Towards a Dataglove for Arthritis…

As rheumatologists we spend a lot of time examining the hands of people with arthritis. We examine them carefully for swelling and tenderness and use this information to assess disease activity. The effort to make this a more scientific assessment has paid off in the success of ‘treat to target’ protocols. This is fine for early arthritis, but there are other important dimensions of the problem we are only beginning to understand. Historically, rheumatologists have not been particularly interested in the scientific measurement of joint movement and function. This is a major gap in our understanding of arthritis and how it affects our patients from day to day. If we could better understand how stiffness affects joints, we could help our patients optimise their function and perhaps allow them to remain in work by testing different functional strategies in the workplace. Stiffness is also the forgotten member of the trio of symptoms that are widely regarded to reflect disease activity in rheumatoid arthritis. Technology has now reached the point where it should be possible to get accurate biometric data to record joint angles, movement and even touch. And technically it is now possible for these measurements to be recorded at home or in the workplace with minimal interruption to the normal routine. So enter stage – the ‘dataglove’. So perhaps it’s time to let our patients’ fingers do the talking…

The history of datagloves

The first wired electronic glove was patented by Thomas Zimmerman in 1982, and in 1989 Jaron Lanier patented ultrasonic and magnetic motion tracking technology to create the Powerglove. Lanier will also be remembered for coining the phrase ‘virtual reality’. The optical flex sensor used in the dataglove was invented by Young L. Harvill who scratched the fiber near the joint to make it locally sensitive to bending. The Power glove was designed for gaming but sadly for Lanier he was to lose control of the company VPL research. Interestingly, one of his VR predictions has been fulfilled: “Medical students could practice surgery on virtual cadavers that spurt virtual blood after a misplaced incision. Such uses are speculative so far, but few people doubt the technology’s potential”. Potential virtual reality applications in rheumatology include virtual homes or workplaces where the patient can explore functional problems and possible solutions. However, Lanier was well ahead of his time, and viable medical VR applications are still few and far between.

The Technology of Datagloves

The state of the art in current dataglove technology is represented by the 14-sensor 5DT dataglove ‘Ultra’ and the 22-sensor Cyberglove II. You can watch videos online of the 5DT and Cyberglove systems. At the moment these are powerful but expensive gloves which often require considerable effort to calibrate and customise. Working in conjunction with a team from the University of Ulster’s Integrated Systems Research Centre in Magee, we have done some work on programming and customising the 5DT Dataglove Ultra for patients with arthritis. Our work so far has focused on improving the repeatability and ease of calibration of the glove. We have also carried out work on the effect of using an thin inner glove – important in the healthcare setting to avoid problems with cross infection between patients. The 5DT dataglove uses optical fibre bend sensors. This technology is already fairly accurate, but has its limitations. We have therefore developed a new type of multi-functional dataglove using no fewer than 47 sensors. Our dataglove is designed to be used by people with arthritis by incorporating features to enable it to be easily put on and taken off. This will be tested in a group of patients with arthritis. We have also developed a user interface that will help patients calibrate the glove independently and use it accurately in the home setting.

project ‘digit-ease’

Our aim is to test the feasibility of using a sophisticated dataglove to take detailed measurements of joint position and movement in people with rheumatoid arthritis. We will test how closely the measurements match how our patients are feeling. We will be testing how much discomfort patients have in using the dataglove and how easy or difficult they find the visual interface. We hope that if the initial tests prove successful that we will be able to test the dataglove’s ability to detect changes in function after treatment.

For those of you who are interested in a little more detail, I have posted a copy of my recent presentation at the .med conference in Dublin on Dec 7, 2012 (#dotmed on Twitter). My co-workers James Connolly, Kevin Curran, Joan Condell and I have also recently submitted a paper for publication on the use of neural network theory to improve the accuracy of the data glove. I will provide a link if and when it is accepted for publication as this paper contains a lot more detail about our results so far.

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Buzzing the brain in Fibromyalgia?

Proposed ‘Neuropoint’ machine

A recent study reported in the journal ‘Pain medicine’ could point to a new type of treatment for people who suffer from Fibromyalgia syndrome. In this small study a group of patients received over 20 brief twice weekly treatment sessions of direct current stimulation to the brain over a 3 month period. The improvement in the treatment group was quite impressive (see below).

The use of transcranial direct current stimulation for treating chronic pain is not new, but studies using this technique in patients with FMS had not previously shown dramatic improvements. The concept behind this type of therapy is that the application of low voltage current to the cortex of the brain can change the excitation level of nerve cells or neurones. Although the nature of FMS cannot yet be proven, current evidence seems to support the theory that it is characterized by central ‘sensitisation’. One hypothesis to explain this suggests that this is due to the resting state of neurones in patients with FMS being ‘over-excited’ and always at or near the threshold for firing. This is sometimes called ‘hyper-vigilance’ If the ‘thermostat’ for pain could be ‘reset’ back down towards normal this could help kick start people into the sort of lifestyle changes needed to bring about long term improvements.

In this study, the authors claim that the use of a combination of high and low frequencies to deliver current helps to ‘permit passage of the low-frequency components to deeper cortical tissues with minimal attenuation’. Since other studies seem to indicate that the problems with signal interpretation, amplification and/or networking in FMS lies deep in the brain, this would seem like a good area of the brain to target.

The positive results reported in this study are quite impressive for those of us used to reviewing FMS studies – they reported major improvements in pain, sleep quality, fatigue and overall quality of life. Results were reported for two groups with 35 patients each: one group received the direct current treatment, the other group ‘sham’ or placebo therapy. On average the patients had a 10 year history of FMS, so these were patients with quite chronic symptoms. The average reduction in the number of ‘tender points’ in the treated group was 7.4 (from a starting point of 17) so it is important to make it clear that this treatment did not cure the patients of their pain. However, the change in the placebo group was 0.2 (not significant). The pain threshold reduced from 36 by 19.6 in the treatment group, but by only 3.2 in the placebo group. The quality of life index (FIQ) improved by 15 from 61.5 in the treatment group with no change in the placebo treatment group. Side effects were few, with 0.3% reporting a short-lived headache.

Discussion:

I was at the session at the American College of Rheumatology meeting where this research was presented in 2010. There was a lot of interest in the results which almost seemed too good to be true. We have had a lot of ‘false dawns’ in FMS treatment, and as a result I’m a bit cautious and keen to wait for the full evidence to come out. The results in the full paper published in Jan 2012 are unchanged, but it is interesting that the conclusion states that the treatment ‘provided modest improvements to pain, tender point measures, fatigue and sleep’. Before we all go out and order a ‘Neuropoint’ machine (see above) to deliver this high/low frequency current to our FMS patients, we really need someone else to independently replicate these results. I do wonder if the ‘blinding’ was effective or if the patients receiving the real treatment felt something more than the placebo group. The paper notes under ‘conflicts of interest’ that the lead author (JBH) has intellectual property interest in the technique used to deliver the current and is a shareholder in the Cerephex Corporation set up to market the equipment used in this study.

The Cerephex Corporation web pages indicate that a follow up study has been carried out: “at 45-months past end of treatment, 76% of surveyed patients reported reduced or eliminated need for pain medications, and 71% report reduced or eliminated need to see doctors or caregivers”. This is an even more impressive result than that reported in the original trial – but again, it needs to be independently verified. If validated, it would seem that the course of treatment could be considered something that provides long lasting relief and not just short term symptom relief. The device – which they are calling ‘Neuropoint’ has not yet been licenced by the FDA and to my knowledge is not yet available in Europe. I understand that a larger trial is about to commence to get further evidence to support an FDA approval.

Reference:
Jeffrey B. Hargrove, Robert M. Bennett David G. Simons, Susan J. Smith, Sunil Nagpal, and Donald E. Deering. A Randomized Placebo-Controlled Study of Noninvasive Cortical Electrostimulation in the Treatment of Fibromyalgia Patients
Pain Medicine 2012; 13: 115–124

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Pharmacogenomics trial – networking ‘out of the box’

Medicine is changing rapidly, and most of the drivers of change are outside of medicine. One of the major ‘hurricanes’ approaching the ‘coast’ of traditional medicine is the field of genomics. As Eric Topol has said in his excellent book, most doctors either remain either ignorant or dismissive of the importance of this field. Much of the outstanding recent work in genomics has been in non-medical science laboratories. As a clinician who has fairly recently woken up to these new developments, I thought I should tell you how this has come about…

As it happens, a major new £1 million research project on the pharmacogenomics of response to anti-TNF drugs was recently launched in N.Ireland. This will involve Rheumatologists in Altnagelvin hospital and Musgrave Park hospital working together with genomics researchers and commercial scientists. So how did a project like this win approval from the MRC and Arthritis Research in competition with well established centers of research excellence in England?

The credit for the research proposal goes mainly to University of Ulster Professor of Genomics Tony Bjourson, the Principal Investigator in the trial. Together with researcher Cathy McGeough he had carried out the preliminary study on the KIR (natural killer)/HLA C gene haplotype markers along with Dr G. Wright and Dr C. Matthews, Rheumatologists in Belfast. This study – though relatively small – showed that this genotype test could predict which patients will respond to anti-TNF and who will not. This is the sort of development that allows us to begin to think about ‘personalized medicine‘ where the treatment can be tailored to the individual. One of the unusual features of the proposal was the strong link with Randox laboratories (Crumlin, N.Ireland) where some of the best hardware for genome analysis has been developed and where a strong team of scientists are based.

My own involvement in the project was been facilitated  by C-TRIC, a unit near my hospital which is designed to facilitate networking between commerce, scientific academia and clinicians. Barry Henderson (manager of C-TRIC) has been trying for a number of years to get clinicians and non-medical university researchers together and find areas of common interest. Barry and Maurice O’Kane (our research director) have been pivotal in promoting and encouraging clinicians to get involved and find synergies with university academics. In this case and in the ‘Data-glove’ project, we as clinicians are the ‘junior partners’ in the network. More of the data-glove project in another article.

 

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