisted of computerized software, two infrared sensors without markers, a video camera, and a projector connected to a large screen.

This device system allows reproducing multiple exercises through the patient performing the exercises by interacting with virtual scenarios and audio-visual stimuli through movement, enhancing cognitive performance

Exercises are performed through movement in a virtual environment that produces changes on the interactive screen.

These movements allow you to move or manipulate specific objects like flowers in different directions or to create associations by dynamic interaction with the virtual environment.

The patient receives audio and video feedback when he touches the virtual objects.

A patient can perform video-motor sequences with the guidance of the therapist; numerical calculation, inhibitory control, and deductive logical reasoning, using a specific virtual task.

RAN System

Cognitive rehabilitation is also used in dyslexia.

The software has been developed with the name of Run the rapid automatized naming (RAN) that uses alphanumeric stimuli.

It involves visual, linguistic, and attentional processes to help patients read and write.

The levels of difficulty for the automation are managed by the operator.

Other Important Software Technologies

Recent application has also been seen in cognitive deficits in pediatric multiple sclerosis and attention-deficit hyperactivity disorder (ADHD) but it is not very beneficial

Tele-cognitive rehabilitation helps resolve cognitive deficits in stroke by improving verbal fluency, mood, attention, and short-term memory.

Tinelli et al. developed an audiovisual telerehabilitation system which has provided a new tool to improve eye movements toward the blind semi-field based on the multisensory ability of the brain.

After testing on patients it was found to improve visual detection skills with long-term effects

Nu!RehaVR system

A virtual reality software by the name of Nu!RehaVR was developed by Gervasi et al in 2010 to rehabilitate patients who suffered a traumatic brain injury.

The rehabilitation software used two exercises, one allowing the patients to be able to “utilize an elevator to reach a given floor” and the second one allowing them to “cross a road using a traffic light”

By performing these considerably dangerous activities, the patient’s progress was monitored

Tele-monitoring

Tele-monitoring refers to assessing and observing patient attitudes and behaviors to improve his medical and general condition

One of the most impactful uses of telemonitoring is for neuromuscular disorders where it helps to improve respiratory difficulties in a patient

In multiple sclerosis (MS), it helps by improving a patient’s bladder and bowel habits, activities of daily living, and mood

Literature suggests that Tele assistance improves cognitive symptoms and social functioning in elderly suffering from depression

Patients quite often, are doubtful of using video-conferencing in comparison to directly meeting a healthcare professional.

This can be overcome by adopting a feedback method and providing appropriate training to the healthcare professionals to overcome patient anxiety

A virtual reality system developed in Italy by the name of “Virtual Reality Rehabilitation System—VRRS” uses programmed exercises catered to individual’s needs, as described in Figure 1

Figure 2: VRRS System

The VRRS system is the Italian Tele-rehab tool used for motor and cognitive rehabilitation. (Property of VRRS® Khymeia Group, Ltd. Noventa Padovana. Italy)

Limitations and Challenges

Computer anxiety, low perception of usefulness, and a belief that the technology is not user-friendly are significant predictors of an individual’s likelihood to use TR

Tele-rehabilitation has not yet reached mainstream status around the globe and only a few countries with well-equipped technology are in use of this software.

Global protocols are yet to be devised to simplify the use of telerehabilitation around the whole world.

It can be especially challenging for the elderly because of limited information about tackling the devices

Cybersickness is a form of sickness that occurs using virtual reality seen in a few people who experience nausea, vomiting, and dizziness while using the software due to an imbalance between perception, and vestibular and visual systems.

There is still a need for numerous randomized controlled trials to analyze the effects of VR-based technologies on human consumption

Development of the software needs capital which might not be possible in low to middle-income countries further restricting the utilization

Bibliography

Klaic, M., & Galea, M. P. (2020). Using the technology acceptance model to identify factors that predict the likelihood to adopt tele-neurorehabilitation. Frontiers in Neurology, 11, 1637.

Laver, K. E., Adey‐Wakeling, Z., Crotty, M., Lannin, N. A., George, S., & Sherrington, C. (2020). Telerehabilitation services for stroke. Cochrane Database of Systematic Reviews, (1).

Khanna, M., Gowda, G. S., Bagevadi, V. I., Gupta, A., Kulkarni, K., Shyam, R. P. S., ... & Math, S. B. (2018). Feasibility and utility of tele-neurorehabilitation service in India: Experience from a quaternary center. Journal of Neurosciences in Rural Practice, 9(04), 541-544.

Chumbler, N. R., Quigley, P., Li, X., Morey, M., Rose, D., Sanford, J., ... & Hoenig, H. (2012). Effects of telerehabilitation on physical function and disability for stroke patients: a randomized, controlled trial. Stroke, 43(8), 2168-2174.

Carpinella, I., Cattaneo, D., Bonora, G., Bowman, T., Martina, L., Montesano, A., & Ferrarin, M. (2017). Wearable sensor-based biofeedback training for balance and gait in Parkinson’s disease: a pilot randomized controlled trial. Archives of physical medicine and rehabilitation, 98(4), 622-630.

Webster, J. S., McFarland, P. T., Rapport, L. J., Morrill, B., Roades, L. A., & Abadee, P. S. (2001). Computer-assisted training for improving wheelchair mobility in unilateral neglect patients. Archives of physical medicine and rehabilitation, 82(6), 769-775.

Johnson, M. J., & Schmidt, H. (2009, December). Robot-assisted neurological rehabilitation at home: Motivational aspects and concepts for telerehabilitation. In Public Health Forum (Vol. 17, No. 4, pp. 8-e1). No longer published by Elsevier.

Maggio, M. G., De Luca, R., Manuli, A., Buda, A., Foti Cuzzola, M., Leonardi, S., ... & Calabrò, R. S. (2020). Do patients with multiple sclerosis benefit from semi-immersive virtual reality? A randomized clinical trial on cognitive and motor outcomes. Applied Neuropsychology: Adult, 1-7.

Maggio, M. G., De Luca, R., Maresca, G., Di Lorenzo, G., Latella, D., Calabro, R. S., & Bramanti, A. (2018). Personal computer‐based cognitive training in Parkinson's disease: A case study. Psychogeriatrics, 18(5), 427-429.

Turolla, A., Dam, M., Ventura, L., Tonin, P., Agostini, M., Zucconi, C., ... & Piron, L. (2013). Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial. Journal of neuroengineering and rehabilitation, 10(1), 1-9.

Hill, A. J., Paik, N. J., Kiran, S., & Tonin, P. (2021). Tele-NeuroRehabilitation. Frontiers in neurology, 12, 761690-761690.

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