The self-regulatory German health care system between growing competition and state hierarchy

This article focuses on the changing role of the state in financing, providing and regulating health care services under the German health care system from 1970-2000. While a reduced role of the state can be observed in terms of financing, our analysis of service provision indicates inconsistent developments. Monetary resource flow analyses indicate a decrease in private service provision as a percentage of total health expenditure, but when analysing the development of health employment we see a growth in “private” health care personnel. The most important changes, however, have taken place in terms of regulation. Since the early 1990s, the traditionally self-regulatory German health care system has simultaneously faced growing competition and state hierarchy

Objective metrics for functional evaluation of upper limb during the ADL of drinking: application in SCI

Three-dimensional kinematic analysis provides quantitative assessment of upper limb motion and is used as an outcome measure to evaluate movement disorders. The aim of the present study is to present a set of kinematic metrics for quantifying characteristics of movement performance and the functional status of the subject during the execution of the activity of daily living (ADL) of drinking from a glass. Then, the objective is to apply these metrics in healthy people and a population with cervical spinal cord injury (SCI), and to analyze the metrics ability to discriminate between healthy and pathologic people. 19 people participated in the study: 7 subjects with metameric level C6 tetraplegia, 4 subjects with metameric level C7 tetraplegia and 8 healthy subjects. The movement was recorded with a photogrammetry system. The ADL of drinking was divided into a series of clearly identifiable phases to facilitate analysis. Metrics describing the time of the reaching phase, the range of motion of the joints analyzed, and characteristics of movement performance such as the efficiency, accuracy and smoothness of the distal segment and inter-joint coordination were obtained. The performance of the drinking task was more variable in people with SCI compared to the control group in relation to the metrics measured. Reaching time was longer in SCI groups. The proposed metrics showed capability to discriminate between healthy and pathologic people. Relative deficits in efficiency were larger in SCI people than in controls. These metrics can provide useful information in a clinical setting about the quality of the movement performed by healthy and SCI people during functional activities

A novel motion tracking system for evaluation of functional rehabilitation of the upper limbs

Upper limb function impairment is one of the most common sequelae of central nervous system injury, especially in stroke patients and when spinal cord injury produces tetraplegia. Conventional assessment methods cannot provide objective evaluation of patient performance and the tiveness of therapies. The most common assessment tools are based on rating scales, which are inefficient when measuring small changes and can yield subjective bias. In this study, we designed an inertial sensor-based monitoring system composed of five sensors to measure and analyze the complex movements of the upper limbs, which are common in activities of daily living. We developed a kinematic model with nine degrees of freedom to analyze upper limb and head movements in three dimensions. This system was then validated using a commercial optoelectronic system. These findings suggest that an inertial sensor-based motion tracking system can be used in patients who have upper limb impairment through data integration with a virtual reality-based neuroretation system

A data-globe and immersive virtual reality environment for upper limb rehabilitation after spinal cord injury

While a number of virtual data-gloves have been used in stroke, there is little evidence about their use in spinal cord injury (SCI). A pilot clinical experience with nine SCI subjects was performed comparing two groups: one carried out a virtual rehabilitation training based on the use of a data glove, CyberTouch combined with traditional rehabilitation, during 30 minutes a day twice a week along two weeks; while the other made only conventional rehabilitation. Furthermore, two functional indexes were developed in order to assess the patient’s performance of the sessions: normalized trajectory lengths and repeatability. While differences between groups were not statistically significant, the data-glove group seemed to obtain better results in the muscle balance and functional parameters, and in the dexterity, coordination and fine grip tests. Related to the indexes that we implemented, normalized trajectory lengths and repeatability, every patient showed an improvement in at least one of the indexes, either along Y-axis trajectory or Z-axis trajectory. This study might be a step in investigating new ways of treatments and objective measures in order to obtain more accurate data about the patient’s evolution, allowing the clinicians to develop rehabilitation treatments, adapted to the abilities and needs of the patients

Quantitative assessment based on kinematic measures of functional impairments during upper extremity movements: a review

Quantitative measures of human movement quality are important for discriminating healthy and pathological conditions and for expressing the outcomes and clinically important changes in subjects' functional state. However the most frequently used instruments for the upper extremity functional assessment are clinical scales, that previously have been standardized and validated, but have a high subjective component depending on the observer who scores the test. But they are not enough to assess motor strategies used during movements, and their use in combination with other more objective measures is necessary. The objective of the present review is to provide an overview on objective metrics found in literature with the aim of quantifying the upper extremity performance during functional tasks, regardless of the equipment or system used for registering kinematic data

Effectiveness of virtual reality as therapeutic complement in the rehabilitation of upper limbs in people with spinal cord injury

In the space of just a few years, the literature has advanced from articles which primarily described the potential benefits of using virtual reality technology, to articles that describe the development of actual working systems, testing of prototypes, and early clinical results with patients who have used some of these systems. A few findings appear to be solidly emerging from the virtual reality work to date, as they have appeared repeatedly in multiple studies by different research groups. These findings are that: (1) patients with disabilities appear capable of motor learning within virtual environments; (2) movements learned in VR by patients with disabilities transfer to real world equivalent motor tasks in most cases, and in some cases even generalize to other untrained tasks; and (3) in the few studies that have compared motor learning in real versus virtual environments, some advantage for virtual reality training has been found in the most cases. However, the published clinical studies, for the most part, still consist of small studies without control groups, or with small samples of patient. Furthermore, at present these devices are not considered a treatment in themselves, but only new technologies tools that can be exploited to enhance motor retraining. Much work remains to be done to identify which types of patients will benefit most from these treatments, which system features are critical, and what types of training routines will work best. This understanding will be the key to designing appropriate virtual reality system features and successful treatment interventions combination. The main objective of this thesis was to assess the efficacy of the application of virtual reality-based therapy, as rehabilitation complement to upper limbs function in people with tetraplegia. Furthermore, we wanted to verify the capacity of virtual reality systems to detect upper limbs kinematic and functional changes

Efectividad de un programa de juego basado en realidad virtual para la mejora cognitiva en la esquizofrenia

Objetivo: Evaluar la efectividad de un programa de juego basado en la realidad virtual para la mejora de los dominios cognitivos en pacientes con esquizofrenia. Método: Ensayo clínico aleatorizado con 40 pacientes con esquizofrenia, 20 en el grupo experimental y 20 en el grupo control. El grupo experimental recibió 10 sesiones con Nintendo Wii® durante 5 semanas, 50 minutos/sesión, 2 días/semana, además del tratamiento convencional. El grupo control sólo recibió tratamiento convencional. Resultados: Se encontraron diferencias estadísticamente significativas de las puntuaciones T-Score entre la preevaluación y la postevaluación en el grupo experimental en cinco de los seis dominios cognitivos evaluados: velocidad de procesamiento (F = 12,04, p = 0,001), atención/vigilancia (F = 12,75, p = 0,001), memoria de trabajo (F = 18,86, p <0,01), aprendizaje verbal (F = 7,6, p = 0,009), y razonamiento y resolución de problemas (F = 11,08, p = 0,002). Conclusiones: La participación en intervenciones de realidad virtual dirigidas al entrenamiento cognitivo ofrece un gran potencial de ganancias significativas en los diferentes dominios cognitivos evaluados en pacientes con esquizofrenia

A Pilot Randomized Clinical Trial

The aim of this study was to investigate the effects of a virtual reality program combined with conventional therapy in upper limb function in people with tetraplegia and to provide data about patients? satisfaction with the virtual reality system. Thirty-one people with subacute complete cervical tetraplegia participated in the study. Experimental group received 15 sessions with Toyra#9415; virtual reality system for 5 weeks, 30 minutes/day, 3 days/week in addition to conventional therapy, while control group only received conventional therapy. All patients were assessed at baseline, after intervention, and at three-month follow-up with a battery of clinical, functional, and satisfaction scales. Control group showed significant improvements in the manual muscle test (#119901; = 0,043, partial #120578;2 = 0,22) in the follow-up evaluation. Both groups demonstrated clinical, but nonsignificant, changes to their armfunction in 4 of the 5 scales used. All patients showed a high level of satisfaction with the virtual reality system. This study showed that virtual reality added to conventional therapy produces similar results in upper limb function compared to only conventional therapy. Moreover, the gaming aspects incorporated in conventional rehabilitation appear to produce high motivation during execution of the assigned tasks.This trial is registered with EudraCT number 2015-002157-35

Voluntary control of wearable robotic exoskeletons by patients with paresis via neuromechanical modeling

Background: Research efforts in neurorehabilitation technologies have been directed towards creating robotic exoskeletons to restore motor function in impaired individuals. However, despite advances in mechatronics and bioelectrical signal processing, current robotic exoskeletons have had only modest clinical impact. A major limitation is the inability to enable exoskeleton voluntary control in neurologically impaired individuals. This hinders the possibility of optimally inducing the activity-driven neuroplastic changes that are required for recovery. Methods: We have developed a patient-specific computational model of the human musculoskeletal system controlled via neural surrogates, i.e., electromyography-derived neural activations to muscles. The electromyography-driven musculoskeletal model was synthesized into a human-machine interface (HMI) that enabled poststroke and incomplete spinal cord injury patients to voluntarily control multiple joints in a multifunctional robotic exoskeleton in real time. Results: We demonstrated patients' control accuracy across a wide range of lower-extremity motor tasks. Remarkably, an increased level of exoskeleton assistance always resulted in a reduction in both amplitude and variability in muscle activations as well as in the mechanical moments required to perform a motor task. Since small discrepancies in onset time between human limb movement and that of the parallel exoskeleton would potentially increase human neuromuscular effort, these results demonstrate that the developed HMI precisely synchronizes the device actuation with residual voluntary muscle contraction capacity in neurologically impaired patients. Conclusions: Continuous voluntary control of robotic exoskeletons (i.e. event-free and task-independent) has never been demonstrated before in populations with paretic and spastic-like muscle activity, such as those investigated in this study. Our proposed methodology may open new avenues for harnessing residual neuromuscular function in neurologically impaired individuals via symbiotic wearable robots

Effectiveness of the Virtual Reality System Toyra on Upper Limb Function in People with Tetraplegia: A Pilot Randomized Clinical Trial

The aim of this study was to investigate the effects of a virtual reality program combined with conventional therapy in upper limb function in people with tetraplegia and to provide data about patients' satisfaction with the virtual reality system. Thirty-one people with subacute complete cervical tetraplegia participated in the study. Experimental group received 15 sessions with Toyra virtual reality system for 5 weeks, 30 minutes/day, 3 days/week in addition to conventional therapy, while control group only received conventional therapy. All patients were assessed at baseline, after intervention, and at three-month follow-up with a battery of clinical, functional, and satisfaction scales. Control group showed significant improvements in the manual muscle test (p = 0,043, partial η 2 = 0,22) in the follow-up evaluation. Both groups demonstrated clinical, but nonsignificant, changes to their arm function in 4 of the 5 scales used. All patients showed a high level of satisfaction with the virtual reality system. This study showed that virtual reality added to conventional therapy produces similar results in upper limb function compared to only conventional therapy. Moreover, the gaming aspects incorporated in conventional rehabilitation appear to produce high motivation during execution of the assigned tasks. This trial is registered with EudraCT number 2015-002157-35.The authors thank the consortium including Foundation Rafael del Pino, Foundation of the Spanish National Hospital for Paraplegic Research and Integration (FUHNPAIIN), and INDRA Systems for funding this research