Tech

NR Times meets CEO Dominic Holmes to learn more about the difference it is set to make to stroke survivors in their ongoing recovery.
“The research behind this dates back 20 years - we were waiting for the hardware technology to catch up”.

For many years, researchers at Ulster University have investigated stroke rehabilitation and the potential of digital, game-based technology in supporting recovery. But while the research was there, it is only more recently that the required hardware technology has entered the marketplace. 
Through the launch of ReNeuro by eXRt Intelligent Healthcare, which brings together the latest cutting-edge gaming development with now readily-available wireless VR headset technology, the game is being changed for stroke survivors.
With its range of in-house developed games, all geared around rehab, and the use of artificial intelligence (AI) to determine whether rehabilitation is effective in more detail than ever before, ReNeuro has already demonstrated its efficacy with a patient trial, showing the potential of remote rehab in times prior to the pandemic - before it had become widely known or accepted within healthcare. 
Now making inroads into the NHS and other healthcare providers, with plans for global expansion thereafter, eXRt is helping to up the ante for stroke rehabilitation, while increasing the options in home-based therapy. 

From the initial research from Ulster, including being the focus of Dr Holmes’ PhD, it was established that gaming as a form of rehabilitation could hold significant potential for improving patient rehabilitation - but how to achieve that with the technology of the day was another challenge. 
“Back then, the technology was clunky, heavy, it wasn’t suitable for patients. But we managed to get a lot of good data research, so we knew what we wanted to do. When technology started to catch up, that’s when we could really move forward,” says Dr Holmes. 
“We were starting to realise that the problems for patients were two-fold. Firstly, they weren’t getting enough physiotherapy, NHS departments were overstretched even before COVID, and it has become worse over the years. But also, that some patients weren’t engaging enough. 
“Gaming has become one of the biggest entertainment industries, so we thought, why not engage people in that way? By using gaming, we can let them have fun while doing their physiotherapy.”
Through Dr Holmes’ research, he recognised the crucial role AI could play in this domain - something which is now helping eXRt to really push boundaries in stroke rehab today. 
“Using AI, we monitor, track movement behaviour. Image processing will track movements in their hands, down to their fine finger movements. We track that data and perform analysis on it,” says Dr Holmes. 
“By doing this, we then have the ability to adapt each game to suit each individual person motor skills, which is really important when they’re doing it at home. If you’re playing an off the shelf game remotely but are having problems and finding it difficult, at some point, you’re not going to be able to play. 
“But through AI, we could see the difficulties and switch and change things a little bit automatically, so we can overcome those difficulties and make it so you can continue to rehab successfully.

“You’ll find in physiotherapy that some exercises may be painful for patients, or they might not be doing it correctly. But through AI, we can see that and make the changes to their rehab to improve this.”
From these findings, eXRt was born, bringing together the expertise of Dr Holmes in research and healthcare technology development with that of Dr Darryl Charles in AI and gaming development. Together, they led the creation of a new business with the ambition of redefining rehab for people recovering from stroke. 
Embarking on a study which concluded in March 2020 - only days before the UK went into lockdown - the potential eXRt held was clear. 
“We wanted to assess how effective this could be used in patients’ homes, could they use it themselves without any major interventions from a physiotherapist or technical support team, that was at the root of everything,” says Dr Holmes. 
“The results were fantastic. We saw we were able to give participants an extra 26 minutes of physiotherapy per day, and after six months, we saw a 50 percent reported an increase in improvements to Quality of life such as their mood, mobility and self-care.”
eXRt was formally launched in October 2021 as an Ulster University spin out company, with its suite of stroke rehabilitation games ready to be used on VR headsets both in clinical and at-home settings. 
Guided by the University’s dedicated Research and Innovation team at Ulster, eXRt founders were given support in harnessing their extensive research into a valuable service for patients at home and beyond.

Going forward, the business is now looking to see the role its technology can play in the care pathway, optimising it for therapists and patients alike.
“After a stroke, a person will have a wide range of medical appointments and therapies, but through our take on physiotherapy, you’re increasing the dose of that in a way that is accessible and engaging to patients,” says Dr Holmes. 
“And the real beauty of it is that a physiotherapist doesn’t need to be present. Therapists can spend more of their time with people who really need the in-person support, and see more patients. 
“People who are suitable for remote physio can benefit from that, with the appropriate supervision. We imagine that once they are in hospital, patients will be introduced to ReNeuro, and then they can take it home to continue their rehabilitation. If it's in a clinical setting, you can have a try and they can be trained in how to use it. It makes that transition between clinical and home so much easier.”
Now, eXRt is looking at potential adoption across the NHS and private healthcare, as well as into other conditions too
“There is a lot of interest, and we are talking to the NHS and private healthcare about what we can do for stroke patients, our longer-term ambition is to alsolook at other health areas that we could support and benefit from ReNeuro,” says Dr Holmes. 
“We are looking at brain injury and other neurological disorders, such as Parkinson’s, where exercise can be beneficial, and physiotherapy is important.
“We are also doing a project at the moment on healthy ageing, to help older people have a more active life, so they’re less likely to have other health problems. The exciting part about eXRt is that is can be applied to a number of issues experienced by our ageing population, improving mobility and giving individuals improved quality of life.” 
“Our main goal is to initially supply the UK healthcare systems such as the NHS, but we do see ourselves ultimately being global. As we grow as a business we plan to target the US market in the hope that patients in the US can also benefit from ReNeuro. 
“We’re concentrating on the UK currently and are excited about the potential to make a difference in patients’ lives in our own country.”

Getting back to carrying out everyday activities independently after a stroke or brain injury is a huge victory for survivors, and certainly no mean feat. 

What is learned non-use?
Learned non-use results from neglect of the affected limbs after stroke, and can happen to anyone who has suffered an injury which impairs their movement. For example, it can happen when an arm is immobilised in a cast for a period of time. It can also occur following a brain injury where a person is affected by hemiplegia.
Stroke survivors sometimes become overly dependent on their non-affected hand to complete daily tasks. Learned non-use occurs when this neglect becomes severe, and the brain completely forgets how to use the affected hand or limb. This can also lead to muscle wastage. 
Learned non-use is not necessarily permanent and can be treated via constraint induced movement therapy (CIMT), which is based on the theory that the affected limb may have a potential but unrealised ability to move due to reliance on the unaffected limb.
So, what can stroke survivors do to break this negative learning loop? Effort and commitment are required to prevent learned non-use, as stroke survivors must strive to use their affected side, even if it’s just a little, every single day. 

Is learned non-use known about?
To gauge fellow stroke survivors’ understanding and knowledge of learned non-use, I consulted my online stroke communities. Some of the responses I received included:
“My brain doesn’t remind my weaker hand to spring into action, so I rarely use it. I do try every so often but it’s useless. I’m just thankful I have full range of movement and my hands look perfectly fine.”
“Learned non-use is tragic, and it doesn’t seem to be something most therapists of today explain to patients unfortunately.”
“I’ve never seen any literature on it. For me,
I use my strong hand all the time because my left has no sensation so no grip.”
“Never heard of it nor saw it discussed anywhere...there seems to be a lot of muscle wastage on my left hand. It doesn’t bother me.” 
Sadly, it is clear to see that the issue is often ignored, and the potential for stroke and brain injury survivors to regain strength and engage with their affected hand or limb isn’t realised, presenting a barrier to rehabilitation. 
The effects of learned non-use on both mental health and motivation can be profound, but with expert support from an occupational therapist, treatment is possible, and this begins with raising awareness and opening a dialogue around what learned non-use is and the effects it can have. 

How can occupational therapists address learned non-use in patients?
Occupational therapist and neurorehabilitation specialist Lauren Edwards has experience with tackling learned non-use in her clients undergoing neuro rehab. 
Speaking about treating the issue, she said: “Constraint induced movement therapy (CIMT) can benefit those experiencing learned non-use. It is generally agreed that CIMT works best when there is a baseline level of movement present. Those with less movement are advised to explore alternative treatments first, but should always seek guidance from their therapist on what will work best for their individual circumstances.
“Studies have shown that six hours a day of CIMT contributes towards recovery of movement in the affected hand, however changes can be seen with just three hours per day.”
“It is important that a variety of tasks and activities are used to challenge and stimulate movement in the affected arm,” Lauren explained. “GripAble is a great tool to use at home for those undertaking a CIMT program. The games encourage wrist and hand movements and can be calibrated to the subtlest range of movement. Gaming can induce a sense of flow which can make those three hours pass a lot more quickly!”

“Studies have shown that six hours a day of CIMT contributes towards recovery of movement in the affected hand, however changes can be seen with just three hours per day.”

Affordable remote rehab
GripAble is a mobile assessment and training platform which includes bespoke hand-held sensors, mobile hardware, software, in-built gamification and data services, to enable home-based rehabilitation for patients with a wide range of neurological and musculoskeletal conditions including upper limb spasticity. GripAble’s unique handgrip sensor connects to a mobile app, allowing users to partake in specifically designed activities selected by their therapist, to train core hand and arm movements.
GripAble has been designed with remote rehab at its heart to enable ongoing training at home, even when face-to-face therapy isn’t possible. With the cost of living hitting many hard, GripAble has launched an affordable monthly rental option for home-based customers. At less than £1.50 a day, the rental has no minimum contract, making it an ideal option for people with short-term rehabilitation or training needs.

Chat to GripAble's friendly team of experts
to see if the platform could help you, your family member, or your patients or clients: https://gripable.co/buy-try-now/ 

If you would like to discuss your experiences of learned non-use and rehab support, please get in touch with Kate Allatt via Twitter: @KateAllatt or email: kate@kateallatt.com.