Posts Tagged Activities of daily living

[ARTICLE] Virtual Reality for Stroke Rehabilitation – Full Text

The use of virtual reality programs specifically designed for stroke rehabilitation is increasing as is the use of commercial video game devices in clinical settings. This review is an update of our review published first in 2011 and then in 2015.1

Objectives

The primary objective of this review was to examine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity. Our secondary objective was to examine the efficacy on gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

Methods

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and 7 additional databases as well as trials registries. We included randomized and quasi-randomized trials of virtual reality in adults after stroke. The primary outcome of interest was upper limb function and activity. Two review authors independently selected trials, extracted data, and assessed risk of bias with input from a third author to moderate disagreements when required.

Main Results

A total of 72 trials (with 2470 participants) were included in the review. This review includes 35 new studies in addition to the studies included in the previous version of this review (published in 2015). Most studies involved small sample sizes and interventions varied in terms of both the goals of treatment and the virtual reality program or device used. Although there are a relatively large number of randomized controlled trials, the evidence remains mostly low quality when rated using the GRADE system because of the risk of bias in the studies and inconsistent findings between studies. Control groups in the included studies usually received either no therapy or conventional therapy which was provided by an occupational therapist or physiotherapist. Primary outcome: when virtual reality was compared with the same dose of conventional therapy the results were not statistically significant for upper limb function (standardized mean difference, 0.07; 95% confidence interval, −0.05–0.20; 22 studies, 1038 participants, low-quality evidence). However, when virtual reality was used to supplement usual care (thereby providing participants in the intervention group with a higher dose of therapy), there was a statistically significant difference between groups (standardized mean difference, 0.49; 95% confidence interval, 0.21–0.77, 10 studies, 210 participants, low-quality evidence). Secondary outcomes: when compared with conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living outcome (standardized mean difference, 0.25; 95% confidence interval, 0.06–0.43; 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. There were few adverse events experienced in the 23 studies which reported on this and adverse events were relatively mild. There was a trend suggesting that customized virtual reality programs were preferable to commercial game products, however, these findings were not statistically significant (Figure).

Figure.

Figure. Virtual reality versus conventional therapy: upper limb function: subgroup analyses, specialized, or gaming program. CI indicates confidence interval.

Implications for Practice

We found that virtual reality therapy may not be more effective than conventional therapy for upper limb outcomes, but there is low-quality evidence that virtual reality may be used to improve outcomes in the absence of other therapy interventions after stroke. Clinicians who currently have access to virtual reality programs should be reassured that their use as part of a comprehensive rehabilitation program seems reasonable, taking into account the patient’s goals, abilities, and preferences.

Sources of Funding

Dr Laver is supported by a National Health and Medical Research Council-Australian Research Council fellowship. Dr Saposnik is supported by the 2017 to 2021 Heart and Stroke Foundation of Canada Career Award following an open and peer-reviewed competition. He also served as the Topic Editor for the Emerging Therapies Section (Stroke Journal).

Disclosures

None.

Footnotes

  • This paper is based on a Cochrane Review published in The Cochrane Library 2017, Issue 11 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review.

  • Received December 13, 2017.
  • Revision received December 13, 2017.
  • Accepted December 21, 2017.

Reference

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via Virtual Reality for Stroke Rehabilitation | Stroke

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[Abstract] Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and sub-acute conditions: an updated systematic review and meta-analysis

Abstract

Objective

To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, are safe and cost effective for patients with acute or sub-acute conditions.

Data sources

Electronic database (AMED, CINAHL, EMBASE, MEDLINE, PEDro, PubMed) searches were updated from 2010 through June 2017.

Study selection

Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay or cost effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.

Data extraction

Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale and The Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach was applied to each meta-analysis.

Data synthesis

Post intervention data were pooled with an inverse variance, random effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate quality evidence that additional physical therapy services reduced length of stay by 3 days in sub-acute settings (MD-2.8, 95%CI -4.6 to -0.9, I20%) and low quality evidence that it reduced length of stay by 0.6 days in acute settings (MD -0.6, 95%CI -1.1 to 0.0, I2 65%). Additional physical therapy led to small improvements in self-care (SMD 0.11, 95%CI 0.03 to 0.19, I2 0%), activities of daily living (SMD 0.13, 95%CI 0.02 to 0.25, I2 15%) and health-related quality of life (SMD 0.12, 95%CI 0.03 to 0.21, I2 0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in sub-acute rehabilitation.

Conclusions

Additional physical therapy services improve patient activity and participation outcomes, while reducing hospital length of stay for adults. These benefits are likely safe and there is preliminary evidence to suggest they may be cost effective.

via Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and sub-acute conditions: an updated systematic review and meta-analysis – Archives of Physical Medicine and Rehabilitation

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[Review] Evolution of Cognitive Rehabilitation After Stroke From Traditional Techniques to Smart and Personalized Home-Based Information and Communication Technology Systems: Literature Review – Full Text

ABSTRACT

Background: Neurological patients after stroke usually present cognitive deficits that cause dependencies in their daily living. These deficits mainly affect the performance of some of their daily activities. For that reason, stroke patients need long-term processes for their cognitive rehabilitation. Considering that classical techniques are focused on acting as guides and are dependent on help from therapists, significant efforts are being made to improve current methodologies and to use eHealth and Web-based architectures to implement information and communication technology (ICT) systems that achieve reliable, personalized, and home-based platforms to increase efficiency and level of attractiveness for patients and carers.

Objective: The goal of this work was to provide an overview of the practices implemented for the assessment of stroke patients and cognitive rehabilitation. This study puts together traditional methods and the most recent personalized platforms based on ICT technologies and Internet of Things.

Methods: A literature review has been distributed to a multidisciplinary team of researchers from engineering, psychology, and sport science fields. The systematic review has been focused on published scientific research, other European projects, and the most current innovative large-scale initiatives in the area. A total of 3469 results were retrieved from Web of Science, 284 studies from Journal of Medical Internet Research, and 15 European research projects from Community Research and Development Information Service from the last 15 years were reviewed for classification and selection regarding their relevance.

Results: A total of 7 relevant studies on the screening of stroke patients have been presented with 6 additional methods for the analysis of kinematics and 9 studies on the execution of goal-oriented activities. Meanwhile, the classical methods to provide cognitive rehabilitation have been classified in the 5 main techniques implemented. Finally, the review has been finalized with the selection of 8 different ICT–based approaches found in scientific-technical studies, 9 European projects funded by the European Commission that offer eHealth architectures, and other large-scale activities such as smart houses and the initiative City4Age.

Conclusions: Stroke is one of the main causes that most negatively affect countries in the socioeconomic aspect. The design of new ICT-based systems should provide 4 main features for an efficient and personalized cognitive rehabilitation: support in the execution of complex daily tasks, automatic error detection, home-based performance, and accessibility. Only 33% of the European projects presented fulfilled those requirements at the same time. For this reason, current and future large-scale initiatives focused on eHealth and smart environments should try to solve this situation by providing more complete and sophisticated platforms.[…]

Continue —> JRAT-Evolution of Cognitive Rehabilitation After Stroke From Traditional Techniques to Smart and Personalized Home-Based Information and Communication Technology Systems: Literature Review | Cogollor | JMIR Rehabilitation and Assistive Technologies

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[ARTICLE] Design and Preliminary Feasibility Study of a Soft Robotic Glove for Hand Function Assistance in Stroke Survivors – Full Text

Various robotic exoskeletons have been proposed for hand function assistance during activities of daily living (ADL) of stroke survivors. However, traditional exoskeletons involve the use of complex rigid systems that impede the natural movement of joints, and thus reduce the wearability and cause discomfort to the user. The objective of this paper is to design and evaluate a soft robotic glove that is able to provide hand function assistance using fabric-reinforced soft pneumatic actuators. These actuators are made of silicone rubber which has an elastic modulus similar to human tissues. Thus, they are intrinsically soft and compliant. Upon air pressurization, they are able to support finger range of motion (ROM) and generate the desired actuation of the finger joints. In this work, the soft actuators were characterized in terms of their blocked tip force, normal and frictional grip force outputs. Combining the soft actuators and flexible textile materials, a soft robotic glove was developed for grasping assistance during ADL for stroke survivors. The glove was evaluated on five healthy participants for its assisted ROM and grip strength. Pilot test was performed in two stroke survivors to evaluate the efficacy of the glove in assisting functional grasping activities. Our results demonstrated that the actuators designed in this study could generate desired force output at a low air pressure. The glove had a high kinematic transparency and did not affect the active ROM of the finger joints when it was being worn by the participants. With the assistance of the glove, the participants were able to perform grasping actions with sufficient assisted ROM and grip strength, without any voluntary effort. Additionally, pilot test on stroke survivors demonstrated that the patient’s grasping performance improved with the presence and assistance of the glove. Patient feedback questionnaires also showed high level of patient satisfaction and comfort. In conclusion, this paper has demonstrated the possibility of using soft wearable exoskeletons that are more wearable, lightweight, and suitable to be used on a daily basis for hand function assistance of stroke survivors during activities of daily living.

Introduction

The ability to perform basic activities of daily living (ADL) impacts a person’s quality of life and independence (Katz, 1983Andersen et al., 2004). However, an individual’s independence to perform ADLs is jeopardized due to hand motor impairments, which can be observed in patients with neurological disorders such as stroke. In order to improve hand motor functions in terms of strength and range of motion (ROM) (Kutner et al., 2010), stroke survivors undergo rehabilitation programs comprising repetitive practice of simulated ADL tasks (Michaelsen et al., 2006). Normally, patients undergo rehabilitation exercises in a specialized rehabilitation center under the guidance of physiotherapists or occupational therapists. However, due to increasing patient population, it is foreseen that there will be a shortage of physiotherapists to assist in the rehabilitative process. Thus, there will be comparatively less therapy time, which will eventually lead to a slower recovery process for the patients. Over the past decade, technological developments in robotics have facilitated the rehabilitative process and have shown potential to assist patients in their daily life (Maciejasz et al., 2014). One example of such a device is the hand exoskeleton, which is secured around the hand to guide and assist the movement of the encompassed joints. However, due to the complexity of the hand, designing a hand exoskeleton remains a challenging task.

Traditional hand exoskeletons involve the use of rigid linkage-based mechanisms. In this kind of mechanism, rigid components, such as linear actuators, rotary motors, racks, and pinions as well as rigid linkages are normally involved (Worsnopp et al., 2007Rotella et al., 2009Martinez et al., 2010). To assist hand movements that have high degrees of freedom (DOFs), traditional exoskeletons can be incorporated with a substantial number of actuators to achieve the requirement. However, this means that their application is limited due to the increasing bulkiness for higher DOFs. Therefore, these devices are normally restricted in clinical settings and not suitable for performing home therapy. Additionally, their rigidity, weight and constraint on the non-actuated DOFs of the joints pose complications. As a result, the level of comfort and safety of patients is reduced. In view of this, there is an apparent need for the development of exoskeletons that may be used in both clinical and home settings. A lightweight and wearable exoskeleton may allow patients to bring back home to continue daily therapy or to serve as an assistive device for the ADLs.

The development of wearable robotic exoskeletons serves to provide an alternative approach toward addressing this need. Instead of using rigid linkage as an interface between the hand and the actuators, wearable exoskeletons typically utilize flexible materials such as fabric (Sasaki et al., 2004Yap et al., 2016a) and polymer (Kang et al., 2016), driven by compliant actuators such as cables (Sangwook et al., 2014Xiloyannis et al., 2016) and soft inflatable actuators (Polygerinos et al., 2015dYap et al., 2016c). Therefore, they are more compliant and lightweight compared to the rigid linkage-based mechanism. Cable-driven based exoskeletons involve the use of cables that are connected to actuators in the form of electrical motors situated away from the hand (Nilsson et al., 2012Ying and Agrawal, 2012Sangwook et al., 2014Varalta et al., 2014). By providing actuations on both dorsal and palmar sides of the hand, bi-directional cable-driven movements are possible (Kang et al., 2016). These cables mimic the capability of the tendons of the human hand and they are able to transmit the required pulling force to induce finger flexion and extension. However, the friction of the cable, derailment of the tendon, and inaccurate routing of the cable due to different hand dimensions can affect the efficiency of force transmission in the system.

On the other hand, examples of the soft inflatable actuators are McKibben type muscles (Feifei et al., 2006Tadano et al., 2010), sheet-like rubber muscles (Sasaki et al., 2004Kadowaki et al., 2011), and soft elastomeric actuators (Polygerinos et al., 2015b,cYap et al., 2015); amongst which, soft elastomeric actuators have drawn increasing research interest due to their high compliance (Martinez et al., 2013). This approach typically embeds pneumatic chamber networks in elastomeric constructs to achieve different desired motions with pressurized air or water (Martinez et al., 2012). Soft elastomeric actuators are highly customizable. They are able to achieve multiple DOFs and complex motions with a single input, such as fluid pressurization. The design of a wearable hand exoskeleton that utilizes soft elastomeric actuators is usually simple and does not require precise routing for actuation, compared to the cable-driven mechanism. Thus, the design reduces the possibility of misalignment and the setup time. These properties allow the development of hand exoskeletons that are more compliant and wearable, with the ability to provide safe human-robot interaction. Additionally, several studies have demonstrated that compactness and ease of use of an assistive device critically affect its user acceptance (Scherer et al., 20052007). Thus, these exoskeletons provide a greater chance of user acceptance.

Table 1 summarizes the-state-of-art of soft robotic assistive glove driven by inflatable actuators. Several pioneer studies on inflatable assistive glove have been conducted by Sasaki et al. (2004)Kadowaki et al. (2011) and Polygerinos et al. (2015a,b,c). Sasaki et al. have developed a pneumatically actuated power assist glove that utilizes sheet-like curved rubber muscle for hand grasping applications. Polygerinos et al. have designed a hydraulically actuated grip glove that utilizes fiber-reinforced elastomeric actuators that can be mechanically programmed to generate complex motion paths similar to the kinematics of the human finger and thumb. Fiber reinforcement has been proved to be an effective method to constrain the undesired radial expansion of the actuators that does not contribute to effective motion during pressurization. However, this method limits the bending capability of the actuators (Figure S1); as a result, higher pressure is needed to achieve desired bending.

Table 1. Hand assistive exoskeletons driven by inflatable actuators.

This paper presents the design and preliminary feasibility study of a soft robotic glove that utilizes fabric-reinforced soft pneumatic actuators. The intended use of the device is to support the functional tasks during ADLs, such as grasping, for stroke survivors. The objectives of this study were to characterize the soft actuators in terms of their force output and to evaluate the performance of the glove with healthy participants and stroke survivors. The glove was evaluated on five healthy participants in order to determine the ROM of individual finger joints and grip strength achieved with the assistance of the glove. Pilot testing with two stroke survivors was conducted to evaluate the feasibility of the glove in providing grasping assistance for ADL tasks. We hypothesized that with the assistance of the glove, the grasping performance of stroke patients improved.

Specific contributions of this work are listed as follows:

(a) Presented fabric-reinforcement as an alternative method to reinforce soft actuators, which enhanced the bending capability and reduced the required operating pressure of the actuators,

(b) Utilized the inherence compliance of soft actuators and allowed the actuators to achieve multiple motions to support ROM of the human fingers,

(c) Integrated elastic fabric with soft actuators to enhance the extension force for finger extension,

(d) Designed and characterized a soft robotic glove using fabric-reinforced soft actuators with the combination of textile materials, and

(e) Conducted pilot tests with stroke survivors to evaluate the feasibility of the glove in providing functional assistance for ADL tasks.

Design Requirements and Rationale

The design requirements of the glove presented in this paper are similar to those presented by Polygerinos et al. (2015a,b,c) in terms of design considerations, force requirements, and control requirements. For design considerations, weight is the most important design criterion when designing a hand exoskeleton. Previous studies have identified the threshold for acceptable weight of device on the hand, which is in the range of 400–500 g (Aubin et al., 2013Gasser and Goldfarb, 2015). Cable-driven, hydraulic, and pneumatic driven mechanisms are found to be suitable options to meet the criteria. To develop a fully portable system for practical use in home setting, reduction in the weight of the glove as well as the control system is required. The total weight of the control system should not exceed 3 kg (Polygerinos et al., 2015a,b,c). In this work, the criteria for the weight of the glove and control system are defined as: (a) the weight of the glove should be <200 g, and (b) the weight of the control system should be <1.5 kg.

Considering the weight requirement, hydraulic systems are not ideal for this application, as the requirement of a water reservoir for hydraulic control systems and actuation of the actuators with pressurized water will add extra weight to the hand. The second consideration is that the hand exoskeleton should allow fast setup time. Therefore, it is preferable for the hand exoskeleton to fit the hand anatomy rapidly without precise joint alignment. Compared to cable-driven mechanisms, soft pneumatic actuators are found to be more suitable as they allow rapid customization to different finger length. Additionally, they do not require precise joint alignment and cable routing for actuation as the attachment of the soft pneumatic actuators on the glove is usually simple. Therefore, in this work, pneumatic mechanisms were selected. Using pneumatic mechanism, Connelly et al. and Thielbar et al. have developed a pneumatically actuated glove, PneuGlove that is able to provide active extension assistance to each finger while allowing the wearer to flex the finger voluntarily (Connelly et al., 2010Thielbar et al., 2014). The device consists of five air bladders on the palmar side of the glove. Inflation of the air bladders due to air pressurization created an extension force that extends the fingers. However, due to the placement of the air bladders on the palmar side, grasping activities such as palmar and pincer grasps were more difficult. Additionally, this device is limited to stroke survivors who are able to flex their fingers voluntarily.

In this work, the soft robotic glove is designed to provide functional grasping assistance for stroke survivors with muscle weakness and impairments in grasping by promoting finger flexion. While the stroke survivors still preserve the ability to modulate grip force within their limited force range, the grip release (i.e., hand opening) is normally prolonged (Lindberg et al., 2012). Therefore, the glove should assist with grip release by allowing passive finger extension via reinforced elastic components, similar to Saeboflex (Farrell et al., 2007) and HandSOME (Brokaw et al., 2011). The elastic components of these devices pull the fingers to the open hand state due to increased tension during finger flexion. Additionally, the glove should generate the grasping force required to manipulate and counteract the weight of the objects of daily living, which are typically below 1.07 kg (Smaby et al., 2004). Additionally, the actuators in the glove should be controlled individually in order to achieve different grasping configurations required in simulated ADL tasks, such as palmar grasp, pincer grasp, and tripod pinch. For the speed of actuation, the glove should reach full grasping motion in <4 s during simulated ADL tasks and rehabilitation training.

For the actuators, we have recently developed a new type of soft fabric-reinforced pneumatic actuator with a corrugated top fabric layer (Yap et al., 2016a) that could minimize the excessive budging and provide better bending capability compared to fiber-reinforced soft actuators developed in previous studies (Polygerinos et al., 2015c,d). This corrugated top fabric layer allows a small initial radial expansion to initiate bending and then constrains further undesired radial expansion (Figure 1). The detailed comparison of the fiber-reinforced actuators and fabric-reinforced actuators can be found in the Supplementary Material.

 

 

Figure 1. (A) A fabric-reinforced soft actuators with a corrugated fabric layer and an elastic fabric later [Actuator thickness, T= 12 mm, and length, L = 160 mm (Thumb), 170 mm (Little Finger), 180 mm (Index & Ring Fingers), 185 mm (Middle Finger)]. (B) Upon air pressurization, the corrugated fabric layer unfolds and expands due to the inflation of the embedded pneumatic chamber. Radial budging is constrained when the corrugated fabric layer unfolds fully. The elastic fabric elongates during air pressurization and stores elastic energy. The actuator achieves bending and extending motions at the same time. (C) A bending motion is preferred at the finger joints (II, IV, VI). An extending motion is preferred over the bending motion at the finger segments (I, III, V) and the opisthenar (VII).

Continue —>  Frontiers | Design and Preliminary Feasibility Study of a Soft Robotic Glove for Hand Function Assistance in Stroke Survivors | Neuroscience

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[ARTICLE] Effectiveness of a multimodal exercise rehabilitation program on walking capacity and functionality after a stroke – Full Text

Abstract

The aim of this study was to determine the effectiveness of a 12-week multimodal exercise rehabilitation program on walking speed, walking ability and activities of daily living (ADLs) among people who had suffered a stroke. Thirty-one stroke survivors who had completed a conventional rehabilitation program voluntarily participated in the study. Twenty-six participants completed the multimodal exercise rehabilitation program (2 days/wk, 1 hr/session). Physical outcome measures were: walking speed (10-m walking test), walking ability (6-min walking test and functional ambulation classification) and ADLs (Barthel Index). The program consisted on: aerobic exercise; task oriented exercises; balance and postural tonic activities; and stretching. Participants also followed a program of progressive ambulation at home. They were evaluated at baseline, postintervention and at the end of a 6-month follow-up period. After the intervention there were significant improvements in all outcomes measures that were maintained 6 months later. Comfortable and fast walking speed increased an average of 0.16 and 0.40 m/sec, respectively. The walking distance in the 6-min walking test increased an average of 59.8 m. At the end of the intervention, participants had achieved independent ambulation both indoors and outdoors. In ADLs, 40% were independent at baseline vs. 64% at the end of the intervention. Our study demonstrates that a multimodal exercise rehabilitation program adapted to stroke survivors has benefits on walking speed, walking ability and independence in ADLs.
Keywords: Exercise, Physical activity, Stroke rehabilitation, Walking speed, Activities of daily living

INTRODUCTION

As life expectancy increases, a larger number of persons may suffer from stroke. Stroke mortality rates have decreased, but the burden of stroke is increasing in terms of stroke survivors per year, correlated deaths and disability-adjusted life-years lost. These deficiencies are further highlighted by a trend towards more strokes in younger people (Feigin et al., 2014). Stroke not only causes permanent neurological deficits, but also a profound degradation of physical condition, which worsens disability and increases cardiovascular risk. Stroke survivors are likely to suffer functional decline due to reduction of aerobic capacity. This may involve further secondary complications such as progressive muscular atrophy, osteoporosis, peripheral circulation worsening and increased cardiovascular risk (Ivey et al., 2006). All these factors cause increased dependency, need of assistance from third parties in activities of daily living (ADLs) and a restriction on participation that can have a profound psychosocial impact (Carod-Artal and Egido, 2009). Gait capacity is one of the main priorities of persons who have suffered a stroke, but is often limited due to the high energy demands of hemiplegic gait and the poor physical condition of these persons (Ivey et al., 2006). Gait speed is a commonly used measure in patients who have suffered a stroke to differentiate the functional capacity to walk indoors or outdoors. Gait speed has been classified as: allowing indoor ambulation (<0.4 m/sec), limited outdoor ambulation (0.4–0.8 m/sec), and outdoor functional ambulation (>0.8 m/sec) (Perry et al., 1995). Gait speed can also help to establish the functional prognosis of the patient. It has been stated that improvements in walking speed correlate with improved function and quality of life (QoL) (Schmid et al., 2007). It is essential to achieve a proper gait speed for outdoors functional ambulation.
Falls are common among stroke survivors and are associated with a worsening of disability and QoL. Balance is a complex process that involves the reception and integration of afferent inputs and the planning and execution of movement. Stroke can impact on different systems involved in postural control. Multifactorial falls risk assessment and management, combined with fitness programs, are effective in reducing risk of falls and fear of falling (Stroke Foundation of New Zealand and New Zealand Guidelines Group, 2010). Falls often occur when getting in and out of a chair (Brunt et al., 2002). The 2013 Cochrane review (Saunders et al., 2013) recommends the repetitive practice of sit-to-stand in order to promote an ergonomic and automatic pattern of this movement. Recent studies demonstrate that exercises that improve trunk stability and balance provide a solid base for body and leg movements that entail an improved gait in people affected by stroke (Sharma and Kaur, 2017). Conventional rehabilitation programs after stroke focus on the subacute period. The aim is to recover basic ADLs, but they do not provide maintenance exercises to provide long-term health gains. Cardiac monitoring demonstrates that conventional physiotherapy exercises do not regularly provide adequate exercise intensity to modify the physical deconditioning, nor sufficient exercise repetition to improve motor learning (Ivey et al., 2006). Therapeutic physical exercise to optimize function, physical condition and cardiovascular health after a stroke is an emerging field within neurorehabilitation (Teasell et al., 2009). The wide range of difficulties experienced by stroke survivors justify the need to explore rehabilitation programs designed to promote an overall improvement and to maintain the gains obtained after rehabilitation programs. Numerous studies have demonstrated the efficacy of aerobic exercise (Saunders et al., 2016), but there are few data on the long term effects of multimodal programs that incorporate aerobic exercise, complemented by task-oriented training and balance exercises. Consequently, the aim of this study is to analyse the impact of a multimodal exercise rehabilitation program tailored to stroke survivors on walking speed, walking ability and ADLs. […]

Continue —> Effectiveness of a multimodal exercise rehabilitation program on walking capacity and functionality after a stroke

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[ARTICLE] The Efficacy of the proprioceptive neuromuscular facilitation (PNF) approach in stroke rehabilitation to improve basic activities of daily living and quality of life: a systematic review and meta-analysis protocol – Full Text

Abstract

Introduction Proprioceptive neuromuscular facilitation (PNF) is a widely used rehabilitation concept, although its efficacy has not yet been demonstrated in stroke survivors. The aim of this systematic review is to identify, assess and synthesise the potential benefits of using PNF to improve the activities of daily living (ADL) and quality of life (QoL) of individuals with stroke.

Methods and analysis A systematic electronic search will be conducted in MEDLINE, Embase, CENTRAL and PEDro. We will include randomised or quasi-randomised controlled trials of PNF interventions conducted in stroke survivors up to April 2017. Two review authors will independently select relevant studies and will extract data using the Cochrane handbook for systematic reviews of interventions approach and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The methodological quality will be assessed by using the PEDro scale. Finally, with the permitted numeric data, we will carry out a meta-analysis.

Ethics and dissemination Ethical considerations will not be required. Results will be disseminated in a peer-review journal. This systematic review aims to examine the effects of PNF (neurophysiological approach) in order to clarify its efficacy in improving ADL and QoL in the rehabilitation process of stroke survivors.

 

Strengths and limitations of this study

  • To our knowledge this study is the first systematic review focused on the proprioceptive neuromuscular facilitation (PNF) approach for stroke survivors.

  • This systematic review has an open eligibility criteria to clarify the efficacy of the PNF method for different clinical situations in stroke patients.

  • The electronic search will only include randomised controlled and quasi-randomised controlled trials published in English, Spanish, French and Portuguese that could limit the inclusion of studies.

 

Introduction

Every year, stroke survivors, related deaths, and disability-adjusted life-years are increasing, although the mortality rates for stroke have decreased in the last two decades.1 Motor and sensory impairments due to stroke often affect the patients’ mobility, limiting their activities of daily living (ADL) and their social participation, and hindering their chances of resuming their professional life. Motor function among other factors (such as social or personal factors) could contribute to a low overall quality of life (QoL).2

Throughout the years, a number of conceptualisations have been used to describe QoL in stroke survivors.3–5 The lack of an agreed definition on QoL means that most QoL outcomes have been assessed using standardised questionnaires. However, these questionnaires do not reveal important domains of patients’ QoL and sometimes scores may be difficult to interpret.5

Dijkers4 separated the QoL term into three categories: (1) QoL as subjective well-being (SWB); (2) QoL as achievement; and (3) QoL as utility. QoL as SWB has been defined as the sum total of the cognitive and emotional reactions that people experience when they compare what they have and do in life with their aspirations, needs, and other expectations. QoL as achievement refers to people’s possessions, relationships and accomplishments, among others, using metrics defined by an outsider’s point of view. Within the medical rehabilitation field, QoL measurements commonly involve health status or are qualified by the term “health-related”. Health-related QoL (HRQoL) is defined by the value assigned to the duration of life when modified by impairment, functional state, perception and social factors that are influenced by disease, injury, treatment or policy.6 According to Dijkers4some researchers base themselves on the WHO’s encompassing definition of health, and may add to this different social health indicators such as interactions with others and social role functioning. Finally, in QoL as utility, achievements and statuses are judged in terms of societal norms and standards that quantify the value of a life.

An optimal rehabilitation effectively addresses components, as coded by the International Classification of Functioning (ICF), such as impairment, activity limitations and participation restrictions, and contextual and personal factors, with the goal of a satisfactory QoL as perceived by the individual. The relationship between the three domains of the ICF is clear: impairments impact activities and activities have an impact on participation. Functionality and ADL take a specific role in influencing QoL in stroke survivors positively. During the recovery process and according to the degree of disability, it is important to impact on those variables at any time throughout the rehabilitation treatment, taking into account that they are variables that change over time.7 Much of the focus of stroke rehabilitation is on the recovery of impaired movement and the associated functions. According to Jørgensen8there seems to be a correlation between motor impairments and activity limitations; for example, lower-limb strength (impairment) has been correlated with independence in walking (activity level). In order to improve the neuromuscular system’s effectiveness in coordinating movement and function, there are different physical rehabilitation approaches used for enhancing recovery in post stroke patients, but neither method was more (or less) effective in terms of improving independence in ADL or motor function.9Proprioceptive neuromuscular facilitation (PNF) is widely used in rehabilitation practice.10

The PNF approach has existed since the late 1930s and ’40s when the physician and neurologist Herman Kabat, and the physiotherapist Margaret Knott, began using proprioceptive techniques on younger individuals with cerebral palsy and other neurological conditions. The main goal of this intervention method is to help patients achieve their highest function level. PNF uses the body’s proprioceptive system to facilitate or inhibit muscle contraction. The definition of PNF encompasses the terms proprioceptive (which has to do with any of the sensory receptors that provide information concerning movement and position of the body); neuromuscular (involving the nerves and muscles); and facilitation (making it easier).11

Recently, various systematic reviews 12–17 and an evidence-based clinical practice guideline18 have evaluated the efficacy of stroke rehabilitation interventions, including PNF techniques. However, none were specifically focused on PNF, and only one narrative review assessed PNF as the principal topic.10 Furthermore, the most frequent objectives to assess the efficacy of this intervention method were motor function and mobility. It is necessary that therapists base their clinical decisions on the most reliable scientific evidence available; hence, this systematic review aims to determine the efficacy of PNF techniques in improving ADL and QoL in stroke survivors.

Objectives

The primary purpose of this systematic review is to examine the efficacy of PNF in improving ADL and QoL in individuals with stroke. Secondary specific aims are to determine the efficacy of the PNF techniques in postural control, gait, upper limb function and muscle strength.[…]

 

Continue —> The Efficacy of the proprioceptive neuromuscular facilitation (PNF) approach in stroke rehabilitation to improve basic activities of daily living and quality of life: a systematic review and meta-analysis protocol | BMJ Open

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[ARTICLE] Design and Preliminary Feasibility Study of a Soft Robotic Glove for Hand Function Assistance in Stroke Survivors – Full Text

Various robotic exoskeletons have been proposed for hand function assistance during activities of daily living (ADL) of stroke survivors. However, traditional exoskeletons involve the use of complex rigid systems that impede the natural movement of joints, and thus reduce the wearability and cause discomfort to the user. The objective of this paper is to design and evaluate a soft robotic glove that is able to provide hand function assistance using fabric-reinforced soft pneumatic actuators. These actuators are made of silicone rubber which has an elastic modulus similar to human tissues. Thus, they are intrinsically soft and compliant. Upon air pressurization, they are able to support finger range of motion (ROM) and generate the desired actuation of the finger joints. In this work, the soft actuators were characterized in terms of their blocked tip force, normal and frictional grip force outputs. Combining the soft actuators and flexible textile materials, a soft robotic glove was developed for grasping assistance during ADL for stroke survivors. The glove was evaluated on five healthy participants for its assisted ROM and grip strength. Pilot test was performed in two stroke survivors to evaluate the efficacy of the glove in assisting functional grasping activities. Our results demonstrated that the actuators designed in this study could generate desired force output at a low air pressure. The glove had a high kinematic transparency and did not affect the active ROM of the finger joints when it was being worn by the participants. With the assistance of the glove, the participants were able to perform grasping actions with sufficient assisted ROM and grip strength, without any voluntary effort. Additionally, pilot test on stroke survivors demonstrated that the patient’s grasping performance improved with the presence and assistance of the glove. Patient feedback questionnaires also showed high level of patient satisfaction and comfort. In conclusion, this paper has demonstrated the possibility of using soft wearable exoskeletons that are more wearable, lightweight, and suitable to be used on a daily basis for hand function assistance of stroke survivors during activities of daily living.

Introduction

The ability to perform basic activities of daily living (ADL) impacts a person’s quality of life and independence (Katz, 1983Andersen et al., 2004). However, an individual’s independence to perform ADLs is jeopardized due to hand motor impairments, which can be observed in patients with neurological disorders such as stroke. In order to improve hand motor functions in terms of strength and range of motion (ROM) (Kutner et al., 2010), stroke survivors undergo rehabilitation programs comprising repetitive practice of simulated ADL tasks (Michaelsen et al., 2006). Normally, patients undergo rehabilitation exercises in a specialized rehabilitation center under the guidance of physiotherapists or occupational therapists. However, due to increasing patient population, it is foreseen that there will be a shortage of physiotherapists to assist in the rehabilitative process. Thus, there will be comparatively less therapy time, which will eventually lead to a slower recovery process for the patients. Over the past decade, technological developments in robotics have facilitated the rehabilitative process and have shown potential to assist patients in their daily life (Maciejasz et al., 2014). One example of such a device is the hand exoskeleton, which is secured around the hand to guide and assist the movement of the encompassed joints. However, due to the complexity of the hand, designing a hand exoskeleton remains a challenging task.

Traditional hand exoskeletons involve the use of rigid linkage-based mechanisms. In this kind of mechanism, rigid components, such as linear actuators, rotary motors, racks, and pinions as well as rigid linkages are normally involved (Worsnopp et al., 2007Rotella et al., 2009Martinez et al., 2010). To assist hand movements that have high degrees of freedom (DOFs), traditional exoskeletons can be incorporated with a substantial number of actuators to achieve the requirement. However, this means that their application is limited due to the increasing bulkiness for higher DOFs. Therefore, these devices are normally restricted in clinical settings and not suitable for performing home therapy. Additionally, their rigidity, weight and constraint on the non-actuated DOFs of the joints pose complications. As a result, the level of comfort and safety of patients is reduced. In view of this, there is an apparent need for the development of exoskeletons that may be used in both clinical and home settings. A lightweight and wearable exoskeleton may allow patients to bring back home to continue daily therapy or to serve as an assistive device for the ADLs.

The development of wearable robotic exoskeletons serves to provide an alternative approach toward addressing this need. Instead of using rigid linkage as an interface between the hand and the actuators, wearable exoskeletons typically utilize flexible materials such as fabric (Sasaki et al., 2004Yap et al., 2016a) and polymer (Kang et al., 2016), driven by compliant actuators such as cables (Sangwook et al., 2014Xiloyannis et al., 2016) and soft inflatable actuators (Polygerinos et al., 2015dYap et al., 2016c). Therefore, they are more compliant and lightweight compared to the rigid linkage-based mechanism. Cable-driven based exoskeletons involve the use of cables that are connected to actuators in the form of electrical motors situated away from the hand (Nilsson et al., 2012Ying and Agrawal, 2012Sangwook et al., 2014Varalta et al., 2014). By providing actuations on both dorsal and palmar sides of the hand, bi-directional cable-driven movements are possible (Kang et al., 2016). These cables mimic the capability of the tendons of the human hand and they are able to transmit the required pulling force to induce finger flexion and extension. However, the friction of the cable, derailment of the tendon, and inaccurate routing of the cable due to different hand dimensions can affect the efficiency of force transmission in the system.

On the other hand, examples of the soft inflatable actuators are McKibben type muscles (Feifei et al., 2006Tadano et al., 2010), sheet-like rubber muscles (Sasaki et al., 2004Kadowaki et al., 2011), and soft elastomeric actuators (Polygerinos et al., 2015b,cYap et al., 2015); amongst which, soft elastomeric actuators have drawn increasing research interest due to their high compliance (Martinez et al., 2013). This approach typically embeds pneumatic chamber networks in elastomeric constructs to achieve different desired motions with pressurized air or water (Martinez et al., 2012). Soft elastomeric actuators are highly customizable. They are able to achieve multiple DOFs and complex motions with a single input, such as fluid pressurization. The design of a wearable hand exoskeleton that utilizes soft elastomeric actuators is usually simple and does not require precise routing for actuation, compared to the cable-driven mechanism. Thus, the design reduces the possibility of misalignment and the setup time. These properties allow the development of hand exoskeletons that are more compliant and wearable, with the ability to provide safe human-robot interaction. Additionally, several studies have demonstrated that compactness and ease of use of an assistive device critically affect its user acceptance (Scherer et al., 20052007). Thus, these exoskeletons provide a greater chance of user acceptance.

Table 1 summarizes the-state-of-art of soft robotic assistive glove driven by inflatable actuators. Several pioneer studies on inflatable assistive glove have been conducted by Sasaki et al. (2004)Kadowaki et al. (2011) and Polygerinos et al. (2015a,b,c). Sasaki et al. have developed a pneumatically actuated power assist glove that utilizes sheet-like curved rubber muscle for hand grasping applications. Polygerinos et al. have designed a hydraulically actuated grip glove that utilizes fiber-reinforced elastomeric actuators that can be mechanically programmed to generate complex motion paths similar to the kinematics of the human finger and thumb. Fiber reinforcement has been proved to be an effective method to constrain the undesired radial expansion of the actuators that does not contribute to effective motion during pressurization. However, this method limits the bending capability of the actuators (Figure S1); as a result, higher pressure is needed to achieve desired bending.

Table 1. Hand assistive exoskeletons driven by inflatable actuators.

Continue —> Frontiers | Design and Preliminary Feasibility Study of a Soft Robotic Glove for Hand Function Assistance in Stroke Survivors | Neuroscience

Figure 1. (A) A fabric-reinforced soft actuators with a corrugated fabric layer and an elastic fabric later [Actuator thickness, T = 12 mm, and length, L = 160 mm (Thumb), 170 mm (Little Finger), 180 mm (Index & Ring Fingers), 185 mm (Middle Finger)]. (B) Upon air pressurization, the corrugated fabric layer unfolds and expands due to the inflation of the embedded pneumatic chamber. Radial budging is constrained when the corrugated fabric layer unfolds fully. The elastic fabric elongates during air pressurization and stores elastic energy. The actuator achieves bending and extending motions at the same time. (C) A bending motion is preferred at the finger joints (II, IV, VI). An extending motion is preferred over the bending motion at the finger segments (I, III, V) and the opisthenar (VII).

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[ARTICLE] Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials – Full Text

Abstract

Background

Transcranial Direct Current Stimulation (tDCS) is an emerging approach for improving capacity in activities of daily living (ADL) and upper limb function after stroke. However, it remains unclear what type of tDCS stimulation is most effective. Our aim was to give an overview of the evidence network regarding the efficacy and safety of tDCS and to estimate the effectiveness of the different stimulation types.

Methods

We performed a systematic review of randomised trials using network meta-analysis (NMA), searching the following databases until 5 July 2016: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, and four other databases. We included studies with adult people with stroke. We compared any kind of active tDCS (anodal, cathodal, or dual, that is applying anodal and cathodal tDCS concurrently) regarding improvement of our primary outcome of ADL capacity, versus control, after stroke. PROSPERO ID: CRD42016042055.

Results

We included 26 studies with 754 participants. Our NMA showed evidence of an effect of cathodal tDCS in improving our primary outcome, that of ADL capacity (standardized mean difference, SMD = 0.42; 95% CI 0.14 to 0.70). tDCS did not improve our secondary outcome, that of arm function, measured by the Fugl-Meyer upper extremity assessment (FM-UE). There was no difference in safety between tDCS and its control interventions, measured by the number of dropouts and adverse events.

Conclusion

Comparing different forms of tDCS shows that cathodal tDCS is the most promising treatment option to improve ADL capacity in people with stroke.

Background

An emerging approach for enhancing neural plasticity and hence rehabilitation outcomes after stroke is non-invasive brain stimulation (NIBS). Several stimulation procedures are available, such as repetitive transcranial magnetic stimulation (rTMS) [1], transcranial direct current stimulation (tDCS) [234], transcranial alternating current stimulation (tACS) [5], and transcranial pulsed ultrasound (TPU) [6]. In recent years a considerable evidence base for NIBS has emerged, especially for rTMS and tDCS.

tDCS is relatively inexpensive, easy to administer and portable, hence constituting an ideal adjuvant therapy during stroke rehabilitation. It works by applying a weak and constant direct current to the brain and has the ability to either enhance or suppress cortical excitability, with effect lasting up to several hours after the stimulation [789]. Hypothetically, this technique makes tDCS a potentially useful tool to modulate neuronal inhibitory and excitatory networks of the affected and the non-affected hemisphere post stroke to enhance, for example, upper limb motor recovery [1011]. Three different stimulation types can be distinguished.

  • In anodal stimulation, the anodal electrode (+) usually is placed over the lesioned brain area and the reference electrode over the contralateral orbit [12]. This leads to subthreshold depolarization, hence promoting neural excitation [3].

  • In cathodal stimulation, the cathode (−) usually is placed over the non-lesioned brain area and the reference electrode over the contralateral orbit [12], leading to subthreshold polarization and hence inhibiting neural activity [3].

  • Dual tDCS means the simultaneous application of anodal and cathodal stimulation [13].

However, the literature does not provide clear guidelines, not only regarding the tDCS type, but also regarding the electrode configuration [14], the amount of current applied and the duration of tDCS, or the question if tDCS should be applied as a standalone therapy or in combination with other treatments, like robot-assisted therapy [15].

Rationale

There is so far conflicting evidence from systematic reviews of randomised controlled trials on the effectiveness of different tDCS approaches after stroke. For example, over the past two decades more than 30 randomised clinical trials have investigated the effects of different tDCS stimulation techniques for stroke, and there are 55 ongoing trials [16]. However, the resulting network of evidence from randomised controlled trials (RCTs) investigating different types of tDCS (i.e., anodal, cathodal or dual) as well as their comparators like sham tDCS, physical rehabilitation or pharmacological agents has not yet been analyzed in a systematic review so far.

A network meta-analysis (NMA), also known as multiple treatment comparison meta-analysis or mixed treatment comparison analysis, allows for a quantitative synthesis of the evidence network. This is made possible by combining direct evidence from head-to-head comparisons of three or more interventions within randomised trials with indirect evidence across randomised trials on the basis of a common comparator [17181920]. Network meta-analysis has many advantages over traditional pairwise meta-analysis, such as visualizing and facilitating the interpretation of the wider picture of the evidence and improving understanding of the relative merits of these different types of neuromodulation when compared to sham tDCS and/or another comparator such as exercise therapy and/or pharmacological agents [2122]. By borrowing strength from indirect evidence to gain certainty about all treatment comparisons, network meta-analysis allows comparative effects that have not been investigated directly in randomised clinical trials to be estimated and ranked [2223].

Objective

The aim of our systematic review with NMA was to give an overview of the evidence network of randomised controlled trials of tDCS (anodal, cathodal, or dual) for improving capacity in activities of daily living (ADL) and upper limb function after stroke, as well as its safety, and to estimate and rank the relative effectiveness of the different stimulation types, while taking into account potentially important treatment effect modifiers.

Continue —>  Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials | Journal of NeuroEngineering and Rehabilitation | Full Text

 

Fig. 1 Study flow diagram

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[Abstract] Repetitive peripheral magnetic stimulation for activities of daily living and functional ability in people after stroke (Cochrane review) [with consumer summary] – PEDro

BACKGROUND: Repetitive peripheral magnetic stimulation (rPMS) is a form of therapy that creates painless stimulation of deep muscle structures to improve motor function in people with physical impairment from brain or nerve disorders. Use of rPMS for people after stroke has been identified as a feasible approach to improve activities of daily living and functional ability. However, no systematic reviews have assessed the findings of available trials. The effect and safety of this intervention for people after stroke currently remain uncertain.

OBJECTIVES: To assess the effect of rPMS for improving activities of daily living and functional ability in people after stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, issue 8) in the Cochrane Library (August 2016), Medline OVID (November 2016), Embase OVID (August 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in Ebsco (August 2016), PsycINFO OVID (August 2016), the Allied and Complementary Medicine Database (AMED) OVID (August 2016), Occupational Therapy Systematic Evaluation of Evidence (OTseeker) (August 2016), the Physiotherapy Evidence Database (PEDro) (October 2016), and ICHUSHI Web (October 2016). We also searched five ongoing trial registries, screened reference lists, and contacted experts in the field. We placed no restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA: We included randomised controlled trials (RCTs) conducted to assess the therapeutic effect of rPMS for people after stroke. Comparisons eligible for inclusion were (1) active rPMS only compared with ‘sham’ rPMS (a very weak form of stimulation or a sound only); (2) active rPMS only compared with no intervention; (3) active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation; and (4) active rPMS plus rehabilitation compared with rehabilitation only.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. The same review authors assessed methods and risk of bias and extracted data. We contacted trial authors to ask for unpublished information if necessary. We resolved all disagreements through discussion.

MAIN RESULTS: We included three trials (two RCTs and one cross-over trial) involving 121 participants. Blinding of participants and physicians was well reported in all trials, and overall risk of bias was low. We found no clear effect of rPMS on activities of daily living at the end of treatment (mean difference (MD) -3.00, 95% confidence interval (CI) -16.35 to 10.35; low-quality evidence) and at the end of follow-up (MD -2.00, 95% CI -14.86 to 10.86; low-quality evidence). Investigators in one study with 63 participants observed no statistical difference in improvement of upper limb function at the end of treatment (MD 2.00, 95% CI -4.91 to 8.91) and at the end of follow-up (MD 4.00, 95% CI -2.92 to 10.92). One trial with 18 participants showed that rPMS treatment was not associated with improved muscle strength at the end of treatment (MD 3.00, 95% CI -2.44 to 8.44). Another study reported a significant decrease in spasticity of the elbow at the end of follow-up (MD -0.48, 95% CI -0.93 to -0.03). No studies provided information on lower limb function and death. Based on the GRADE approach, we judged the certainty of evidence related to the primary outcome as low owing to the small sample size of one study.

AUTHORS’ CONCLUSIONS: Available trials provided inadequate evidence to permit any conclusions about routine use of rPMS for people after stroke. Additional trials with large sample sizes are needed to determine an appropriate rPMS protocol as well as long-term effects. We identified three ongoing trials and will include these trials in the next review update.

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Source: PEDro – Search Detailed Search Results

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