Posts Tagged Arm weakness
Telerehabilitation was not inferior to in-clinic rehabilitation therapy in helping to improve arm function after stroke but could substantially increase access to therapy for those who are unable to access a rehabilitation clinic, researchers opine.
“Few patients fully recover from arm weakness after a stroke. The remainder demonstrate persistent arm impairments that are directly linked to activity limitations, participation restrictions, reduced quality of life, and decreased well-being,” Steven C. Cramer, MD, from the department of neurology at the University of California, Irvine, and colleagues write, in a study published in JAMA Neurology.
“Some rehabilitation therapies can improve these deficits, with higher doses associated with better outcomes. However, many patients do not receive high doses of rehabilitation therapy, for reasons that include cost, difficulty traveling to the location where therapy is provided, shortage of regional rehabilitation care, and poor adherence with assignments,” they continue, in a media release from Healio.
Cramer and colleagues conducted a randomized, assessor-blinded, noninferiority clinical trial to compare telerehabilitation and in-clinic rehabilitation therapy outcomes for patients who had a stroke that resulted in arm motor deficit.
Patients were enrolled in the study at 4 to 36 weeks after experiencing an ischemic stroke or intracerebral hemorrhage that resulted in arm weakness. After enrollment, participants were randomly assigned to receive intensive arm motor therapy in a rehabilitation clinic or in their home using telerehabilitation delivery services with a computer connected to the internet. Scores on the Fugl-Myer arm motor scale were measured at the baseline and after treatment to determine changes in arm motor function.
All patients received 36 treatment sessions (70 minutes) in a 6- to 8-week period, which included 18 supervised and 18 unsupervised sessions. The content of therapy was carefully matched, with each group using the same exercises and standard exercise equipment.
A total of 124 participants were included in the study. Participants had a mean age of 61 years, a mean baseline Fugl-Meyer score of 43 points and were enrolled for a mean 18.7 weeks following stroke, the release explains.
Patients in the in-clinic group were adherent to 33.6 of 36 therapy sessions (93.3%), and those who received telerehabilitation at home were adherent to 35.4 of 36 therapy sessions (98.3%).
Both groups experienced significant changes in Fugl-Meyer scores from the baseline period to 30 days after treatment, with a mean change of 8.36 points in patients who received in-clinic therapy and 7.86 points in those who received telerehabilitation therapy.
The noninferiority margin was 2.47 and fell outside the 95% confidence interval, suggesting that telerehabilitation was not inferior to in-clinic therapy.
“Our study found that a 6-week course of daily home-based [telerehabilitation] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic,” Cramer and colleagues conclude, in the release.
[Source: Healio Primary Care]
Balloon Buddies is a video game designed by researchers at Imperial College London to help stroke patients and others with musculoskeletal injuries, arthritis, or cerebral palsy to play with healthy cohorts as a form of rehabilitation.
The point of the game is to balance a ball on a beam, which is lifted at each of its ends by balloons controlled by the players. Points are awarded according to how well the players vary the height of the beam so that the ball collides with moving targets. Players are also required to work together to keep the beam horizontal so that the ball doesn’t roll off the platform.
The game, which uses animation, sounds, and vibration-feedback, is played using a wireless handgrip called a GripAble, which is engineered to enable people with arm weakness to control video games on any standard tablet device.
According to the researchers, in a news story from Imperial College London, Balloon Buddies is designed to level the playing field by allowing healthy participants to support the less abled player. This type of collaboration makes it more rewarding for the less-abled partner, more challenging for the better partner, and overall more fun for both, as they have to continuously work together to score points.
“Video games are a great way of providing repetitive exercise to help patients recover from debilitating illnesses. However, most games are designed for users to play on their own, which can actually discourage and isolate many patients,” says Dr Michael Mace, lead author of a study about the game, published in the Journal of NeuroEngineering and Rehabilitation.
“We developed the Balloon Buddy game to enable patients to train with their friends, family or caregivers in a collaborative and playful manner. The technology is still being developed, but we have shown that playing jointly with another individual may lead to increased engagement and better outcomes for patients,” adds Mace, from the Department of Bioengineering at Imperial College London, in the news story.
In their study, the research team tested the game using 16 patients with arm weakness following a stroke, teamed with a healthy volunteer, over a 3-month period, at Charing Cross Hospital, which is part of Imperial College Healthcare NHS Trust. They previously tested the game using 16 pairs of healthy participants with different baseline abilities.
The team will now carry out a larger study to examine whether the game leads to more efficient learning, and to examine if patients are more motivated to train for longer periods. They will also explore social implications of interaction such as the effect of patients playing with a relative versus a stranger, as stated in the news story.
[Source: Imperial College London]
The gripAble device, developed by researchers from Imperial College London, is a lightweight electronic handgrip that interacts wirelessly with a standard PC tablet to enable users to play arm-training games.
To use the device, patients squeeze, turn, or lift the handgrip, and it vibrates in response to the patients’ performance. A mechanism within the device can detect even tiny flicker movements from severely paralyzed patients and channel them into controlling a computer game.
A study published recently in PLoS ONE notes that, according to the researchers, use of the gripAble device among stroke patients with arm paralysis may help increase the patients’ ability to direct movements on a tablet screen, compared to standard methods such as swiping or tapping, by up to 50%, according to a news release from Imperial College London.
Additionally, they note in the release, the device enabled more than half of the severely disabled patients in the study to engage with arm-training software, whereas none of the patients were able to use conventional control methods such as swiping and tapping on tablets and smartphones.
In the study, carried out at Charing Cross Hospital, part of Imperial College Healthcare Trust, between 2014 and 2015, the device was tested among stroke patients with arm paralysis. The researchers assessed the patients’ ability to use gripAble to control mobile gaming devices such as tablets, and compared this to their use of conventional methods such as swiping and tapping.
According to their examination, 93% of the patients were able to make meaningful movements to direct the cursor as a result of using gripAble. In contrast, 67% of patients were able to use mobile gaming devices by swiping on a tablet. For other types of control over the tablet, such as tapping or using joysticks, the number of patients able to make meaningful movements was lower, the release continues.
The success of the device was most apparent for patients with severe arm weakness, the researchers note: no patients in this group were able to use conventional controls to play training games, whereas 58% could use gripAble.
“We have developed the gripAble device to improve arm and cognitive function of patients who have mild to severe arm weaknesses. Unlike other therapies currently on the NHS, gripAble is a low-cost device, which can be used in hospitals and independently by patients at home. As such it could potentially help save the health service millions of pounds,” says lead researcher Dr Paul Bentley, a clinical senior lecturer at Imperial College London and Honorary Consultant Neurologist at Imperial College Healthcare NHS Trust, in the release.
“We now intend to further develop the device so we can help more patients who are currently suffering from the effects of poor arm and upper body mobility,” he adds.
[Source(s): Imperial College London, Science Daily]
The Upper Limb and Stroke
Arm weakness is common after stroke and its treatment is recognised as an area of considerable need.1 Approximately 85% of patients with stroke present with arm weakness2 and 60% of stroke survivors with poorly functioning arms at one week do not recover meaningful function by six months.3 Arm weakness is a major factor contributing to disability following stroke.4Current treatment for arm weakness typically comprises intensive, task-specific and repetitive rehabilitative interventions or occasionally methods such as constraint induced movement therapy and robotic therapy.5 A recent meta-analysis and large-scale trials show the effects of current treatments for arm weakness to be modest.6,7 Improvement in arm function should improve quality of life for stroke survivors, reduce co-morbidities associated with loss of independence, and reduce cost to the health care system.8
Neuroplasticity and Recovery
Neuroplasticity is the brain’s ability to form new neural pathways in response to injury or disease. It has been a target for the treatment of many neurological disorders including epilepsy and tinnitus. Recent studies have suggested that augmentation of neuroplasticity is required to more fully recover motor function.9 Novel techniques that drive the growth of new neural pathways related to motor function are needed; vagus nerve stimulation (VNS) may achieve this.
Vagus Nerve Stimulation
VNS is the delivery of small electrical impulses to the vagus nerve (Figure 1). VNS activates neurons in the basal forebrain and locus coeruleus and results in the release of acetylcholine and norepinephrine. These neurotransmitters are known to facilitate the reorganisation of cortical networks.10 VNS is already used to treat patients with medically refractory epilepsy, with studies showing a reduction in seizure frequency of 50% in 24.5 to 46.6% of patients.11,12,13 In excess of 75,000 patients with refractory epilepsy have been implanted with VNS devices.14 The concept of using VNS to restore normal neuronal activity / drive neuroplasticity is under investigation in other chronic neurological conditions.
In noise induced tinnitus, cochlear trauma can lead to a disorganised auditory cortex resulting in chronic symptoms.15,16,17 The severity of tinnitus is related to the degree of map re-organisation in the auditory cortex.15,16,17 In pre-clinical studies, pairing auditory tones with brief pulses of VNS has been shown to cause re-organisation of auditory cortex maps specific to that tone.18 Further, noise-exposed rats were noted to have a significant reduction in startle response, presumably due to tinnitus, and pairing VNS with multiple tones reversed this effect.18 Thus, VNS paired with a specific stimulus may drive neuroplasticity specifically for that stimulus, thereby restoring auditory cortex architecture and reducing tinnitus. Studies suggest that VNS may help humans with tinnitus.19 Ten patients known to have unilateral or bilateral tinnitus for over a year received four weeks of VNS paired with auditory tone therapy (using MicroTransponder Inc’s Serenity© system). Subjective and objective primary outcome measures were identified in the form of the Tinnitus Handicap Inventory (THI) and the Minimum Masking Level (MML). In patients who had not been taking drugs which could interfere with VNS (muscarinic antagonists, noradrenergic reuptake inhibitors and γ-amino butyric acid agonists), a significant fall in THI of 28.17% was seen following VNS paired with auditory tones.19 Three out of five such patients had a clinically meaningful decrease in THI (44.3% decrease).19 Similar results were seen in the MML test which detects the lowest level of noise required to “drown out” the tinnitus. Results of a recently completed and larger, double blind and randomised study of VNS paired with auditory tones in tinnitus are eagerly awaited. Another study looked at the use of transcutaneous vagus nerve (t-VNS) stimulation in tinnitus. When used in combination with sound therapy t-VNS was found to modulate auditory cortical activation, resulting in reduced tinnitus and tinnitus associated distress.20