Janet M. Powell

Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke

BACKGROUND Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. METHODS In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. RESULTS At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. CONCLUSIONS In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

Outcome 3 to 5 years after moderate to severe traumatic brain injury

OBJECTIVE To investigate neuropsychologic, emotional, and functional status and quality of life (QOL) 3 to 5 years after moderate to severe traumatic brain injury (TBI). DESIGN Observational cohort. SETTING Level I trauma center. PARTICIPANTS Consecutive adult admissions with TBI involving intracranial abnormalities, prospectively followed up for 3 to 5 years, with 80% follow-up. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Neuropsychologic functioning (Paced Auditory Serial Addition Test, California Verbal Learning Test), emotional status (Center for Epidemiologic Studies Depression Scale, Brief Symptom Inventory), functional status (Functional Status Examination, Glasgow Outcome Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, employment), and perceived QOL. RESULTS Significant functional limitations were observed in all areas. Recovery to preinjury levels ranged from 65% of cases in personal care to approximately 40% in cognitive competency, major activity, and leisure and recreation. Brain injury severity, measured by the modified Abbreviated Injury Scale, related to functional status and neuropsychologic functioning, but not to emotional or QOL measures. Length of impaired consciousness appeared to contribute to outcome more than did anatomic lesions. CONCLUSIONS The results provide representative estimates of long-term morbidity in patients with TBI involving intracranial lesions. The magnitude of morbidity was high. Although direct costs of TBI have received the most attention, the long-term consequences and their cost implications are much larger, unfold over time, and are borne by the survivors, their families, and the public subsidy system.

Accuracy of Mild Traumatic Brain Injury Diagnosis

OBJECTIVE To determine how often emergency department (ED) patients meeting the Centers for Disease Control and Prevention (CDC) mild traumatic brain injury (TBI) criteria were diagnosed with a mild TBI by the ED physician. DESIGN Prospective identification of cases of mild TBI in the ED by study personnel using scripted interviews and medical record data was compared with retrospective review of ED medical record documentation of mild TBI. SETTING EDs of a level I trauma center and an academic nontrauma hospital. PARTICIPANTS Prospective cohort of subjects (N=197; mean age, 32.6 y; 70% men) with arrival at the ED within 48 hours of injury, Glasgow Coma Scale score of 13 to 15, and injury circumstances, alteration of consciousness, and memory dysfunction consistent with the CDC mild TBI definition. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE ED medical record documentation of mild TBI. RESULTS Fifty-six percent of mild TBI cases identified by study personnel did not have a documented mild TBI-related diagnosis in the ED record. The greatest agreement between study personnel and ED physicians for positive mild TBI-related findings was for loss of consciousness (72% vs 65%) with the greatest discrepancy for confusion (94% vs 28%). CONCLUSIONS The diagnosis of mild TBI was frequently absent from ED medical records despite patients reporting findings consistent with a mild TBI diagnosis when interviewed by study personnel. Asking a few targeted questions of ED patients with likely mechanisms of injury that could result in mild TBI could begin to improve diagnosis and, in turn, begin to improve patient management and the accuracy of estimates of mild TBI incidence.

The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: A randomised trial

Background: Mild traumatic brain injury (MTBI) is a significant public health problem affecting approximately 1 million people annually in the USA. A total of 10–15% of individuals are estimated to have persistent post-traumatic symptoms. This study aimed to determine whether focused, scheduled telephone counselling during the first 3 months after MTBI decreases symptoms and improves functioning at 6 months. Methods: This was a two-group, parallel, randomised clinical trial with the outcome assessed by blinded examiner at 6 months after injury. 366 of 389 eligible subjects aged 16 years or older with MTBI were enrolled in the emergency department, with an 85% follow-up completion rate. Five telephone calls were completed, individualised for patient concerns and scripted to address education, reassurance and reactivation. Two composites were analysed, one relating to post-traumatic symptoms that developed or worsened after injury and their impact on functioning, the other related to general health status. Results: The telephone counselling group had a significantly better outcome for symptoms (6.6 difference in adjusted mean symptom score, 95% confidence interval (CI) 1.2 to 12.0), but no difference in general health outcome (1.5 difference in adjusted mean functional score, 95% CI 2.2 to 5.2). A smaller proportion of the treatment group had each individual symptom (except anxiety) at assessment. Similarly, fewer of the treatment group had daily functioning negatively impacted by symptoms with the largest differences in work, leisure activities, memory and concentration and financial independence. Conclusions: Telephone counselling, focusing on symptom management, was successful in reducing chronic symptoms after MTBI. Trial registration number: ClinicalTrials.gov, #NCT00483444

A Randomized Controlled Trial of Exercise to Improve Mood After Traumatic Brain Injury

To test the hypothesis that a structured aerobic exercise regimen would decrease the severity of depressive symptoms in people with traumatic brain injury (TBI) who reported at least mild depression severity at baseline.

Benefits of Exercise Maintenance After Traumatic Brain Injury

OBJECTIVE To examine the effect of exercise intervention on exercise maintenance, depression, quality of life, and mental health at 6 months for people with traumatic brain injury (TBI) with at least mild depression. DESIGN Treatment group participants were assessed at baseline, after a 10-week exercise intervention, and 6 months after completion of the intervention. SETTING Community. PARTICIPANTS Participants (N=40) with self-reported TBI from 6 months to 5 years prior to study enrollment and a score of 5 or greater on the Patient Health Questionnaire-9. INTERVENTIONS Ten-week exercise intervention program consisting of supervised weekly 60-minute sessions and unsupervised 30 minutes of aerobic exercises 4 times each week. Telephone follow-up was conducted every 2 weeks for an additional 6 months to promote exercise maintenance for individuals randomized to the intervention group. MAIN OUTCOME MEASURE Beck Depression Inventory (BDI) comparing participant outcomes over time. Post hoc analyses included comparison among those who exercised more or less than 90 minutes per week. RESULTS Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health. CONCLUSIONS Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment.

Return to driving within 5 years of moderate-severe traumatic brain injury

Primary objective: To examine return to driving and variables associated with that activity in a longitudinal database. Research design: Retrospective analysis of a large, national database. Methods and procedures: The sample was comprised of people with predominantly moderate–severe traumatic brain injury (TBI) enrolled in the TBI Model System national database at 16 centres and followed at 1 (n = 5942), 2 (n = 4628) and 5 (n = 2324) years after injury. Main outcomes and results: Respondents were classified as driving or not driving at each follow-up interval. Five years after injury, half the sample had returned to driving. Those with less severe injuries were quicker to return to driving, but, by 5 years, severity was not a factor. Those who were driving expressed a higher life satisfaction. Functional status at rehabilitation discharge, age at injury, race, pre-injury residence, pre-injury employment status and education level were associated with the odds of a person driving. Conclusions: Half of those with a moderate–severe TBI return to driving within 5 years and most of those within 1 year of injury. Driving is associated with increased life satisfaction. There are multiple factors that contribute to return to driving that do not relate to actual driving ability.

Experiences of Living With Non-Cancer-Related Lymphedema: Implications for Clinical Practice

Lymphedema is a chronic medical condition caused by lymphatic insufficiency that can lead to extreme swelling and susceptibility to infection. Physical and psychosocial effects of the condition can have a significant impact on an individuals life and level of participation. Research about experiences of individuals living with lymphedema has focused primarily on women with breast cancer, yet individuals with non-cancer-related lymphedema are a distinct group. In this study, the authors used qualitative description to explore the experience of 7 individuals living with advanced and complicated cases of lymphedema who had been treated in an inpatient setting. Findings reveal the extensive impact lymphedema has on those who live with it. Participants spoke of difficulty finding a correct diagnosis and effective treatment, the importance of their inpatient experiences, and the challenges of daily self-management. The authors make recommendations to increase lymphedema awareness, promote inpatient treatment programs, and create effective self-management techniques.

Isotropy of an upper limb exoskeleton and the kinematics and dynamics of the human arm

The integration of human and robot into a single system offers remarkable opportunities for a new generation of assistive technology. Despite the recent prominence of upper limb exoskeletons in assistive applications, the human arm kinematics and dynamics are usually described in single or multiple arm movements that are not associated with any concrete activity of daily living ADL. Moreover, the design of an exoskeleton, which is physically linked to the human body, must have a workspace that matches as close as possible with the workspace of the human body, while at the same time avoid singular configurations of the exoskeleton within the human workspace. The aims of the research reported in this manuscript are 1 to study the kinematics and the dynamics of the human arm during daily activities in a free and unconstrained environment, 2 to study the manipulability isotropy of a 7-degree-of-freedom DOF-powered exoskeleton arm given the kinematics and the dynamics of the human arm in ADLs. Kinematic data of the upper limb were acquired with a motion capture system while performing 24 daily activities from six subjects. Utilising a 7-DOF model of the human arm, the equations of motion were used to calculate joint torques from measured kinematics. In addition, the exoskeleton isotropy was calculated and mapped with respect to the spacial distribution of the human arm configurations during the 24 daily activities. The results indicate that the kinematic joint distributions representing all 24 actions appear normally distributed except for elbow flexion--extension with the emergence of three modal centres. Velocity and acceleration components of joint torque distributions were normally distributed about 0 Nm, whereas gravitational component distributions varied with joint. Additionally, velocity effects were found to contribute only 1/100th of the total joint torque, whereas acceleration components contribute 1/10th of the total torque at the shoulder and elbow, and nearly half of the total torque at the wrist. These results suggest that the majority of human arm joint torques are devoted to supporting the human arm position in space while compensating gravitational loads whereas a minor portion of the joint torques is dedicated to arm motion itself. A unique axial orientation at the base of the exoskeleton allowed the singular configuration of the shoulder joint to be moved towards the boundary of the human arm workspace while supporting 95% of the arms workspace. At the same time, this orientation allowed the best exoskeleton manipulability at the most commonly used human arm configuration during ADLs. One of the potential implications of these results might be the need to compensate gravitational load during robotic-assistive rehabilitation treatment. Moreover, results of a manipulability analysis of the exoskeleton system indicate that the singular configuration of the exoskeleton system may be moved out of the human arm physiological workspace while maximising the overlap between the human arm and the exoskeleton workspaces. The collected database along with kinematic and dynamic analyses may provide a fundamental basis towards the development of assistive technologies for the human arm.

Development of a telephone follow-up program for individuals following traumatic brain injury

ObjectiveTo describe the development of a telephone follow-up program that addresses the needs of survivors of traumatic brain injury (TBI) and their families in the year following injury. The process of developing the program is reviewed from the initial steps of identifying needs through final implementation of the program. ParticipantsEighty-four TBI survivors with moderate to severe injuries and their families. ResultsDescriptive statistics are presented including number of contacts, areas of concern for participants, and the types of interventions conducted. Case examples are provided to illustrate the impact of the telephone follow-up program. ConclusionThis project demonstrated the feasibility of using the telephone as a means of providing information and support during the first year after moderate to severe traumatic brain injury. Telephone follow-up may enhance service provision for persons with TBI, especially those with a lack of transportation or geographic isolation.