Background: Most stroke survivors continue to experience motor impairments even after hospital discharge. Virtual reality-based techniques have shown potential for rehabilitative training of these motor impairments. Here we assess the impact of at-home VR-based motor training on functional motor recovery, corticospinal excitability and cortical reorganization.
Objective: The aim of this study was to identify the effects of home-based VR-based motor rehabilitation on (1) cortical reorganization, (2) corticospinal tract, and (3) functional recovery after stroke in comparison to home-based occupational therapy.
Methods: We conducted a parallel-group, controlled trial to compare the effectiveness of domiciliary VR-based therapy with occupational therapy in inducing motor recovery of the upper extremities. A total of 35 participants with chronic stroke underwent 3 weeks of home-based treatment. A group of subjects was trained using a VR-based system for motor rehabilitation, while the control group followed a conventional therapy. Motor function was evaluated at baseline, after the intervention, and at 12-weeks follow-up. In a subgroup of subjects, we used Navigated Brain Stimulation (NBS) procedures to measure the effect of the interventions on corticospinal excitability and cortical reorganization.
Results: Results from the system’s recordings and clinical evaluation showed significantly greater functional recovery for the experimental group when compared with the control group (1.53, SD 2.4 in Chedoke Arm and Hand Activity Inventory). However, functional improvements did not reach clinical significance. After the therapy, physiological measures obtained from a subgroup of subjects revealed an increased corticospinal excitability for distal muscles driven by the pathological hemisphere, that is, abductor pollicis brevis. We also observed a displacement of the centroid of the cortical map for each tested muscle in the damaged hemisphere, which strongly correlated with improvements in clinical scales.
Conclusions: These findings suggest that, in chronic stages, remote delivery of customized VR-based motor training promotes functional gains that are accompanied by neuroplastic changes.
After initial hospitalization, many stroke patients return home relatively soon despite still suffering from impairments that require continuous rehabilitation . Therefore, ¼ to ¾ of patients display persistent functional limitations for a period of 3 to 6 months after stroke [ ]. Although clinicians may prescribe a home exercise regimen, reports indicate that only one-third of patients actually accomplish it [ ]. Consequently, substantial gains in health-related quality of life during inpatient stroke rehabilitation may be followed by equally substantial declines in the 6 months after discharge [ ]. Multiple studies have shown, however, that supported discharge combined with at home rehabilitation services does not compromise clinical inpatient outcomes [ – ] and may enhance recovery in subacute stroke patients [ ]. Hence, it is essential that new approaches are deployed that help to manage chronic conditions associated with stroke, including domiciliary interventions [ ] and the augmentation of current rehabilitation approaches in order to enhance their efficiency. There should be increased provision of home-based rehabilitation services for community-based adults following stroke, taking cost-effectiveness, and a quick family and social reintegration into account [ ].
One of the latest approaches in rehabilitation science is based on the use of robotics and virtual reality (VR), which allow remote delivery of customized treatment by combining dedicated interface devices with automatized training scenarios [– ]. Several studies have tested the acceptability of VR-based setups as an intervention and evaluation tool for rehabilitation [ – ]. One example of this technology is the, so called, Rehabilitation Gaming System (RGS) [ ], which has been shown to be effective in the rehabilitation of the upper extremities in the acute and the chronic phases of stroke [ ]. However, so far little work exists on the quantitative assessment of the clinical impact of VR based approaches and their effects on neural reorganization that can directly inform the design of these systems and their application in the domiciliary context. The main objective of this paper is to further explore the potential and limitations of VR technologies in domiciliary settings. Specifically, we examine the efficacy of a VR-based therapy when used at home for (1) assessing functional improvement, (2) facilitating functional recovery of the upper-limbs, and (3) inducing cortical reorganization. This is the first study testing the effects of VR-based therapy on cortical reorganization and corticospinal integrity using NBS.
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