虛擬康復(fù)訓(xùn)練系統(tǒng)在脊髓損傷康復(fù)的應(yīng)用2013-1-3

1China,Summer2012Virtualrehabilitationtrainingsysteminspinalcordinjuryrehabilitationapplications虛擬康復(fù)訓(xùn)練系統(tǒng)在脊髓損傷康復(fù)的應(yīng)用

1.Introduction1.簡(jiǎn)介3MynameisJorisWiersinga,andIamthechairmanofthecompanySilverFit我是JorisWiersinga，是SilverFit公司的董事長(zhǎng)。Ourgamesarecurrentlybeingusedin>450clinicsworldwide在世界范圍內(nèi)有超過(guò)450個(gè)診所正在使用我們的產(chǎn)品5SilverFithasdevelopedanumberofaward-winningproductsforgeriatriccareSilverFit公司研發(fā)了很多用于老年康復(fù)的一流產(chǎn)品RGFBrabantQualityAwardTraingrossmotormovementssuchassit-stand,balance,armtraining,walking.粗大動(dòng)作運(yùn)動(dòng)訓(xùn)練，如坐-站，平衡，上肢訓(xùn)練，行走。Strengthtrainingusingweightstackequipmentsuchasapulley,legpress,rowingmachine.利用重量可疊加設(shè)備進(jìn)行力量訓(xùn)練，如滑輪、伸腿器、劃船機(jī)。Gaittrainingonatreadmill跑臺(tái)上進(jìn)行步行訓(xùn)練PrizeswonTherapygoal治療目標(biāo)SilverFitcamerasystemsilverfit攝像系統(tǒng)SilverFitNewtonSilverFitMileVirtualTherapySolution虛擬治療方案2.Exerciseisessentialforhealthandrehabilitation2.鍛煉是健康和康復(fù)所必需的7Scientificproofforefficacyofexerciseisstrong鍛煉的效果具有強(qiáng)有力的科學(xué)支持Highestlevelofevidenceforpositiveeffect正面作用的最高水平證據(jù)Strongevidenceforpositiveeffect正面作用的強(qiáng)有力證據(jù)Someevidenceforpositiveeffect正面作用的一些證據(jù)Bodyweight體重Fat脂肪Bloodpressure血壓HDL/LDLcholesterol高密度脂蛋白/低密度脂蛋白膽固醇Glucosetolerance糖耐量Effectivenessofinsuline胰島素的有效性Bonestructure骨結(jié)構(gòu)Sleeppattern睡眠模式Coordination協(xié)調(diào)性Reactionspeed反應(yīng)速度Psychosocialwellbeing心理健康Self-efficacy自我效能Self-worth自我價(jià)值Self-confidence自信心Heart&Coronary心臟及冠狀動(dòng)脈DiabetesMellitusIIⅡ型糖尿病Obesitas肥胖Osteoporosis骨質(zhì)疏松癥Stroke中風(fēng)Depression抑郁癥Coloncancer結(jié)腸癌Breastcancer乳腺癌Heart&Coronary心臟及冠狀動(dòng)脈DiabetesmellitusIIⅡ型糖尿病Obesitas肥胖CARAOsteoporosis骨質(zhì)疏松癥Stroke中風(fēng)Depression,Anxiety抑郁，焦慮Reumatoidartritis類風(fēng)濕性關(guān)節(jié)炎Epilepsy癲癇Cysticfibrosis囊性纖維化Arthrosis關(guān)節(jié)病Pelvicinstability骨盆不穩(wěn)定Kidneydiseases腎臟疾病Lowbackpain低腰疼Parkinson’sdisease帕金森氏病Physical,cognitiveandsensorylimitations身體，認(rèn)知和感官的局限性HealthParameters健康參數(shù)Preventdiseaseonset(primaryprevention)防止疾病發(fā)生（初級(jí)預(yù)防）Softendiseaseimpact(tertiaryprevention)減輕疾病影響（三級(jí)預(yù)防）Source:presentationprof.MarijkeHopman-Rock,AmericanAssociationforSportsMedicine

資源：演示教授MarijkeHopman-Rock，美國(guó)運(yùn)動(dòng)醫(yī)學(xué)協(xié)會(huì)8Regularexerciseisvitalelementofgeriatriccare規(guī)律運(yùn)動(dòng)對(duì)老年保健非常關(guān)鍵Examples例子Stroke中風(fēng)Strongscientificevidencethatexercising1hour/daymoreleadsto20%extraimprovementindailylifeactivities.強(qiáng)有力的科學(xué)證據(jù)表明每天運(yùn)動(dòng)超過(guò)1小時(shí)會(huì)給日?；顒?dòng)帶來(lái)20%的額外改善。Fallprevention預(yù)防跌倒Oneinthreeadults65andolderfallseachyear(USA).

在65歲及以上的成年人中，每年有三分之一會(huì)跌倒（美國(guó)）。Ofthosewhofall,20%to30%suffermoderatetosevereinjuriesthatmakethemlessindependentandincreasetheirchancesofearlydeath.20%到30%的跌倒人群會(huì)遭到中度到重度傷害，致使他們的獨(dú)立性降低，增加提前死亡的可能性。Fallpreventionexerciselowersriskoffalling30-40%.跌倒預(yù)防運(yùn)動(dòng)可以使跌倒的風(fēng)險(xiǎn)降低30%到40%。Dementia老年癡呆TotalcostintheNetherlands3.1bln/year,morethanallformsofcancercombined.荷蘭老年癡呆的總成本是31億/年，超過(guò)所有形式的癌癥的總和。Exercise3xweeklydecreasesriskofdementiaby60%(forwomen).每周鍛煉3次可以使老年癡呆的風(fēng)險(xiǎn)降低60%。9However,peopledonotmove然而，不運(yùn)動(dòng)的人們Stroke中風(fēng)Patientsexercisefor2hrs/week,shouldbe6hrs/week.病人每周運(yùn)動(dòng)2個(gè)小時(shí)，應(yīng)該是6個(gè)小時(shí)/周。Dementia老年癡呆Patients/atriskpeopleexercisefor5minutes/day,shouldbe90minutesintensivetrainingperweek.病人/高危人群每天鍛煉5分鐘，應(yīng)該是每周90分鐘的高強(qiáng)度訓(xùn)練。Falltraining跌倒訓(xùn)練Patientsmostatrisknormallydonottrainatall.病人/高危人群一般不進(jìn)行任何訓(xùn)練。10Virtual/Gametherapycanhelp虛擬/游戲療法可能會(huì)起作用NormalTherapy常規(guī)治療Boringandrepetitive無(wú)聊而重復(fù)Noexercise沒(méi)有運(yùn)動(dòng)VirtualGameTherapy虛擬游戲療法Fun有趣的Goodexercise良好的鍛煉3.OurSilverFitProductFamilySilverFit產(chǎn)品系列Webuildrehabilitationfacilitieswherepatientscandoeveryexercisewithvirtualrehabilitation我們建了一個(gè)訓(xùn)練大廳，這樣患者就可以使用虛擬設(shè)備進(jìn)行各種訓(xùn)練。13InourSilverFitnessfacilities,peoplecantrainwith1therapistforevery4patients用我們的SilverFitness設(shè)備，1個(gè)治療師可以為4個(gè)病人進(jìn)行治療14SilverFit3DcamerasystemSilverFit3D攝像系統(tǒng)15SilverFitNewtonSilverFit牛頓16SilverFitNewtonSilverFit牛頓17SilverFitMileSilverFit英里Thesystemscanbeusedbypatientsofmanydifferentlevels這個(gè)系統(tǒng)有不同的難易級(jí)別可供患者選擇。4.Exampleexercises訓(xùn)練舉例TheSilverFitcantrainalllargemotormovementsSilverFit可以訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作。21TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example1:Bodyposture(sittingexampleshown)例1：身體姿勢(shì)（如圖所示的坐姿）22TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example2:Standingup/sittingdown例2：站立/坐下23TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example3:Armexercises(post-strokeexampleshown)例3：手臂練習(xí)（如圖所示中風(fēng)后）Thisexercisecanalsobeplayedonatable.Thisallowsthepatienttopracticeonherown.這項(xiàng)活動(dòng)也可以在桌子上進(jìn)行，病人就可以自己來(lái)完成了。24TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example4:Walking例4：行走25TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example5:Balance(2-playergameshown)例5：平衡（如圖所示的兩人游戲）26TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example6:Leg/kneeexercises例6：腿/膝關(guān)節(jié)運(yùn)動(dòng)27TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動(dòng)動(dòng)作：舉例Example7:Intensivetraining例7：強(qiáng)化訓(xùn)練28TheSilverFitNewtonprovidesdifferentformsoftrainingsuitableforstrengthequipment29ExampleexerciseonNewtonwithapulleynewton滑輪機(jī)訓(xùn)練舉例30ExampleexerciseonNewtonwithalegpressnewton伸腿器訓(xùn)練舉例31ExampleSilverFitMile5.Eachexercisecanbeadjustedpreciselytothelevelofthepatient每個(gè)訓(xùn)練都可以調(diào)節(jié)以適合于不同水平的患者。Thetherapistcansettheleveloftheexercisetoexactlytherightlevel治療師可以設(shè)定運(yùn)動(dòng)等級(jí)詳細(xì)菜單玩家數(shù)雙人游戲選擇游戲人數(shù)；下面的橘黃色部分就只顯示雙人游戲運(yùn)動(dòng)為最左邊的選手設(shè)定所需運(yùn)動(dòng)站立站立為橘黃色部分里面的第二個(gè)選手設(shè)定運(yùn)動(dòng)和難度。這里只顯示雙人模式。左邊選手右邊選手運(yùn)動(dòng)難度設(shè)置撲克牌的大小撲克牌的大小是4X4（中等大?。┌磾?shù)字進(jìn)行排療撲克牌的大小是4X4（中等大?。┌磾?shù)字進(jìn)行排療選擇將數(shù)字進(jìn)行排序或不隨機(jī)排放。從認(rèn)知的角度來(lái)講，不隨機(jī)數(shù)字更難。反應(yīng)時(shí)間：00：30休息時(shí)間：00：03病人沒(méi)有反應(yīng)時(shí)球的最長(zhǎng)等待時(shí)間休息時(shí)間：下一個(gè)球下來(lái)之前的停頓時(shí)間圖形完整圖形選擇完整圖形或簡(jiǎn)化圖形兩個(gè)選手都可以得分，彼此之間不存在競(jìng)爭(zhēng)。設(shè)置為合作（兩選手每次均可得分）或競(jìng)爭(zhēng)（只有第一名選手得分）34Example:settheexactmovementpatternforeachpatientseparately舉例：分別為每個(gè)病人設(shè)定確定的運(yùn)動(dòng)方式運(yùn)動(dòng)為最左邊的選手設(shè)定需要的運(yùn)動(dòng)35Example:setthecognitivedifficultyforeachpatientseparately舉例：分別為每個(gè)病人設(shè)置認(rèn)知難度撲克牌的大小是4X4（中等大?。┌磾?shù)字進(jìn)行排療反應(yīng)時(shí)間：00：30休息時(shí)間游戲難度設(shè)定撲克牌的大小選擇將數(shù)字進(jìn)行排序或不隨機(jī)排放。從認(rèn)知的角度來(lái)講，隨機(jī)數(shù)字更難。36Example:setthevisualdifficultyforpeoplewhocannotseeverywell舉例：對(duì)看不清楚的病人設(shè)置視覺(jué)障礙圖形6.Clinicalfoundationoftheexercises訓(xùn)練的臨床基礎(chǔ)The

exerciseshavebeenselectedusingevidence-basedclinicalpracticeguidelinesbyTheRoyalDutchSocietyforPhysiotherapy運(yùn)動(dòng)的選擇是依據(jù)于荷蘭皇家理療學(xué)會(huì)的循證臨床實(shí)踐指南Wherepossible,wechooseourexercisesfromthosethathavebeenvalidatedintheguidelinesExample:improvingmobilityafterstrokeSource:GuidelinesRoyalDutchSocietyforPhysiotherapy,seehttps://www.kngfrichtlijnen.nl/654/KNGF-Guidelines-in-English.htm“Ithasbeendemonstratedthatreachingexerciseswiththenon-pareticarmduringsitting,inwhichpatientslearntoreachbeyondthebaseofsupport(i.e.,beyondarm’slength)andareawareoftheirownbodyposture,haveapositiveeffectonsittingbalance.Itisunclearwhetherimprovedsittingbalancealsoresultsinimprovementsinstanding,standingup,sittingdownandwalking.”Evidence:level1;4RCTsWherepossible,wechooseourexercisesfromthosethathavebeenvalidatedintheguidelinesExample:improvingmobilityafterstrokeSource:GuidelinesRoyalDutchSocietyforPhysiotherapy,seehttps://www.kngfrichtlijnen.nl/654/KNGF-Guidelines-in-English.htm“Ithasbeendemonstratedthatexercisingsymmetricstandingupandsittingdownhasapositiveeffectonanevenleft-rightdistributionofbodyweightduringthesepositionchangesandonthespeedofperformanceoftheseactivities.Thiseffecthasbeendemonstratedinpatientsinthepost-acuteandchronicphases.Itisuncleariftheseeffectsonspeedofstandingupandsittingdownpersistsaftertheendoftheintervention.”Evidence:level1;5RCTs41Inmanycases,theruleisthat“moretrainingisbetter”Meta-analysisof20studiesofeffectofmoreintensivetrainingonADLoutcomesImprovementinADLoutcomesinunitsofstandarddeviation#extrahoursoftrainingSource:Kwakkele.a.,Stroke,2004;35(11):2529-2536AddingvideogamesimprovestheadherencetotherapyandmakesitpossibletotrainwithlesssupevisionPredictingtheeffectofinteractivevideobikesonexerciseadherence:Anefficacytrial.RhodesRE,WarburtonDE,BredinSS.SourceBehaviouralMedicineLaboratory,UniversityofVictoria,Victoria,Canada.rhodes@uvic.caAbstractExercisegamesthatemployvideogametechnologyareincreasinginthemarketplacebuthavereceivedscantresearchattentiondespitetheirpopularity.Thepurposeofthisstudywastoevaluatetheeffectofvideobikegamingontheconstructsofthetheoryofplannedbehavior(TPB)andadherenceincomparisontoacyclingconditionwhereparticipantslistentoself-selectedmusic.Participantswere29inactiveyoungmenassignedrandomlytoexperimental(n=16)orcomparison(n=13)conditions.Therecommendedtrainingregimeconsistedofmoderateintensityactivity(60-75%heartratereserve),3days/weekfor30min/dayfor6weeks.Attheendofthefirstsession,participantswereaskedtocompleteTPBmeasuresandtheseweresubsequentlymeasured6weekslater.Attendancewasusedasthemeasureofadherence.Resultsshowedthataffectiveattitudeandadherenceacrossthe6weekssignificantlyfavoredthevideobikeconditionoverthecomparisoncondition.Regressionanalysessuggestedpartialmediationoftheeffectofthevideobikeconditiononadherenceviaaffectiveattitude.Thisisthefirststudytoprovideevidencethatinteractivevideobikesmayimproveadherenceovertraditionalcyclingbecausetheactivityproduceshigheraffectiveattitudes.Theresultsarepromisingforexpandingtocommunity-basedevaluation.Source:PsycholHealthMed.2009Dec;14(6):631-40.43Therearetreatmentprotocolsforspecificpatientgrousps針對(duì)特定患者人群的治療方案EXAMPLE:TOTALHIPprotocol,byL.OudeAarninkhof/Avans+University舉例：全髖關(guān)節(jié)置換術(shù)案例，byL.OudeAarninkhof/Avans+UniversityTheprotocolsareevaluatedscientifically該案例的科學(xué)評(píng)價(jià)Example:evaluationoffallpreventionprotocol舉例：預(yù)防跌倒協(xié)議評(píng)估Bron:M.VanGastel,StageverslagVerminderenvanVallenmetdeSilverFit,Avans+,2011來(lái)源：M.VanGastel,實(shí)習(xí)報(bào)告：在秋季減少SilverFit，Avans+，2011年Onderwerp主題Test測(cè)試Uitkomsten結(jié)果

Patient1病人1Patient2病人2Patient3病人3Valangst

恐懼下降FES

VAS

Kracht

克拉赫特m.Quadricepsrechts米右股四頭肌

m.Quadricepslinksm.米四頭肌連接

Hamstringslinks腿筋連接

n/a

Hamstringsrechts彎腿

n/a

Balans平衡TimedBalanceTest定時(shí)平衡測(cè)試

6GroteStappenTest六大步驟測(cè)試

BBS

Steptest臺(tái)階試驗(yàn)

TimedChairStandTest定時(shí)椅架測(cè)試

Loopvaardigheid行走技巧TU&G

10meterlooptest10米步行測(cè)試

Positiveeffect正面效應(yīng)

Nosignificanteffect沒(méi)有明顯影響

Negativeeffect負(fù)面效應(yīng)Interventie:6weken2xperweek1uurtrainingmetSilverFit,1therapeut:3patienten注意：6周每周2次每次1小時(shí)訓(xùn)練符合SilverFit，一位醫(yī)師：三個(gè)病人7.Tracingpatientsovertime患者追蹤47Computersystemsalsomakeitmucheasi