Archive for category Virtual reality rehabilitation

[WEB PAGE] VIRTUAL GAMES HELP PEOPLE STAND, WALK IN REHAB

 

Virtual reality video games, activity monitors, and handheld computer devices can help people stand as well as walk, the largest trial worldwide into the effects of digital devices in rehabilitation has found. The study was undertaken at hospitals in Sydney and Adelaide, Australia, and had 300 participants ranging from 18 to 101 years old. Those who exercised using digital devices in addition to their usual rehabilitation were found to have better mobility (walking, standing up, and balance) after 3 weeks and after 6 months than those who just completed their usual rehabilitation. The results were published in PLOS Medicine.

Trial participants were recovering from strokes, brain injuries, falls, and fractures. Participants used on average 4 different devices while in hospital and 2 different devices when at home. Fitbits were the most used digital device but also tested were a suite of devices like Xbox, Wii, and iPads, making the exercises more interactive and enabling remote connection between patients and their physical therapists. Having a selection meant the physical therapist could tailor the choice of devices to meet the patient’s mobility problems while considering patient preferences.

Lead author Leanne Hassett, PhD, from the Faculty of Medicine and Health at the University of Sydney, said benefits reported by patients using the digital devices in rehabilitation included variety, fun, feedback about performance, cognitive challenge, that they enabled additional exercise, and the potential to use the devices with others, such as family, therapists, and other patients. “These benefits meant patients were more likely to continue their therapy when and where it suited them, with the assistance of digital healthcare,” she said.

Participants reported doing more walking at 6 months, meaning their rehabilitation was improved, but this was not detected in the physical activity measure (time spent upright) generally. In the younger age group, the devices also increased daily step count. Distinctions between physical activity were made through measurements with an activPAL, a small device attached to the thigh that records how much time is spent in different positions (sitting, standing, lying) as well as number of steps taken each day.

This study used research physical therapists to deliver the study; the next step will be to trial the approach in clinical practice by incorporating it into the work of physical therapists.

via VIRTUAL GAMES HELP PEOPLE STAND, WALK IN REHAB | Lower Extremity Review Magazine

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[ARTICLE] Reinforced Feedback in Virtual Environment for Plantar Flexor Poststroke Spasticity Reduction and Gait Function Improvement – Full Text

Abstract

Background

Ankle spasticity is a frequent phenomenon that limits functionality in poststroke patients.

Objectives

Our aim was to determine if there was decreased spasticity in the ankle plantar flex (PF) muscles in the plegic lower extremity (LE) and improvement of gait function in stroke patients after traditional rehabilitation (TR) in combination with virtual reality with reinforced feedback, which is termed “reinforced feedback virtual environment” (RFVE).

Methods

The evaluation, before and after treatment, of 10 hemiparetic patients was performed using the Modified Ashworth Scale (MAS), Functional Ambulatory Category (FAC), and Functional Independence Measure (FIM). The intervention consisted of 1 hour/day of TR plus 1 hour/day of RFVE (5 days/week for 3 weeks; 15 sessions in total).

Results

The MAS and FAC reached statistical significance (P < 0.05). The changes in the FIM did not reach statistical significance (P=0.066). The analysis between the ischemic and haemorrhagic patients showed significant differences in favour of the haemorrhagic group in the FIM scale. A significant correlation between the FAC and the months after the stroke was established (P=−0.711). Indeed, patients who most increased their score on the FAC at the end of treatment were those who started the treatment earliest after stroke.

Conclusions

The combined treatment of TR and RFVE showed encouraging results regarding the reduction of spasticity and improvement of gait function. An early commencement of the treatment seems to be ideal, and future research should increase the sample size and assessment tools.

1. Introduction

Stroke patients suffer several deficits that affect (mildly to severely) the cognitive, psychological, or motor areas of the brain, at the expense of their quality of life []. Although rehabilitation techniques do not only act on the motor deficits [], the effects associated with the interruptions of the corticospinal tract, as well as the subsequent adaptive changes, commonly require specific interventions. Among them, the most important changes are muscle weakness, loss of dexterity, cocontraction, and increased tone and abnormal postures [].

Hemiparesis is the most common problem in poststroke patients, and its severity correlates with the functional capabilities of the individual [], being that impairment of gait function is one of the most important limitations. Furthermore, weakness of the ankle muscles caused by injury to supraspinal centres and spasticity are the most frequent phenomena that limit functionality []. The degree of spasticity of the affected ankle plantar flex (PF) muscles primarily influences gait asymmetry [], which is, in addition to depression, another independent factor for predicting falls in ambulatory stroke patients []. Physiological changes in the paretic muscles, passive or active restraint of agonist activation, and abnormal muscle activation patterns (coactivation of the opposing lower extremity (LE)) have been shown to occur after a stroke and can lead to joint stiffness (foot deformities are present in 30% of stroke patients) [], deficits in postural stabilization, and reduced muscle force generation []. To enhance this postural stability during gait, it seems that poststroke patients with impaired balance and paretic ankle muscle weakness use a compensation strategy of increased ankle muscle coactivation on the paretic side [].

Scientific evidence shows that the use of mixed techniques with different physiotherapy approaches under very broad classifications (i.e., neurophysiological, motor learning, and orthopaedic) provides significantly better results regarding recovery of autonomy, postural control, and recovery of LE in the hemiparetic patient (HP) as compared to no treatment or the use of placebo []. Within the latter techniques, we may emphasize the relearning of motor-oriented tasks [], as well as other approaches based on new technologies (e.g., treadmill [], robotics [], and functional electrical stimulation (FES) []), which are often used as additional treatments to traditional rehabilitation (TR). However, some of these emerging therapies, such as vibratory platforms [], have not been shown yet to produce as positive results as the prior ones. Thus, obtaining better results with mixed and more intensive rehabilitation treatment has been demonstrated []. Therefore, we propose to add the use of virtual reality (VR) techniques to TR to optimize results. We can use the label “VR-based therapy” because it acknowledges the VR system as the tool being used by the clinician in therapy, not as the therapy itself. It is essential to transfer the obtained gains in VR-based therapy to better functioning in the real world []. In this way, the intersection of a promising technological tool with the skills of confident and competent clinicians will more likely yield high-quality evidence and enhanced outcomes for physical rehabilitation patients [].

The application of VR to motor recovery of the hemiparetic LE (HLE) has been addressed by several authors in the last decade [], obtaining satisfactory results, in general terms, in the increase of walking speed [], cortical reorganization, balance, and kinetic-kinematic parameters. Other authors have reported improvements in the balance of patients treated with nonimmersive VR systems based on video games, using specific software and with the guidance of a therapist []. A recent study showed that VR-based eccentric training using a slow velocity is effective for improving LE muscle activity to the gastrocnemius muscle and balance in stroke []; however, the spasticity of PF muscles was not analysed in any of these studies.

Virtual reality acts as an augmented environment where feedback can be delivered in the form of enhanced information about knowledge of results and knowledge of performance (KP) []. There are systems that use this KP through the representation of trajectories during the execution of the movement, as well as visualizing these once performed, to visually check the amount of deviation from the path proposed by the physiotherapist. Several studies demonstrated that this treatment enriched by reinforced feedback in a virtual environment (RFVE) may be more effective than TR to improve the motor function of the upper limb after stroke []. In our study, the use of a VR-based system, together with a motion capture tool, allowed us to modify the artificial environment with which the patient could interact, exploiting some mechanisms of motor learning [], thus allowing greater flexibility and effective improvement in task learning. This system has been highly successful in the functional recovery of the hemiparetic upper extremity [], but its combined effect with TR on the LE has not yet reported conclusive data []. The continuous supply of feedback during voluntary movement makes it possible to continuously adjust contractile activity [], thus mitigating increments in spasticity and cocontraction processes of the patient. These settings are of great significance in motor control, and certain variables (such as the speed of the movement) can be controlled, having a direct influence on spasticity. In this line, the aim of this study is to determine if there is a decrease in the spasticity of the PF muscles and improved gait function, following a program that includes the combination of TR and VR with reinforced feedback, which is called “reinforced feedback virtual environment” (RFVE).

Moreover, as a complementary aim, we analysed the modulatory effects of demographic and clinical factors on the recovery of patients treated with TR and VR. The analysis of the influence of these modulatory variables was focused on better highlighting what type of patients would benefit most from the combined treatment of TR and VR. Particularly, we looked into the effects of age and time elapsed from the moment the stroke occurs until the patient starts neurorehabilitation. As shown in various studies, a better outcome for treatment can be expected for younger patients and for those who start the treatment earlier []. Also, comparisons were made between patients with an ischemic and haemorrhagic stroke, since differences in their recovery prognostic have been reported elsewhere, with better outcomes for the latter group [].[…]

Continue —-> Reinforced Feedback in Virtual Environment for Plantar Flexor Poststroke Spasticity Reduction and Gait Function Improvement

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Figure 2. Patient carrying out a task set out by the physiotherapist in front of the RFVE equipment.

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[Abstract] How brain imaging provides predictive biomarkers for therapeutic success in the context of virtual reality cognitive training

Highlight

VR environments help improve rehabilitation of impaired complex cognitive functions

Combining neuroimaging and VR boosts ecological validity, generates practical gains

These are the first neurofunctional predictive biomarkers of VR cognitive training

Abstract

As Virtual reality (VR) is increasingly used in neurological disorders such as stroke, traumatic brain injury, or attention deficit disorder, the question of how it impacts the brain’s neuronal activity and function becomes essential. VR can be combined with neuroimaging to offer invaluable insight into how the targeted brain areas respond to stimulation during neurorehabilitation training. That, in turn, could eventually serve as a predictive marker for therapeutic success. Functional magnetic resonance imaging (fMRI) identified neuronal activity related to blood flow to reveal with a high spatial resolution how activation patterns change, and restructuring occurs after VR training. Portable and quiet, electroencephalography (EEG) conveniently allows the clinician to track spontaneous electrical brain activity in high temporal resolution. Then, functional near-infrared spectroscopy (fNIRS) combines the spatial precision level of fMRIs with the portability and high temporal resolution of EEG to constitute an ideal measuring tool in virtual environments (VEs). This narrative review explores the role of VR and concurrent neuroimaging in cognitive rehabilitation.

Source: https://www.sciencedirect.com/science/article/abs/pii/S0149763420304218?dgcid=rss_sd_all&utm_campaign=RESR_MRKT_Researcher_inbound&utm_medium=referral&utm_source=researcher_app

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[Abstract] Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application

Highlights

• BCI methods are among the most effective tool for designing rehabilitation systems

.• Use of virtual reality (VR) can increase the efficiency of BCI rehab systems

.• “FES,” “Robotics Assistance,” and “Hybrid VR based Models” are main BCI approaches.

• In the future, flexible electronics can be used for designing stroke rehab systems.

Abstract

Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including “Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models,” have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.

Source: https://www.sciencedirect.com/science/article/abs/pii/S0010482520302031?dgcid=rss_sd_all&utm_campaign=RESR_MRKT_Researcher_inbound&utm_medium=referral&utm_source=researcher_app

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[ARTICLE] Adaptive Treadmill-Assisted Virtual Reality-Based Gait Rehabilitation for Post-Stroke Physical Reconditioning—a Feasibility Study in Low-Resource Settings – Full Text

Abstract

Objectives: Individuals with chronic stroke suffer from heterogeneous functional limitations, including cardiovascular dysfunction and gait disorders (associated with increased energy expenditure) besides psychological factors, e.g., motivation. To recondition their cardiovascular endurance and gait, rehabilitation exercises with gradually increasing exercise intensity suiting their individualized capabilities need to be offered. In principal accordance, here we (i) implemented an adaptive Virtual Reality (VR)-based treadmill-assisted platform sensitive to energy expenditure, (ii) investigated its safety and feasibility of use and (iii) examined the implications of gait exercise with this platform on cardiac and gait performance along with energy expenditure, clinical measures (to estimate physical reconditioning of subjects with stroke) and their views on community ambulation capabilities. Methods: Ten able-bodied subjects volunteered in a study to ensure its safety and feasibility of use. Nine subjects with chronic stroke underwent physical reconditioning over multiple exposures using our platform. We investigated the patients’ cardiac and gait performance prior and post exposure to our platform along with studying the clinical relevance of gait parameters in estimating their physical reconditioning. We collected the patients’ feedback. Results: We found statistical improvement in the gait parameters and reduction in energy expenditure during overground walk following ~1 month of gait exercise with our platform. They reported that the VR-based tasks were motivating. Conclusion: Results show that this platform can pave the way towards implementing home-based individualized exercise platform that can monitor one’s cardiac and gait performance capabilities while offering an adaptive and progressive gait exercise environment within safety thresholds suiting one’s exercise capabilities.

Physiological Cost Index sensitive Adaptive Response Technology (PCI-ART) for post-stroke physical reconditioning. Note: PCI- Physiological Cost Index; SST-Single Support Time; AL- Affected limb; UAL- Unaffected limb.

Physiological Cost Index sensitive Adaptive Response Technology (PCI-ART) for post-stroke physical reconditioning. Note: PCI- Physiological Cost Index; SST-Single Support Time; AL- Affected limb; UAL- Unaffected limb. 

SECTION I.

Introduction

Neurological disorders, such as stroke is a leading cause of disability with a prevalence rate of 424 in 100,000 individuals in India [1]. Often, these patients suffer from functional disabilities, heterogeneous physical deconditioning along with deteriorated cardiac functioning [2], [3] and a sedentary lifestyle immediately following stroke [4]. A deconditioned patient requires reconditioning of his/her cardiac capacity and ambulation capabilities that can be achieved through individualized rehabilitation [5]. This needs to be done under the supervision of a clinician who can monitor one’s functional capability, cardiac capacity and gait performance thereby recommending an appropriate dosage of the gait rehabilitation exercise intensity to the patient along with feedback. Such gait rehabilitation is crucial since about 80% of these patients have been reported to suffer from gait-related disorders [6] along with more energy expenditure than able-bodied individuals [7] often accompanied with reduced cardiac capacity [2], [4]. However, given the low doctor-to-patient ratio [8], lack of rehabilitation facilities and patients being released early from rehabilitation clinics followed by home-based exercise [9], particularly in developing countries like India, availing individualized rehabilitation services becomes difficult. Again, undergoing home-based exercises under clinician’s one-on-one supervision becomes difficult given the restricted healthcare resources, thereby limiting the rehabilitation outcomes [10]. Again, given the restricted healthcare resources, getting a clinician visiting the homes for delivering therapy sessions to patients is often costly causing the patients to miss the expert inputs on the exercise intensity suiting his/her exercise capability along with motivational feedback from the clinician [11]. This necessitates the use of a complementary technology-assisted rehabilitation platform that can be availed by the patient at his/her home [12] following a short stay at the rehabilitation clinic [13]. Again, it is preferred that this platform be capable of offering individualized gait exercise while varying the dosage of exercise intensity (based on the patient’s exercise capability) along with motivational feedback [14]. Additionally, exercise administered by this platform can be complemented with intermediate clinician-mediated assessments of rehabilitation outcomes, thereby reducing continuous demands on the restricted clinical resources. Thus, it is important to investigate the use of such technology-assisted gait exercise platforms that are capable of offering exercise based on one’s individualized capability along with motivational feedback.

Researchers have explored the use of technology-assisted solutions to offer rehabilitative gait exercises to these patients, along with presenting motivational feedback [15]–[16][17][18][19][20][21][22][23][24]. Specifically, investigators have used Virtual Reality (VR) coupled with a treadmill (having a limited footprint and making it suitable for home-based settings) while delivering individualized feedback [15] to the patient during exercise. Again, VR can help to project scenarios that can make the exercise engaging and interactive for a user [16]–[17][18][19]. In fact, Finley et al. have shown that the visual feedback offered by VR provides an optical flow that can induce changes in the gait performance (quantified in terms of gait parameters, e.g., Step Length, Step Symmetry, etc.) of such patients during treadmill-assisted walk [20]. Further, Jaffe et al. have reported positive implications of VR-based treadmill-assisted walking exercise on the gait performance of individuals with stroke [23], leading to improvement in their community ambulation [24]. These studies have shown the efficacy of the VR-based treadmill-assisted gait exercise platform to contribute towards gait rehabilitation of individuals suffering from stroke. Though promising, none of these platforms are sensitive to one’s individualized exercise capability and thus, in turn, could not decide an optimum dosage of exercise intensity suiting one’s capability, e.g., cardiac capacity and ambulation capability. This is particularly critical for individuals with stroke since they possess diminished exercise ability along with deteriorated cardiac functioning [2], [4].

From literature review, we find that after stroke, treadmill-assisted cardiac exercise programs can lead to one’s improved fitness and exercise capability [25]. For example, researchers have presented studies on Moderate-Intensity Continuous Exercise and High-Intensity Interval Training in which exercise protocols are individualized by a clinician based on one’s cardiac capacity while contributing to effective gait rehabilitation [26]–[27][28][29]. Though promising, these have not offered a progressive and adaptive exercise environment in which the dosage of exercise intensity is varied based on one’s cardiac capacity in real-time. Thus, the choice of optimum dosage of exercise intensity that can be individualized in real-time for a patient, still remains as inadequately explored [4]. For deciding the optimal dosage of rehabilitative exercise intensity, clinicians often refer to the guidelines recommended by the American College of Sports Medicine (ACSM) [30]. These guidelines suggest thresholds to decide the intensity of the exercise based on one’s metabolic energy consumption in terms of oxygen intake, heart rate, etc. Deciding the dosage of exercise intensity is crucial, particularly for individuals with stroke since their energy requirements have been reported to be 55-100% higher than that of their able-bodied counterparts [7]. Specifically, higher energy requirement often limits the capabilities of these patients and challenges their rehabilitation outcomes. This can be addressed if the technology-assisted gait exercise platform can offer individualized exercise (maintaining the safe exercise thresholds) based on the energy expenditure of the patients acquired in real-time during the exercise.

The energy expenditure can be defined as the cost of physical activity [4] and it is often expressed in terms of oxygen consumption or heart rate [31]. Thus, investigators have monitored the oxygen consumption and heart rate to estimate the energy expenditure of individuals with stroke during their walk [31], [32]. However, monitoring oxygen consumption during exercise requires a cumbersome setup [31], making it unsuitable for home-based rehabilitation. On the other hand, one’s heart rate (HR) can be monitored using portable solutions [33] that can be integrated with a treadmill in home-based settings. Researchers have explored treadmill-assisted gait exercise platforms that are sensitive to the user’s heart rate. For example, researchers have offered treadmill training to subjects with stroke in which some of them varied treadmill speed to achieve 45%-50% [34], while others varied speed to achieve 85% to 95% [35], [36] of one’s age-related maximum heart rate. Again, Pohl et al. have offered treadmill-assisted exercise to subjects with stroke while ensuring that the user’s heart rate settled to the respective resting-state heart rate [37]. Again of late, there had been advanced treadmills, available off-the-shelf, that can monitor one’s heart rate and vary the treadmill speed to maintain the user’s heart rate at a predefined level [38], [39]. Though one’s heart rate is an important indicator that needs to be considered during treadmill-assisted exercise, one’s walking speed while using the treadmill also offers important information on one’s exercise capability. This is because gait rehabilitation aims to improve one’s community ambulation that is related to one’s walking speed [40]. Thus, it would be interesting to explore the composite effect of one’s walking speed along with working and resting-state heart rates during treadmill-assisted gait exercise to study one’s energy expenditure, quantified in terms of a proxy index, namely Physiological Cost Index (PCI) [31].

Given that there are no existing studies that have used a treadmill-assisted gait exercise platform deciding the dosage of exercise intensity based on one’s PCI estimated in real-time during exercise, it might be interesting to explore the use of such an individualized gait exercise platform for individuals with stroke. Thus, we wanted to extend a treadmill-assisted gait exercise platform by making it adaptive to one’s individualized PCI. Additionally, we wanted to augment this platform with VR-based user interface to offer visual feedback to the user undergoing gait exercise. We hypothesized that such a gait exercise platform can recondition a patient’s exercise capability in terms of cardiac and gait performance to achieve improved community ambulation. The objectives of our research were three-fold, namely to (i) implement a novel PCI-sensitive Adaptive Response Technology (PCI-ART) offering VR-based treadmill-assisted gait exercise, (ii) investigate the safety and feasibility of use of this platform among able-bodied individuals before applying it to subjects with stroke and (iii) examine implications of undergoing gait exercise with this platform on the patients’ (a) cardiac and gait performance along with energy expenditure, (b) clinical measures estimating the physical reconditioning and (c) views on their community ambulation capabilities.

The rest of the paper is organized as follows: Section II presents our system design. Section III explains the experiments and procedures of this study. Section IV discusses the results. In Section V, we summarize our findings, limitations, and scope of future research.[…]

Continue —-> Adaptive Treadmill-Assisted Virtual Reality-Based Gait Rehabilitation for Post-Stroke Physical Reconditioning—a Feasibility Study in Low-Resource Settings – IEEE Journals & Magazine

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[Abstract] Exercise intensity of the upper limb can be enhanced using a virtual rehabilitation system.

Purpose: Motor recovery of the upper limb (UL) is related to exercise intensity, defined as movement repetitions divided by minutes in active therapy, and task difficulty. However, the degree to which UL training in virtual reality (VR) applications deliver intense and challenging exercise and whether these factors are considered in different centres for people with different sensorimotor impairment levels is not evidenced. We determined if (1) a VR programme can deliver high UL exercise intensity in people with sub-acute stroke across different environments and (2) exercise intensity and difficulty differed among patients with different levels of UL sensorimotor impairment.

Methods: Participants with sub-acute stroke (<6 months) with Fugl-Meyer scores ranging from 14 to 57, completed 10 ∼ 50-min UL training sessions using three unilateral and one bilateral VR activity over 2 weeks in centres located in three countries. Training time, number of movement repetitions, and success rates were extracted from game activity logs. Exercise intensity was calculated for each participant, related to UL impairment, and compared between centres.

Results: Exercise intensity was high and was progressed similarly in all centres. Participants had most difficulty with bilateral and lateral reaching activities. Exercise intensity was not, while success rate of only one unilateral activity was related to UL severity.

Conclusion: The level of intensity attained with this VR exercise programme was higher than that reported in current stroke therapy practice. Although progression through different activity levels was similar between centres, clearer guidelines for exercise progression should be provided by the VR application.

  • Implications for rehabilitation
  • VR rehabilitation systems can be used to deliver intensive exercise programmes.

  • VR rehabilitation systems need to be designed with measurable progressions through difficulty levels.

via Exercise intensity of the upper limb can be enhanced using a virtual rehabilitation system: Disability and Rehabilitation: Assistive Technology: Vol 0, No 0

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[ARTICLE] Nervous System Pathophysiology: A critical time window for recovery extends beyond one-year post-stroke. – Full Text

Abstract

The impact of rehabilitation on post-stroke motor recovery and its dependency on the patient’s chronicity remain unclear. The field has widely accepted the notion of a proportional recovery rule with a “critical window for recovery” within the first 3–6 mo poststroke. This hypothesis justifies the general cessation of physical therapy at chronic stages. However, the limits of this critical window have, so far, been poorly defined. In this analysis, we address this question, and we further explore the temporal structure of motor recovery using individual patient data from a homogeneous sample of 219 individuals with mild to moderate upper-limb hemiparesis. We observed that improvement in body function and structure was possible even at late chronic stages. A bootstrapping analysis revealed a gradient of enhanced sensitivity to treatment that extended beyond 12 mo poststroke. Clinical guidelines for rehabilitation should be revised in the context of this temporal structure.

NEW & NOTEWORTHY Previous studies in humans suggest that there is a 3- to 6-mo “critical window” of heightened neuroplasticity poststroke. We analyze the temporal structure of recovery in patients with hemiparesis and uncover a precise gradient of enhanced sensitivity to treatment that expands far beyond the limits of the so-called critical window. These findings highlight the need for providing therapy to patients at the chronic and late chronic stages.

 

INTRODUCTION

The absolute incidence of stroke will continue to rise globally with a predicted 12 million stroke deaths in 2030 and 60 million stroke survivors worldwide (). Stroke leads to focal lesions in the brain due to cell death following hypoxia and inflammation, affecting both gray and white matter tracts (). After a stroke, a wide range of deficits can occur with varying onset latencies such as hemiparesis, abnormal posture, spatial hemineglect, aphasia, and spasticity, along with affective and cognitive deficits, chronic pain, and depression (). Due to improved treatment procedures during the acute stage of stroke (e.g., thrombolysis and thrombectomy), the associated reduction in stroke mortality has led to a greater proportion of patients facing impairments and needing long-term care and rehabilitation. However, prevention, diagnostics, rehabilitation, and prognostics of stroke recovery have not kept pace ().

Motor recovery after stroke has been widely operationalized as the individual’s change in two domains: 1) body function and structure (), whose improvement has been called “true recovery” () and refers to the restitution of a movement repertoire that the individual had before the injury; and 2) the ability to successfully perform the activities of daily living (). While the former is mainly due to the interaction of poststroke plasticity mechanisms and sensorimotor training, the latter is also influenced by the use of explicit and implicit compensatory strategies (). The most accepted measure for recovery of body function and structure is the change in the Fugl-Meyer Assessment of the upper extremity (UE-FM) scores (), while other clinical scales focus on the assessment of activities, such as the Chedoke Arm and Hand Activity Inventory (CAHAI) () or the Barthel Index for Activities of Daily Living (BI) ().

Poststroke motor recovery mostly follows a nonlinear trajectory that reaches asymptotic levels a few months after the injury (). This model suggests the existence of a period of heightened plasticity in which the patient seems to be more responsive to treatment, the so-called “critical window” for recovery. Aiming at characterizing the temporal structure of recovery, animal models and clinical research have identified a combination of mechanisms underlying neurological repair that seems to be unique to the injured brain, including neurogenesis, gliogenesis, axonal sprouting, and the rebalancing of excitation and inhibition in cortical networks (). This state of enhanced plasticity seems to be transient and interacts closely with sensorimotor training to facilitate the recovery of motor function (). However, there is no clear evidence of the exact temporal structure of enhanced responsiveness to treatment in humans, and as a result the optimal timing and intensity of treatment remain unclear. A systematic review of 14 studies suggested that, on average, recovery reaches a plateau at 15 wk poststroke for patients with severe hemiparesis and at 6.5 wk for patients with mild hemiparesis (). This study however failed to conduct a meta-analysis due to substantial heterogeneity of the sample and protocols. Currently, an ongoing clinical trial is investigating the existence and the duration of a critical window of enhanced neuroplasticity in humans following ischemic stroke (). Based on the assumption of the existence of this critical period, the SMARTS 2 trial (NCT02292251) () is currently investigating the effect of early and intensive therapy on upper extremity motor recovery. Sharing the same research question, the Critical Periods After Stroke Study (CPASS) is a large ongoing randomized controlled trial that focuses on determining the optimal time after stroke for intensive motor training (). To contribute to the delineation of a temporal structure of stroke recovery in humans, we performed an analysis of individual patient clinical data from 219 subjects with upper-limb hemiparesis, who followed occupational therapy (OT) or a virtual reality (VR)-based training protocol using the Rehabilitation Gaming System (RGS) () (Fig. S1 in Supplemental Material; all Supplemental material is available at https://doi.org/10.5281/zenodo.3246368). We show that physical therapy has a significant impact on the function of the upper extremity (UE) at all periods poststroke considered, uncovering a gradient of responsiveness to treatment that extends >12 mo poststroke.[…]

Continue —->  Nervous System Pathophysiology: A critical time window for recovery extends beyond one-year post-stroke

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[ARTICLE] Immersive Virtual Reality in Stroke Patients as a New Approach for Reducing Postural Disabilities and Falls Risk: A Case Series – Full Text HTML

Graphical abstract

Abstract

Stroke is a neurologic disorder considered the first cause of disability worldwide due to motor, cognitive, and sensorial sequels. Balance dysfunctions in stroke survivors increase the risk of falls and physiotherapeutic rehabilitation is essential to reduce it. Virtual reality (VR) seems to be an alternative to conventional physiotherapy (CT), providing virtual environments and multisensorial inputs to train balance in stroke patients. The aim of this study was to assess if immersive VR treatment is more effective than CT to improve balance after stroke. This study got the approval from the Ethics Committee of the University of Almeria. Three chronic ischemic stroke patients were selected. One patient who received 25 sessions of immersive VR intervention for two months was compared with another patient who received equivalent CT and a third patient with no intervention. Balance, gait, risk of falling, and vestibular and visual implications in the equilibrium were assessed. After the interventions, the two patients receiving any of the treatments showed an improvement in balance compared to the untreated patient. In comparison to CT, our results suggest a higher effect of immersive VR in the improvement of balance and a reduction of falls risk due to the active upright work during the VR intervention.

1. Introduction

Stroke is considered the first cause of disability [1] and the third cause of death in westernized countries after cardiovascular diseases and cancer [2]. Stroke is a central nervous system disorder produced by a local interruption of the cerebral blood flow due to the occlusion (ischemic stroke) or rupture (hemorrhagic stroke) of a cerebral blood vessel [3]. As result of brain cortex injury, afferent and efferent neural pathways are affected, and motor, sensitive and cognitive functions become impaired. Motor and cognitive impairments observed in post-stroke patients reduce their functional capacity, their personal autonomy [4], and social abilities, which results in intensive care and rehabilitation needs with the subsequent economic burden to society and families [5].
Postural instability or poor balance is a relevant central vestibular symptom in neurologic disorders, such as stroke [6], in which approximately 83% of stroke survivors show balance impairments [7]. Proprioceptive visual and vestibular inputs to the central nervous system are essential to guarantee the upright position [8]. Thus, errors in the central integration of this postural information can induce gait difficulties with the subsequent increase in risk of falls [9]. In addition, stroke survivors show a number of neurological issues like visual neglect, sensory loss, reduced muscle strength and spasticity, which also increase the risk of fall 1.5–2 times more in post-stroke patients than older adults without brain damage [10]. This results in fractures, tissue injuries, immobility, and psychological fear of falling as additional consequences of falls in stroke patients [11]. Besides, large hospitalization periods due to injury falls are devastating for patient recovery [12].
The use of virtual reality (VR) has been booming during the last decade, becoming a potential tool in the field of stroke rehabilitation [13]. Virtual reality technology works by displaying a set of digital images that allow the user interacts with a virtual environment or situation that is perceived equivalent to the real physical world [14]. VR has been used in neurorehabilitation in order to encourage a higher number of exercise repetitions and their intensity, and enhances motor learning thanks to the quick feedback possibilities and the multisensorial stimulation [15]. This promotes neuronal plasticity, which would the responsible of VR-induced benefits in stroke rehabilitation [16]. Recent studies have shown that immersive VR protocols in a sitting position and Wii exergames (non-immersive VR) improve motor function, balance, and gait in stroke patients in comparison with conventional therapy (CT) [17]. However, other studies report no statistical differences when comparing immersive or non-immersive VR in a sitting position with CT [18,19]. Moreover, several studies suggest that a neurorehabilitation program combining VR and CT produces a greater improvement than each treatment separately [20].
Nevertheless, the majority of published works have used non-immersive VR therapies, such as Wii exergames for balance training [21,22]. Recently, improved versions of immersive VR have become available for clinical and research purposes in physical rehabilitation. Thus, immersive VR, thanks to the use of headsets that display 3D digital images that simulate any scenario with high realism, has the capability to make individuals feel as if they’re inside the virtual environment. Moreover, the use of hand-held controllers allows users to interact with virtual elements using their hands as they do real life, allowing exercise repetition, intensity variation, and task-oriented training. Thus, immersive VR postulates as a promising tool for the rehabilitation of motivated stroke patients. The aim of this study is to assess if an experimental protocol based on immersive VR therapy is valid for stroke rehabilitation and produces positive effects in balance and falls risk in comparisons to a CT protocol. For such a reason, two intervention protocols (immersive VR or CT) in comparison with the absence of treatment were tested in three patients diagnosed with ischemic stroke[…]

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[Abstract] The Use of Virtual Reality Applications in Stroke Rehabilitation for Older Adults : Technology Enhanced Relearning

Abstract

After stroke rehabilitation is a long-term relearning process that can be divided into cognitive relearning, speech relearning and motoric relearning. Today with an aging population it it interesting to look at technology enhanced and game-based solutions that can facilitate independent living for older adults. The aim of the study was to identify and categorise recently conducted research in the field of virtual reality applications for older adults’ relearning after stroke. This study was conducted as a systematic literature review with results categorised in a pre-defined framework. Findings indicate that virtual reality-based stroke rehabilitation is an emerging field that can renew after stroke rehabilitation. Most found studies were on stroke patients’ motoric and game-based relearning, and with less studies on speech rehabilitation. The conclusion is that virtual reality systems should not replace the existing stroke rehabilitation, but rather to have the idea of combining and extending the traditional relearning process where human-to-human interaction is essential. Finally, there are no virtual reality applications that can fit all stroke patients’ needs, but a thoughtful selection of exercises that matches each individual user would have a potential to enhance the current relearning therapy for older adults after stroke.

via The Use of Virtual Reality Applications in Stroke Rehabilitation for Older Adults : Technology Enhanced Relearning

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[Abstract] Examining the effect of virtual reality therapy on cognition post-stroke: a systematic review and meta-analysis

Introduction: Virtual reality (VR) are user-computer interface platforms that implement real-time simulation of an activity or environment, allowing user interaction via multiple sensory modalities. VR therapy may be an effective intervention for improving cognitive function following stroke. The aim of this systematic review was to examine the effectiveness of exercise-based VR therapy on cognition post-stroke.

Methods: Electronic databases were searched for terms related to “stroke”, “virtual reality”, “exercise” and “cognition”. Studies were included if they: (1) were randomized-controlled trials; (2) included VR-based interventions; (3) included individuals with stroke; and (4) included outcome measures related to cognitive function. Data from included studies were synthesised qualitatively and where possible, random effects meta-analyses were performed.

Results: Eight studies involving 196 participants were included in the review, of which five were included in meta-analyses (n = 124 participants). Studies varied in terms of type (combination of VR therapy and conventional therapy, combination of VR therapy and computer-based cognitive training, VR therapy alone) and duration of interventions (20–180 min), sample size (n = 12–42), length of the interventions (4–8 weeks), and cognitive outcomes examined. VR therapy was not more effective than control for improving global cognition (n = 5, SMD = 0.24, 95%CI:−0.30,0.78, p = .38), memory (n = 2 studies, SMD= 0.00, 95%CI: −0.58, 0.59, p = .99), attention (n = 2 studies, MD = 8.90, 95%CI: −27.89, 45.70, p = .64) or language (n = 2 studies, SMD = 0.56, 95%CI: −0.08,1.21, p = .09).

Conclusion: VR therapy was not superior to control interventions in improving cognition in individuals with stroke. Future research should include high-quality and adequately powered trials examining the impact of virtual reality therapy on cognition post-stroke.

Implications for rehabilitation

  • Virtual reality therapy is a promising new form of technology that has been shown to increase patient satisfaction towards stroke rehabilitation.

  • Virtual reality therapy has the added benefits of providing instant feedback, and the difficulty can be easily modified, underscoring the user-friendliness of this form of rehabilitation.

  • Virtual reality therapy has the potential to improve various motor, cognitive and physical deficits following stroke, highlighting its usefulness in rehabilitation settings.

via Examining the effect of virtual reality therapy on cognition post-stroke: a systematic review and meta-analysis: Disability and Rehabilitation: Assistive Technology: Vol 0, No 0

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