Grigore C. Burdea

Integrative rehabilitation of elderly stroke survivors: The design and evaluation of the BrightArm™

Purpose: To describe the development of the BrightArm upper extremity rehabilitation system, and to determine its clinical feasibility with older hemiplegic patients. Method: The BrightArm adjusted arm gravity loading through table tilting. Patients wore an arm support that sensed grasp strength and communicated wirelessly with a personal computer. Games were written to improve cognitive, psychosocial and the upper extremity motor function and adapted automatically to each patient. The system underwent feasibility trials spanning 6 weeks. Participants were evaluated pre-therapy, post-therapy, and at 6 weeks follow-up using standardized clinical measures. Computerized measures of supported arm reach and game performance were stored on a remote server. Results: Five participants had clinically significant improvements in their active range of shoulder movement, shoulder strength, grasp strength, and their ability to focus. Several participants demonstrated substantially higher arm function (measured with the Fugl-Meyer test) and two were less-depressed (measured with the Becks Depression Inventory, Second Edition). The BrightArm technology was well-accepted by the participants, who gave it an overall subjective rating of 4.1 on a 5 point Likert scale. Conclusions: Given these preliminary findings, it will be beneficial to evaluate the BrightArm through controlled clinical trials and to investigate its application to other clinical populations. Implications for Rehabilitation It is possible to improve arm function in older hemiplegic patients many years after stroke. Integrative rehabilitation through games combining cognitive (memory, focusing, executive function) and physical (arm movement, hand-eye coordination, grasping, dual-tasking) elements is enjoyable for this population. The severity of depression in the elderly can be reduced through virtual reality games, as long as games adapt to the patient, are winnable and provide rewards for success.

Feasibility study of the BrightBrainer™ integrative cognitive rehabilitation system for elderly with dementia.

Abstract Purpose: To describe the development of BrightBrainer™ integrative cognitive rehabilitation system and determine clinical feasibility with nursing home-bound dementia patients. Method: BrightBrainer cognitive rehabilitation simulations were first played uni-manually, then bimanually. Participants sat in front of a laptop and interacted through a game controller that measured hand movements in 3D, as well as flexion of both index fingers. Interactive serious games were designed to improve basic and complex attention (concentration, short-term memory, dual tasking), memory recall, executive functioning and emotional well-being. Individual simulations adapted automatically to each participant’s level of motor functioning. The system underwent feasibility trials spanning 16 sessions over 8 weeks. Participants were evaluated pre- and post-intervention, using standardized neuropsychological measures. Computerized measures of movement repetitions and task performance were stored on a remote server. Results: Group analysis for 10 participants showed statistically significant improvement in decision making (p < 0.01), with trend improvements in depression (p < 0.056). Improvements were also seen in processing speed (p < 0.13) and auditory attention (p < 0.17); however, these were not statistically significant (partly attributable to the modest sample size). Eight of nine neuropsychological tests showed changes in the improvement direction indicating an effective rehabilitation (p < 0.01). BrightBrainer technology was well tolerated with mean satisfaction ratings of 4.9/5.0 across participants. Conclusions: Preliminary findings demonstrate utility within an advanced dementia population, suggesting that it will be beneficial to evaluate BrightBrainer through controlled clinical trials and to investigate its application in other clinical populations. Implications for Rehabilitation It is possible to improve cognitive function in older low-functioning patients. Integrative rehabilitation through games combining cognitive (memory, focusing, executive function) and physical (bimanual whole arm movement, grasping, task sequencing) elements is enjoyable for this population. The severity of depression in these elderly can be reduced through virtual reality bimanual games. The number of upper extremity active repetitions performed in the process of solving cognitive problems with the BrightBrainer™ system is 600. This number is 18 times (1875%) larger than those observed by other researchers in conventional physical or occupational rehabilitation sessions.

Novel integrative virtual rehabilitation reduces symptomatology of primary progressive aphasia - a case report

Purpose: BrightBrainer™ integrative cognitive rehabilitation system evaluation in an Adult Day Program by a subject with Primary Progressive Aphasia (PPA) assumed to be of the mixed nonfluent/logopenic variant, and for determination of potential benefits. Methods: The subject was a 51-year-old Caucasian male diagnosed with PPA who had attended an Adult Day Program for 18 months prior to BrightBrainer training. The subject interacted with therapeutic games using a controller that measured 3D hand movements and flexion of both index fingers. The computer simulations adapted difficulty level based on task performance; results were stored on a remote server. The clinical trial consisted of 16 sessions, twice/week for 8 weeks. The subject was evaluated through neuropsychological measures, therapy notes and caregiver feedback forms. Results: Neuropsychological testing indicated no depression (BDI 0) and severe dementia (BIMS 1 and MMSE 3). The 6.5 h of therapy consisted of games targeting Language comprehension; Executive functions; Focusing; Short-term memory; and Immediate/working memory. The subject attained the highest difficulty level in all-but-one game, while averaging 1300-arm task-oriented active movement repetitions and 320 index finger flexion movements per session. While neuropsychological testing showed no benefits, the caregiver reported strong improvements in verbal responses, vocabulary use, speaking in complete sentences, following one-step directions and participating in daily activities. This corroborated well with therapy notes. Conclusions: Preliminary findings demonstrate a meaningful reduction of PPA symptoms for the subject, suggesting follow-up imaging studies to detail neuronal changes induced by BrightBrainer system and controlled studies with a sufficiently large number of PPA subjects.

Integrative rehabilitation of residents chronic post-stroke in skilled nursing facilities: the design and evaluation of the BrightArm Duo.

Abstract Purpose: To describe the novel BrightArm Duo bimanual upper extremity (UE) rehabilitation system; to determine its technology acceptance and clinical benefit for older hemiplegic participants. Methods: The system table tilted to adjust arm gravity loading. Participants wore arm supports that sensed grasp strength and wrist position on the table. Wrist weights further increased shoulder exertion. Games were designed to improve UE strength, motor function, cognition and emotive state and adapted automatically to each participant. The system underwent feasibility trials spanning 8 weeks in two skilled nursing facilities (SNFs). Participants were evaluated pre-therapy and post-therapy using standardized clinical measures. Computerized measures of supported arm reach, table tilt and number of arm repetitions were stored on a remote server. Outcomes: Seven participants had significant improvements in their active range of shoulder movement, supported arm reach, shoulder strength, grasp strength and their ability to focus. The group demonstrated higher arm function measured with FMA (p = 0.01) and CAHAI (p = 0.05), and had an improvement in depression (Becks Depression Inventory, II). BrightArm Duo technology was well accepted by participants with a rating of 4.4 out of 5 points. Conclusions: Given these findings, it will be beneficial to evaluate the BrightArm Duo application in SNF maintenance programs. Implications for Rehabilitation Integrative rehabilitation that addresses both physical and cognitive domains is promising for post-stroke maintenance in skilled nursing facilities. Simultaneous bilateral arm exercise may improve arm function in older hemiplegic patients several years after stroke. Virtual reality games that adapt to the patient can increase attention and working memory while decreasing depression in elderly.

BrightArm™ therapy for patients with advanced dementia: A feasibility study

Virtual reality use in cognitive rehabilitation of advanced dementia has been sparse. Three residents of a Dementia Ward participated in a feasibility study of the BrightArm™ system. They played custom games targeting several cognitive domains including short-term and working memory. Clinician observation revealed a positive effect on emotive state, with technology well accepted by all participants.

Integrative motor, emotive and cognitive therapy for elderly patients chronic post-stroke A feasibility study of the BrightArm™ rehabilitation system

The BrightArm rehabilitation system is designed for integrative motor, emotive and cognitive training of low- and higher-functioning individuals. This paper presents the BrightArms first feasibility study on 5 elderly skilled nursing facility residents chronic post-stroke. Results show improvements in motor impairments, upper extremity function, independence in activities of daily living, as well as better focusing and short-term visual memory following therapy. There was uniformly good acceptance of the technology by the participants which gave it an overall rating of 4.1 out of 5.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery

Background: Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain. Objectives: The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression. Methods: BrightArm Duo is a robotic rehabilitation table modulating gravity loading on supported forearms. It tracks arm position and grasping strength while patients play three-dimensional (3D) custom integrative rehabilitation games. Community-dwelling women (N = 6) with post-surgical breast cancer pain in the upper arm trained on the system twice a week for 8 weeks. Training difficulty increased progressively in game complexity, table tilt and session length (20–50 minutes). Standardized assessments were performed before and after therapy for pain, cognition, emotion, UE function and activities of daily living. Results: Subjects averaged upwards of 1300 arm repetitions and 850 hand grasps per session. Pain intensity showed a 20% downward trend (p = 0.1) that was corroborated by therapist observations and participant feedback. A total of 10 out of 11 cognitive metrics improved post-training (p = 0.01) with a significant 8.3-point reduction in depression severity (p = 0.04). A total of 17 of 18 range of motion metrics increased (p < 0.01), with five affected-side shoulder improvements above the Minimal Clinically Important Difference (8°). In all, 13 out of 15 strength and function metrics improved (p = 0.02) with lateral deltoid strength increasing 7.4 N on the affected side (p = 0.05). Conclusion: This pilot study demonstrated feasibility of using the BrightArm Duo Rehabilitation System to treat cancer survivors coping with upper body chronic pain. Outcomes indicate improvement in cognition, shoulder range, strength, function and depression.

A review of integrative virtual reality games for rehabilitation

This paper presents a new type of integrative medicine called virtual rehabilitation, or the use of virtual reality in therapy. A number of games designed for improving motor (range of movement, endurance, motor control) and cognitive (focusing, short term memory, executive functions) impairments are presented. We include a description of a typical clinical protocol in which these games are used and a sample of clinical outcomes.

Integrative Upper-Limb Rehabilitation with BrightArm DuoTM in the Early Sub-Acute Phase of Recovery Post-Stroke

The Bright Arm Duo is a low-friction robotic rehabilitation table that adaptably trains dual arm movement and grasp through interaction with serious games. In early sub-acute phase post-stroke, N=3 experimental group received conventional rehabilitation plus 12 BrightArm Duo sessions, each inducing up to 600 arm and hand repetitions. N=9 control group received conventional rehabilitation only. Improvement for the experimental group was better than controls across 11 of 12 functional metrics and activities of daily living (p=0.006).