The following is a selection of comments and links to articles from experts in the field, demonstrating the extent of musculo-skeletal problems in the community, and the associated costs.
The importance of hands
Prof E Burdet (Imperial College, London) at iCREATe 2009 stated in his plenary speech that more than anything, stroke patients miss their hand manipulation functions.
http://icreate.start-centre.com/icreate2009/plenary.php
Issues that influence hand therapy
Prof W Zev Rymer (Rehabilitation institute, Chicago), says the key element of therapy is time spent practicing moving the arm in a task–motivated manner. Reasons that limit patient practice include:
- The patient is too weak and becomes discouraged and stops exercise
- Boredom from the simplicity and repetitious nature of the exercise
- Activation of shoulder muscles invokes unhelpful muscle activation patterns
http://www.inrs2009.com/fileadmin/user/PDF/INRS/
Rymer_RehabilitationRobotics__INRS2009.pdf
Tangible and intangible costs of limb disorders
''The costs of musculo-skeletal disorders is an enormous burden that no-one has really thought about.'' - “The Crippling Burden, Musculo – Skeletal conditions in New Zealand, The bone and Join decade 2000 -2010,” C. J Bossley and K. B Miles.
“The segment of health suffers in terms of awareness and preventative funding because the disorders are generally not fatal, they can be relatively invisible (i.e. chronic) and are often just dismissed as a consequence of ageing…..”
The psychological aspects, physical, financial and emotional upset to the patient, close family members, and disruption of quality of life, impact on community and economy have not been quantified, but are considered substantial.
http://www.physiotherapy.org.nz/Index02/Publications/PublicationPDF/BJD%20Publication%202009.pdf
Musculo-Skeletal Conditions in New Zealand, Q&A at interview, C.J. Bossley, K.B. Miles, 2009
Very high numbers with musculo-skeletal disorders
Musculoskeletal disorders are a major cause of activity limitation and long term disability in the population. The United State health survey indicated that 30% of the population between 25-74 years had musculoskeletal symptoms.
http://resources.metapress.com/pdf-review.axd?code=k045516n211m8723&size=largest
Increased risk of stroke in low to medium income countries
This study shows that the incidence of stroke in low-to-medium income countries has increased by more than 100 per cent, and that people living in these countries face a 20 per cent greater risk of stroke than those living in high-income countries, where the incidence of stroke has declined by 42 per cent.
http://www.nzdoctor.co.nz/news?article=558f5af0-1f76-4016-8446-f3bbed5dee61
Stroke as third leading cause of death in USA
Acute cerebrovascular disease, or stroke, was the third-leading cause of death for Americans and the leading cause of disability in 2005.
In 2005, there were an estimated 892,300 hospitalizations for cerebrovascular disease, which represented a hospitalization rate of 77.3 stays per 10,000 persons older than 45 years of age.
The total hospital cost for cerebrovascular disease was $8.5 billion—about three percent of the total cost of hospital care in the U.S.
On average, hospital stays for cerebrovascular disease had similar resource requirements as hospital stays for all conditions given that the length of stay was similar (5.0 days) and the average cost per stay was equal ($9,500).
Nearly one-third (29.8 percent) of cerebrovascular disease hospitalisations resulted in discharge to a nursing home or rehabilitation facility—almost twice the percentage of all hospital stays discharged to these facilities.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb51.pdf
Costs for rehabilitation are substantial
The average daily charge for the acute rehabilitation stroke programme was $1,021. Total treatment charges for this set of 331 patients was $9,665,399. For the subacute programme, the average charge per day was $502, totalling $1,178,395 in charges for 97 patients.
The average cost per successful case for patients returned to the community after acute rehabilitation was $41,129 versus $18,129 for subacute rehabilitation. The average charge per point of FIM gain was $960 (acute) and $591 (subacute).
(http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?View=Full&ID=21995000747)
When withdrawn socially, stroke patients are not likely to venture into the neighbourhood for walks, use the public swimming pool for low-impact aquatic training, or travel to a local gym for exercise classes.
Studies have shown that even in stroke survivors with a significant degree of physical recovery, social isolation was still evident. Many stroke patients will not have equipment or facilities in their home to sustain interest in an exercise program in the long term. They will need to seek assistance, equipment, and facilities in the community.
To enhance exercise compliance, the issue of social isolation will need to be actively addressed and resolved.
The complex interplay between physiological and emotional barriers to continuing recovery after a stroke demand creative and individualized rehabilitative programs to be designed and implemented by a multidisciplinary team.
The relevant clinical, emotional, and social variations present in each stroke survivor preclude the application of a template to post stroke rehabilitation.
When applicable tools are used to assess the individual for physiological and emotional barriers and known and adapted techniques to remove or ameliorate such barriers are applied, each patient is best prepared to reach their optimal state of function and well-being.
(http://circ.ahajournals.org/cgi/content/full/109/16/2031)
Paper by M King, A Nicholls and F Collins entitled ‘A wrist extension operated lateral key-pinch grip orthosis for people with tetraplegia” , July 2008 can be found at http://iospress.metapress.com/content/g6q626830373852v/.
The orthosis utilises wrist extension to produce a lateral key grip between the thumb and proximal or middle phalanx of the index finger.
An assessment tool was developed to measure functionality using ADL tasks and a Preston pinch meter was used to measure grip strength.
After 6-weeks training, use of the orthosis increased lateral key grip on average by 3 times and the number of tasks achieved increased from 6 to 11 out of the 13 tasks measured.
The learning effect from the training protocol was significant (P = 0.04) and use of the orthosis reinforced the movement pattern required to achieve a standard tenodesis grasp.
Robotic-assisted therapy with virtual reality, leads to improvements in motor function, but, there is a need to improve the cost-to-benefit ratio of these therapies.
This case series study investigated an augmented reality computer game which provided a rewarded, goal-directed task to upper limb rehabilitation via a reaching task motivated by a computer game.
A device was developed to increase the exercise effort for the table-based therapy. Of the 4 participants in the case study, 2 showed improvement in ability to play the game and in arm function. Participants felt that the system provided a worthwhile exercise that they would carry out in a home rehabilitation setting.
