Rehabilitation for people with MS has changed a lot in recent years. And it’s likely to change even more as new technology and tools become available. Dr Lorna Paul trained as a physiotherapist, and has been involved with a number of innovative developments at the University of Glasgow. She tells us how she believes new technologies could make rehab more accessible, sociable and even fun
Rehabilitation therapists work with people with MS in lots of ways: from assessing where they’re having problems, helping them set goals, through to planning, monitoring and reviewing their progress. We also try to help people understand their health better and learn to manage MS themselves. There are roles for technology right through our work.
In this article I’m going to talk about technology in treatment. But the most immediate impact of technology on MS therapy might come in communication – all the tools from email, to Skype to the telephone, that can help us keep in contact with people more easily.
Virtual reality (VR) is something that has been talked about for a long time, and is now finally entering everyday life. When you buy a new mobile phone you can get a cheap VR set with it. VR is essentially the digital simulation of an environment that you are part of and can interact with. It’s a broad spectrum from headsets to simple games on computer screens.
The Ninetendo Wii is the VR game most people are aware of. If you’ve used a Wii, you’ll know that you have a handheld device to control onscreen characters. Quite a few therapists have used Wii in rehab. We’ve used it for people with diabetes with a high risk of falls. There is now evidence that the Wii is safe and feasible in a rehab setting. It’s relatively low cost, you can use it at home or in the clinic.
There is some evidence for the benefits of short four to five week sessions on the Wii. An Italian group scanned their patients and found improvements in the cerebellum after five weeks of training on the Wii. However, they scanned them 12 weeks later and the improvement had gone. The challenge for rehab therapists is how can we make these improvements more long lasting?
The Microsoft Kinect system is something we’ve been looking at. It’s relatively cheap and easy to use at home. It’s different from the Wii in that it uses cameras, so there’s no hand-held controller. Crucially, because it’s a Microsoft product, our computing science guys can get into the code and develop their own software for it.
One of the advantages of the Kinect is that it allows you to digitally record your exercise, so you get real-time performance feedback on how you’re doing, and it can be sent to your physio who can monitor your progress and give their feedback. It has huge potential in terms of applications. Kinect, and whatever comes next, may have more use to therapists than the Wii.
Telerehab simply means delivering rehab from a distance. It has big advantages – especially for people who have problems getting to therapists based in clinics or hospitals.
At the University of Glasgow we developed a website called Web-Based Physio as a way of delivering exercise programmes to people who couldn’t come to our classes. The site consists of exercise videos with written descriptions and audio explanation, plus links to further info on the MS Trust website.
The programme begins with a face-to-face assessment. Your physio chooses from a library over 100 clips the exercises that are most appropriate for you. So when you log in at home, you just see the exercises in your programme.
It’s individualised and targeted. When you complete your programme you can leave comments on how you got on. And when your physio logs in, they can see your comments, and comments from all their other patients.
Depending on how you’re getting on, the physio can change your programme to add or remove exercises, taking you up a level.
We found that web-based physio wasn’t for everybody. Some people used it as a stepping stone. One person did 12 weeks of sessions then joined the gym. For them it was a transition thing.
For others it was an alternative to the gym. Some of the men in the group weren’t the type to go to an exercise group. I remember one man saying “This is great. I don’t have to get out of my pyjamas, I don’t have to make anyone a cup of tea, I don’t have to say hello to anyone.” But he was doing his programme twice a week! So we were reaching people we wouldn’t reach normally.
Starfish is another project we’re working on. We call it a “facilitated behavioural change programme to encourage physical activity”, but you would recognise it as a simple mobile phone app.
It’s a very basic app – my kids would absolutely laugh at it. But it seems to be encouraging people with long-term conditions to be physically active. The sensors in the phone record your steps and these get fed into the app. When you walk, the fish in the app swims around and blows bubbles. As you reach your targets your fish starts to change shape, a bit like a Pokémon – you grow fins and tails as you reach your own targets.
One of the great things about Starfish is that it’s social. You can set up groups so you can see which of your friends are also moving. Everyone has individual targets. You get feedback on everyone else in your group, but it’s proportional. So one person might have a target of 5,000 steps a day and another person might have a targets of 8,000 a day, but their feedback is proportional on how well they’ve met their individual target.
Every time someone meets their target we increase their next week target by 5% to keep everyone progressing. You can also set a group target so people have a sense of collaboration. If everyone in the group meets their target on five out of seven days in the week, a new creature such as a seahorse, an octopus and finally a starfish, comes to swim in the tank. We have found that people are really keen to get these creatures! They didn’t like the jellyfish but they liked the diver and the lobster.
One of the exciting possibilities of Starfish is creating mixed groups. We’ve thought about doing it with stroke survivors and their family members, who are likely to have the same risk of having a stroke. Everyone can have a different target and enjoy being active together.
It’s not sophisticated in any way shape or form, but the simplicity is a virtue – it makes it easier to use. It’s a great way of motivating people to be active in a social way. We did a trial of Starfish with 16 older people for 6 weeks, and we found there was a 32% increase in steps per day. But we only looked at number of steps – not the gait pattern which may be an issue in people with MS. We’d be really interested in trialling Starfish with more people with MS.
On the face of it, adopting new technology seems like it could offer a solution to a lot of the challenges facing rehab teams today. More and more people with MS are being referred for rehab, and in many cases they will need support for long periods. Technology offers the possibility of making expert-led rehab available, accessible and engaging to even more people.
However, there are still big barriers. Technology can be expensive and can sometimes requires special skills to use. It raises issues around patient data and confidentiality. And there’s still a very limited, if growing, evidence base. But if we don’t know exactly what the future of rehab will look like, we can be sure it will definitely be a future with technology in it.