Archive for January, 2015
[ARTICLE] Bioelectronic Medicine and the Dawn of Robotic Training to Improve Motor Outcome in Chronic Stroke – Full Text PDF
Engineers and clinicians have cooperated to produce and test new classes of bioelectronics that have altered motor impairment that occurs after stroke. The rationale that increased intensity of training alters outcome derives from past clinical and preclinical work. Now several studies have demonstrated that interactive robotic devices are a potent tool for the therapist to deliver effortlessly, reproducible high intensity movement training. These robots are safe and can provide a platform so that recovery might be influenced by a combination of noninvasive novel treatment programs. Also, these robotic devices provide a continuous objective history of movement parameters that will open the horizon for their use in generating novel movement biomarkers to understand, predict and measure the influence of new treatments on motor outcome after neurological injury.
The enormous personal and societal burden caused by diseases of the brain and spinal cord make imperative innovative attempts to reduce illness and alter permanent disability. Colleagues at MIT, HI Krebs and N Hogan, developed an array of interactive robotic devices that we have used to aid and abet treatment programs for neurological recovery of motor function of the limbs in patients who have had a stroke (1–4).
These interactive robots move a patient’s paretic arm and when the patient begins to move, these robots “get out of the way” so the patient can execute the movement with very little resistance from the device. With these robots, a therapist can generate training sessions that are intensity controlled (a single one-hour session requires over 1,000 to and fro movements of a limb segment). The robots are tireless agents that produce reliable, reproducible movement sequences. In addition, the controllers on these robotic devices can be tuned to individual patients so that the robot can present different physical challenges at the point when a patient is moving the robot arm, so that training can focus, for example, on the speed, trajectory (aiming) or force of a movement (5,6). The success of controlled multicenter randomized studies that used robotic protocols to improve the outcome of upper limb motor recovery in patients with chronic stroke prompted the American Heart Association to make robotic training standard care (5,7–9).
This work will review the continued relationship between rehabilitation robotics for the paretic upper extremity after chronic stroke and focus on frequent questions that arise in clinical practice: Can intensive training alter the dreaded “performance plateau”? Can the human–robot interaction be optimized for an individual patient? Can explicit training of the affected limb generalize to improvement on untrained motor tasks? Can the control group be trained in an intensive manner to mimic the robot training? Can the robot-derived measurements of movement provide an objective biomarker for studies of other treatments, especially new pharmacology for acute stroke? Can the robot training emerge as a platform for combination therapy?
[ARTICLE] Improving arm function in chronic stroke: a pilot study of sensory amplitude electrical stimulation via glove electrode during task-specific training
Objective: To investigate the effects of sensory amplitude electrical stimulation (SES) delivered by glove electrode during task-specific exercise on arm movement, function, and sensation in chronic stroke.
Design: Intervention pilot study, pre-test, post-test, follow-up design.
Setting: University research laboratory and home-based intervention.
Participants: 11 individuals with chronic stroke (7.2 ± 4.1 years post onset) and moderate arm paresis [10.82/20 ± 2.27 on the Stroke Rehabilitation Assessment of Movement (STREAM) — Arm Subscale]. Participants were seven males and four females (mean age: 59 years). Participants were recruited from university-based database.
Intervention: Participants engaged in task-specific training at home for 30 min, twice daily, for 5 weeks, while receiving SES via glove electrode. Participants received supervised task practice at least twice during intervention period for 1 hour.
Main outcome measures: Jebsen–Taylor Hand Function Test (JTHFT), STREAM — Arm Subscale, Motor Activity Log-14 (MAL-14) — Amount and Quality Subscales, and Nottingham Stereognosis Assessment (NSA).
Results: Significant changes were found in group mean pre- and post-test comparisons on the NSA (P = 0.042), MAL amount subscale (P = 0.047), and JTHFT (with writing item 29 excluded) (P = 0.003) and in pre-test to follow-up comparisons on NSA (P = 0.027) and JTHFT (writing item excluded) (P = 0.009). There was no significant change on the STREAM (P = 1.0). Individuals with a greater baseline motor capacity determined by STREAM scores (P = 0.048) and more recent stroke (P = 0.014) had significantly greater improvements.
Conclusion: Combining task-specific training with glove-based SES in chronic stroke resulted in changes in arm sensation and function that were maintained at 3-month follow-up.
via Improving arm function in chronic stroke: a pilot study of sensory amplitude electrical stimulation via glove electrode during task-specific training: Topics in Stroke Rehabilitation: Vol 0, No 0.
[ARTICLE] A one-year follow-up after modified constraint-induced movement therapy for chronic stroke patients with paretic arm: a prospective case series study
Background: Despite the confirmed short-term effects of constraint-induced movement therapy, the long-term effects have not been sufficiently verified in terms of functional improvement of the affected arm.
Objective: To evaluate the long-term effects and relationship between arm use in activities of daily living and arm improvement with modified constraint-induced movement therapy in chronic stroke patients.
Methods: At 1 year after completing modified constraint-induced movement therapy, arm function (Fugl-Meyer Assessment) and amount of daily arm use (motor activity log) were assessed.
Results: Fourteen post-stroke patients with mild to moderate impairment of arm function were analyzed. One year after completing modified constraint-induced movement therapy, participants consistently showed improvements in arm function and amount of daily arm use (analysis of variance: Fugl-Meyer Assessment, P < 0.001; Motor Activity Log, P < 0.001). For the Fugl-Meyer Assessment, post-hoc tests detected significant improvements (pre versus post, P = 0.009; pre versus 1 year, P < 0.0001; post versus 1 year, P < 0.036). For the Motor Activity Log, post-hoc tests also detected significant improvements (pre versus post, P = 0.0001; pre versus 1 year, P < 0.0001; post versus 1 year, P = 0.0014). The magnitude of the change in Fugl-Meyer Assessment score correlated significantly with the change in Motor Activity Log score (R = 0.778, P = 0.001).
Conclusions: Among post-stroke patients with mild to moderate impairments of arm function, modified constraint-induced movement therapy without any other rehabilitation after intervention may improve arm function and increase arm use for 1 year. In addition, increasing arm use may represent an important factor in improving arm function, and vice versa.
via A one-year follow-up after modified constraint-induced movement therapy for chronic stroke patients with paretic arm: a prospective case series study: Topics in Stroke Rehabilitation: Vol 0, No 0.
[ARTICLE] Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis?
Objective: To contrast changes in clinical and kinematic measures of upper extremity movement in response to virtually simulated and traditionally presented rehabilitation interventions in persons with upper extremity hemiparesis due to chronic stroke.
Design: Non-randomized controlled trial.
Setting: Ambulatory research facility.
Participants: Subjects were a volunteer sample of twenty one community-dwelling adults (mean age: 51 ± 12 years) with residual hemiparesis due to stroke more than 6 months before enrollment (mean: 74 ± 48 months), recruited at support groups. Partial range, against gravity shoulder movement and at least 10° of active finger extension were required for inclusion. All subjects completed the study without adverse events.
Interventions: A 2 weeks, 24-hour program of robotic/virtually simulated, arm and finger rehabilitation activities was compared to the same dose of traditionally presented arm and finger activities.
Results: Subjects in both groups demonstrated statistically significant improvements in the ability to interact with real-world objects as measured by the Wolf Motor Function Test (P = 0.01). The robotic/virtually simulated activity (VR) group but not the traditional, repetitive task practice (RTP) group demonstrated significant improvements in peak reaching velocity (P = 0.03) and finger extension excursion (P = 0.03). Both groups also demonstrated similar improvements in kinematic measures of reaching and grasping performance such as increased shoulder and elbow excursion along with decreased trunk excursion.
Conclusions: Kinematic measurements identified differing adaptations to training that clinical measurements did not. These adaptations were targeted in the design of four of the six simulations performed by the simulated activity group. Finer grained measures may be necessary to accurately depict the relative benefits of dose matched motor interventions.
via Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis?: Topics in Stroke Rehabilitation: Vol 0, No 0.
[ARTICLE] Unilateral and Bilateral Upper-Limb Training Interventions After Stroke Have Similar Effects on Bimanual Coupling Strength
Background: Bilateral training in poststroke upper-limb rehabilitation is based on the premise that simultaneous movements of the nonparetic upper limb facilitate performance and recovery of paretic upper-limb function through neural coupling effects.
Objective: To determine whether the degree of coupling between both hands is higher after bilateral than after unilateral training and control treatment.
Methods: In a single-blinded randomized controlled trial, we investigated rhythmic interlimb coordination after unilateral (mCIMT) and bilateral (mBATRAC) upper-limb training and a dose-matched control treatment (DMCT) in 60 patients suffering from stroke. To this end, we used a series of tasks to discern intended and unintended coupling effects between the hands. In addition, we investigated the control over the paretic hand as reflected by movement harmonicity and amplitude. All tasks were performed before and after a 6-week intervention period and at follow-up 6 weeks later.
Results: There were no significant between-group differences in change scores from baseline to postintervention and from postintervention to follow-up with regard to interlimb coupling. However, the mBATRAC group showed greater movement harmonicity and larger amplitudes with the paretic hand after training than the mCIMT and DMCT groups.
Conclusions: The degree of coupling between both hands was not significantly higher after bilateral than after unilateral training and control treatment. Although improvements in movement harmonicity and amplitude following mBATRAC may indicate a beneficial influence of the interlimb coupling, those effects were more likely due to the particular type of limb movements employed during this training protocol.
[RESEARCH] Commercial gaming devices for stroke upper limb rehabilitation: a survey of current practice
Purpose: Stroke upper limb impairment is associated with disability in activities of daily living. Gaming (Nintendo Wii) is being introduced to rehabilitation despite limited evidence regarding effectiveness. Little data exists on how gaming is implemented resulting in a lack of clinical information. We aimed to gather therapists’ opinions on gaming.
Methods: A survey was posted to therapists, identified from stroke services across Scotland. A second survey was posted to non-responders. Survey data were analysed using descriptive statistics and thematic coding.
Results: Surveys were sent to 127 therapists (70 stroke services) and returned by 88% (112/127). Gaming was used by 18% of therapists, 61% (68/112) stated they would use this intervention should equipment be available. The most commonly used device was Nintendo Wii (83% of therapists using gaming) for 30 min or less once or twice per week. Half of therapists (51%) reported observing at least one adverse event, such as fatigue, stiffness or pain. Gaming was reported to be enjoyable but therapists described barriers, which relate to time, space and cost.
Conclusions: Gaming is used by almost a fifth of therapists. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage.
Implications for Rehabilitation
- Commercial gaming devices are reported to be used by 1/5th of therapists for stroke upper limb rehabilitation, 3/5ths would use gaming if available.
- Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage.
- Current use of gaming in practice may not be achieving intense and repetitive upper limb task-specific practice.
Lost & Found: What Brain Injury Survivors Want You to Know
I need a lot more rest than I used to. I’m not being lazy. I get physical fatigue as well as a “brain fatigue.” It is very difficult and tiring for my brain to think, process, and organize. Fatiguemakes it even harder to think.
My stamina fluctuates, even though I may look good or “all better” on the outside. Cognition is a fragile function for a brain injury survivor. Some days are better than others. Pushing too hard usually leads to setbacks, sometimes to illness.
Brain injury rehabilitation takes a very long time; it is usually measured in years. It continues long after formal has ended. Please resist expecting me to be who I was, even though I look better.
I am not being difficult if I resist social situations. Crowds, , and loud sounds quickly overload my brain, it doesn’t filter sounds as well as it used to. Limiting my exposure is a coping strategy, not a behavioral problem.
If there is more than one person talking, I may seem uninterested in the conversation. That is because I have trouble following all the different “lines” of discussion. It is exhausting to keep trying to piece it all together. I’m not dumb or rude; my brain is getting overloaded!
If we are talking and I tell you that I need to stop, I need to stop NOW! And it is not because I’m avoiding the subject, it’s just that I need time to process our discussion and “take a break” from all the thinking. Later I will be able to rejoin the conversation and really be present for the subject and for you.
Try to notice the circumstances if a behavior problem arises. “ problems” are often an indication of my inability to cope with a specific situation and not a mental health issue. I may be frustrated, in pain, overtired or there may be too much or noise for my brain to filter.
Patience is the best gift you can give me. It allows me to work deliberately and at my own pace, allowing me to rebuild pathways in my brain. Rushing and multi-tasking inhibit .
Please listen to me with patience. Try not to interrupt. Allow me to find my words and follow my thoughts. It will help me rebuild my language skills.
Please have patience with my memory. Know that not remembering does not mean that I don’t care.
Please don’t be condescending or talk to me like I am a child. I’m not stupid, my brain is injured and it doesn’t work as well as it used to. Try to think of me as if my brain were in a cast.
If I seem “rigid,” needing to do tasks the same way all the time; it is because I am retraining my brain. It’s like learning main roads before you can learn the shortcuts. Repeating tasks in the same sequence is astrategy.
If I seem “stuck,” my brain may be stuck in the processing of information. Coaching me, suggesting other options or asking what you can do to help may help me figure it out. Taking over and doing it for me will not be constructive and it will make me feel inadequate. (It may also be an indication that I need to take a break.)
You may not be able to help me do something if helping requires me to frequently interrupt what I am doing to give you directives. I work best on my own, one step at a time and at my own pace.
If I repeat actions, like checking to see if the doors are locked or the stove is turned off, it may seem like I have OCD — obsessive-compulsive disorder — but I may not. It may be that I am having trouble registering what I am doing in my brain. Repetitionsenhance memory. (It can also be a cue that I need to stop and rest.)
If I seem sensitive, it could be emotional as a result of the injury or it may be a reflection of the extraordinary effort it takes to do things now. Tasks that used to feel “automatic” and take minimal effort, now take much longer, require the implementation of numerous strategies and are huge accomplishments for me.
We need cheerleaders now, as we start over, just like children do when they are growing up. Please help me and encourage all efforts. Please don’t be negative or critical. I am doing the best I can.
Don’t confuse Hope for Denial. We are learning more and more about the amazing brain and there are remarkable stories about healing in the news every day. No one can know for certain what our potential is. We need Hope to be able to employ the many, many coping mechanisms, accommodations and strategies needed to navigate our new lives. Everything single thing in our lives is extraordinarily difficult for us now. It would be easy to give up without Hope.
The Innovative YouGrabber Concept
Complete Pair of Therapy Data Gloves