A new device from an Imperial start-up company is enabling people with arm disabilities to do more physical training, which is particularly important at a time when access to physiotherapy is severely hampered
Many people who are not disabled assume that the most important aspect of rehabilitation after a stroke, or another condition that affects the movements, is to walk again. Yet in terms of daily living, arm movement is usually much more important.
Arm movement is fundamental for the activities like dressing oneself, turning on a tap, holding a cup and so on, which make up independent living. A new device from an Imperial spin-out company is enabling people with arm disabilities to increase the amount of physical training they perform and has been designed for home use, in liaison with a physiotherapist or occupational therapist (OT) who monitors their progress. This has become particularly useful as a result of the COVID-19 pandemic because most physiotherapists and OTs have been working remotely.
Building new connections
Over five million people in the UK live with arm weakness. Sometimes this is the result musculoskeletal disorders such as arthritis which affect the joints and make movements stiff and painful. It can also be the result of brain damage which has affected the areas of the brain that control those specific movements. Stroke damage is a particular culprit here, accounting for one million people in the UK with arm weakness.
'Functional movement’ – the ability to carry out those day-to-day activities – is severely restricted or impossible with arm weakness. Some people may become long-term physically disabled, and require expensive care. For others, it may be possible to recover a range of movement. But usually that’s only manageable with support and through a huge amount of practice: doing the same movements – which may be very, very small ones to start with – again and again.
“If you want to be good at a skill or a sport, the more you practise the better. It’s common knowledge: the more you do something, the better you are at it,” says Dr Paul Bentley, Clinical Director of the Imperial College Network of Excellence in Rehabilitation Technology; Clinical Senior Lecturer and Honorary Consultant Neurologist within Brain Sciences at Imperial College Healthcare NHS Trust.
“A large body of research that has shown that in order to get better from a brain injury, the intensity and the dosage of the activity is important.”
In fact, when it comes to brain damage, he explains, that practice is not so much strengthening the muscles as enabling the brain to build new connections, because the previous ones have been damaged or even destroyed. “Primarily, you want to reactivate new pathways between the brain and the muscles, and train the brain to identify new pathways that are not damaged. It’s about reinforcing those neural pathways in the brain.”
“Stroke patients should be performing at least several hundred repetitions of an exercise a day to get their movement back,” adds Dr Paul Rinne, who trained as a neuroscientist at Imperial and is now the chief executive of GripAble, the company for which Dr Bentley is also a clinical advisor. “Therapists work hands-on with the patient using putty, wooden blocks and so on.”
But that’s easier said than done: several hundred repetitions is a lot, and most people fall short. “On average, in a therapy session with supervision, they’re only hitting 32 movements,” says Dr Rinne. One reason for this is that the brain damage caused by a stroke or head injury can also impair the centres of the brain that enable motivation; but it is also because repeating the same movements again and again is very hard work, at a time when people are often feeling very disempowered and unhappy. “Those blocks and putty are insensitive, they’re not motivating and they also provide no feedback for the therapist,” Dr Rinne points out. “How do you track how many grip and releases someone has done on a piece of putty?”
Ideally, one-to-one physiotherapy would be available to everyone who needs it. However, this is expensive and hard to arrange. Even before the COVID-19 pandemic and lockdown, only around two-thirds of stroke patients were receiving the minimum level of physiotherapy that the NHS recommends.
“The challenge is how do you make people do those reps when they don’t want to do it themselves?” says Dr Bentley. “Intense one-on-one is the gold standard. That’s probably the best they’ll get, when a therapist is encouraging them to do exercises and concentrating on them; and research has shown that people do get better as a result. But that’s not feasible on a daily basis for everyone with a brain injury in the country. So the question is how technology can be involved in motivating people. That was our challenge: a device that was motivating, accessible, easy to use and fun.”
Dr Bentley and Dr Rinne teamed up with Professor Etienne Burdet and Dr Mike Mace, colleagues from Imperial's Department of Bioengineering, to develop GripAble, a device which aims to meet those criteria. It is equipped with games, which require those functional movements, carefully developed so that people with limited arm function can play them (whereas ordinary computer games and devices like Wii are much harder to use). The system consists of a lightweight electronic handgrip which connects wirelessly to a standard PC tablet. Users squeeze, turn or lift the handgrip, and the device detects even very small movements in order to control the game.
It is also possible for the therapist who is working with that patient to monitor how they are doing, and set them new goals. This is part of the overall move towards personalised ‘telerehabilitation’ but adds in, as Dr Rinne puts it, “the human touch”. He explains: “Usually, with telerehab, the therapist is no longer able to move this patient’s arm, do this assessment, work out whether this patient is getting better, and so on. Here’s where the GripAble sensor device will come into its own. It’s able to pick up on strength, and range of movement, and that can be fed back to a therapist and tracked over time.” And the therapist can then set further targets accordingly.
Research into practice
Dr Rinne describes the beginnings of the project. “I was a neuroscientist, working at Imperial and doing a PhD on neuroplasticity, looking at how we can track and improve patients’ recovery. I sat down and started to work with our patient and therapy teams. We needed to build something that fits into the current clinical workflow, rather than disrupting it; and which fitted into the objects the therapists already used.”
GripAble took shape with a team based in London’s ‘Tech City’ area, which is located around the Old Street roundabout. Taking it through from concept to prototype involved not only working with engineers and software developers, but also developing a whole business case, including working with a business accelerator in Dubai for six months. It’s also involved raising funds, putting together a commercial team, testing the potential market and getting commitments to buy the device.
“There’s a lot of new tech coming through in this field, such as robots and motion capture/VR systems but its being used by a very small number of clinics and not in the real world by therapists.
"They get a 25 minute slot with a patient, and can’t spend 20 minutes of that setting up a robot, few places can afford this sort of technology and time. And no matter how good the robot, it’s never going to be as good as a therapist sitting there with the patient, moving their arm and so on.” He and his colleagues looked at different options that might bridge this disconnect, bringing in technology in a way that everyone could use and benefit from.
The team tried different shapes and styles, working their way through around 100 different possible shapes in a collaboration with the Royal College of Art’s specialists in medical device design. “These were really iterative projects; we took different shapes to the bedsides of stroke patients in hospital and explored with therapists which ones were the most functional, attractive and comfortable,” says Dr Bentley.
The games on GripAble focus on the core movements that we require to perform daily living: grip strength, wrist and lower arm movements, and so on. They have also been designed for a range of users, both in terms of strength and in terms of their familiarity with computer games. “We have made a range of games that are like standard computer games, but also ones for people who’re not familiar with computer technology,” Dr Bentley explains.
“There's a series of photos that you flick through, for instance: and it’s possible for someone to upload this with photos of the person’s own family or pets. That’s very simple, so even if they have comprehension problems, they should be able to associate moving their hand with a reward. We’ve made a glider game and one like a bird, where you lift your wrist up and down to control the ascent and descent. We’ve also made games for two people to play, which is again more motivating.”
Playing the games
“It’s all about trying to engage the user with simple activities,” Dr Rinne adds. “For example, we are developing a news reader, where you use the hand you should be training to squeeze to reveal a line of text. Small children could do the same with pictures or a story-book.” So far, the results from clinical trials are looking very good, showing that a significantly greater number of patients have been able to make meaningful movements as a result of using the device compared to, for instance, swiping on a tablet.
The team is focusing on hospital departments and specialist clinics (a mix of private and NHS provision), who can train up clients to use GripAble at home. Emma Hunter is a paediatric occupational therapist, working mainly with children with cerebral palsy (where the brain’s messages are not being properly received, so the person’s movement and/or coordination are affected). A lot of her work focuses on hands and arms, because these are so crucial for children’s independence. “We work on the principle ‘stability before mobility’, and we tend to do programmes that get that stability there first before looking at finger movements.” She’s used GripAble with a number of her young clients, and has been impressed with it.
“We’ve been able to work on precise movements, rather than the patterns you want to avoid.” It’s also much more fun for children after a day at school - children with cerebral palsy typically have a huge battle with fatigue, and come home exhausted.
“This is a type of technology they’re very familiar with. I didn’t expect children to engage with it for a prolonged period, and I’ve been surprised. Even the ones who’re now back at school after lockdown have opted to use it at weekends or evenings.”
This has taken a burden off their parents too. “Parents can carry around a lot of guilt if they haven’t managed to achieve any therapy. I feel they feel positive for their children, and they’re overjoyed when they see actual results going up and children are able to do things they weren’t able to do before.”
Helen Broome describes how her seven-year-old daughter Kelis has used the device. “Kelis has cerebral palsy, which affects her whole body. She’s a very confident little girl, who wants to try and do everything, and we do lots of different therapies from horse-riding to strength training. Her occupational therapist suggested GripAble early in 2020, because we’re working on handwriting skills and dressing skills.
“When she plays the games, she’s having to do movements that strengthen her hands and arms, including movements she wouldn’t usually do. It’s fun and she enjoys it. There are some movements that are almost impossible at the moment, and with some she does need a lot of help from me. I do have to make sure she gets a full range, and she does need a bit of encouragement with movements she finds difficult. But it’s definitely more fun than if I said ‘hold this bar and turn it upside down, and do that 10 times’. She’s seeing that her hand movements is actually helping her play the game. She absolutely loves the circus bear game, which is squeeze and release and then has more challenges as you move up the different levels.”
The COVID-19 crisis and beyond
The COVID-19 pandemic, inevitably, affected the whole production and distribution process. Many of the team ended up working from home, while production was conducted on several different sites. But it has also affected the market in a different way. The shift to providing support at home rather than in clinics has accelerated, along with a general move towards teleconsultations for a whole range of conditions. By early 2021, the team had deployed more than 900 GripAbles, with a user base of well over 3,000. The device is being made available to both therapists and home users on a ‘try before you buy’ trial basis.
“Whereas before the idea of getting people engaged and interacting when they were isolated was relatively new, it’s now at the top of the agenda because we’re in an environment where many patients are at home. So the demand and buy-in have massively increased,” Dr Rinne explains. “A lot of people are now reaching out to us from the top rehabilitation hospitals, because they now need something for home too,” At the moment it is mainly being used in the UK, but there is international interest as well.
The team is now looking forward, but is also very much in touch with its roots. The relationship with the university continues, with funds that have been raised for the project also now being ploughed back into funding PhD students; employing current and former PhD students on the project; and industry placements for interns. “A whole spread of PhD students, from therapists to neuroscientists to bioengineers, are working on projects including clinical testing, methodologies for monitoring outcomes and implementing strategies,” Dr Bentley says.
Earlier this month, GripAble raised £1.6m to support its goals of further developing their technology platform, and reaching patients in new markets such as the US. It has also announced the launch of its Series A funding round, which is expected to close later on this year.
The team is now thinking about new ways to extend the GripAble system’s capabilities. “We’re looking at individual finger training, or elbow or shoulder tracking,” says Dr Rinne. “The ambition is eventually to provide a whole-body tracker.” “What we set out to do initially was to bridge a gap we realised was affecting a lot of patients: to provide them with something that is a step up from the blocks and playdough, but is also not the kind of high-tech that isn’t accessible to them. Above all, we wanted to create something that they would enjoy, because that is the best way to motivate people into practising movements again and again and again. Ultimately, they are the ones doing the work; what we’ve done is make that work more feasible. If what we’ve devised helps more people with arm weakness regain function – and all the work so far is tailored for that purpose – we will know that we’ve succeeded.”
GripAble raised £1.6m this month to support its goals of further developing their technology platform, and reaching patients in new markets such as the US. It has also announced the launch of its Series A funding round, which is expected to close later on this year.