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.簡介3MynameisJorisWiersinga,andIamthechairmanofthecompanySilverFit我是JorisWiersinga，是SilverFit公司的董事長。Ourgamesarecurrentlybeingusedin>450clinicsworldwide在世界范圍內(nèi)有超過450個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.粗大動作運(yùn)動訓(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（初級預(yù)防）Softendiseaseimpact(tertiaryprevention)減輕疾病影響（三級預(yù)防）Source:presentationprof.MarijkeHopman-Rock,AmericanAssociationforSportsMedicine

資源：演示教授MarijkeHopman-Rock，美國運(yùn)動醫(yī)學(xué)協(xié)會8Regularexerciseisvitalelementofgeriatriccare規(guī)律運(yùn)動對老年保健非常關(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)動超過1小時會給日?；顒訋?0%的額外改善。Fallprevention預(yù)防跌倒Oneinthreeadults65andolderfallseachyear(USA).

在65歲及以上的成年人中，每年有三分之一會跌倒（美國）。Ofthosewhofall,20%to30%suffermoderatetosevereinjuriesthatmakethemlessindependentandincreasetheirchancesofearlydeath.20%到30%的跌倒人群會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)動的人們Stroke中風(fēng)Patientsexercisefor2hrs/week,shouldbe6hrs/week.病人每周運(yùn)動2個小時，應(yīng)該是6個小時/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/游戲療法可能會起作用NormalTherapy常規(guī)治療Boringandrepetitive無聊而重復(fù)Noexercise沒有運(yùn)動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個治療師可以為4個病人進(jìn)行治療14SilverFit3DcamerasystemSilverFit3D攝像系統(tǒng)15SilverFitNewtonSilverFit牛頓16SilverFitNewtonSilverFit牛頓17SilverFitMileSilverFit英里Thesystemscanbeusedbypatientsofmanydifferentlevels這個系統(tǒng)有不同的難易級別可供患者選擇。4.Exampleexercises訓(xùn)練舉例TheSilverFitcantrainalllargemotormovementsSilverFit可以訓(xùn)練所有的大運(yùn)動動作。21TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動動作：舉例Example1:Bodyposture(sittingexampleshown)例1：身體姿勢（如圖所示的坐姿）22TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動動作：舉例Example2:Standingup/sittingdown例2：站立/坐下23TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動動作：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)活動也可以在桌子上進(jìn)行，病人就可以自己來完成了。24TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動動作：舉例Example4:Walking例4：行走25TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動動作：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)動動作：舉例Example6:Leg/kneeexercises例6：腿/膝關(guān)節(jié)運(yùn)動27TheSilverFittrainsallgrossmotormovements:examplesSilverFit訓(xùn)練所有的大運(yùn)動動作：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)動等級詳細(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)動為最左邊的選手設(shè)定所需運(yùn)動站立站立為橘黃色部分里面的第二個選手設(shè)定運(yùn)動和難度。這里只顯示雙人模式。左邊選手右邊選手運(yùn)動難度設(shè)置撲克牌的大小撲克牌的大小是4X4（中等大小）按數(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)知的角度來講，不隨機(jī)數(shù)字更難。反應(yīng)時間：00：30休息時間：00：03病人沒有反應(yīng)時球的最長等待時間休息時間：下一個球下來之前的停頓時間圖形完整圖形選擇完整圖形或簡化圖形兩個選手都可以得分，彼此之間不存在競爭。設(shè)置為合作（兩選手每次均可得分）或競爭（只有第一名選手得分）34Example:settheexactmovementpatternforeachpatientseparately舉例：分別為每個病人設(shè)定確定的運(yùn)動方式運(yùn)動為最左邊的選手設(shè)定需要的運(yùn)動35Example:setthecognitivedifficultyforeachpatientseparately舉例：分別為每個病人設(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)時間：00：30休息時間游戲難度設(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)知的角度來講，隨機(jī)數(shù)字更難。36Example:setthevisualdifficultyforpeoplewhocannotseeverywell舉例：對看不清楚的病人設(shè)置視覺障礙圖形6.Clinicalfoundationoftheexercises訓(xùn)練的臨床基礎(chǔ)The

exerciseshavebeenselectedusingevidence-basedclinicalpracticeguidelinesbyTheRoyalDutchSocietyforPhysiotherapy運(yùn)動的選擇是依據(jù)于荷蘭皇家理療學(xué)會的循證臨床實(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)評價(jià)Example:evaluationoffallpreventionprotocol舉例：預(yù)防跌倒協(xié)議評估Bron:M.VanGastel,StageverslagVerminderenvanVallenmetdeSilverFit,Avans+,2011來源：M.VanGastel,實(shí)習(xí)報(bào)告：在秋季減少SilverFit，Avans+，2011年Onderwerp主題Test測試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定時平衡測試

6GroteStappenTest六大步驟測試

BBS

Steptest臺階試驗(yàn)

TimedChairStandTest定時椅架測試

Loopvaardigheid行走技巧TU&G

10meterlooptest10米步行測試

Positiveeffect正面效應(yīng)

Nosignificanteffect沒有明顯影響

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