Posts Tagged Arm
[ARTICLE] Does motivation matter in upper-limb rehabilitation after stroke? ArmeoSenso-Reward: study protocol for a randomized controlled trial – Full Text
Fifty percent of all stroke survivors remain with functional impairments of their upper limb. While there is a need to improve the effectiveness of rehabilitative training, so far no new training approach has proven to be clearly superior to conventional therapy. As training with rewarding feedback has been shown to improve motor learning in humans, it is hypothesized that rehabilitative arm training could be enhanced by rewarding feedback. In this paper, we propose a trial protocol investigating rewards in the form of performance feedback and monetary gains as ways to improve effectiveness of rehabilitative training.
This multicentric, assessor-blinded, randomized controlled trial uses the ArmeoSenso virtual reality rehabilitation system to train 74 first-ever stroke patients (< 100 days post stroke) to lift their impaired upper limb against gravity and to improve the workspace of the paretic arm. Three sensors are attached to forearm, upper arm, and trunk to track arm movements in three-dimensional space while controlling for trunk compensation. Whole-arm movements serve as input for a therapy game. The reward group (n = 37) will train with performance feedback and contingent monetary reward. The control group (n = 37) uses the same system but without monetary reward and with reduced performance feedback. Primary outcome is the change in the hand workspace in the transversal plane. Standard clinical assessments are used as secondary outcome measures.
This randomized controlled trial will be the first to directly evaluate the effect of rewarding feedback, including monetary rewards, on the recovery process of the upper limb following stroke. This could pave the way for novel types of interventions with significantly improved treatment benefits, e.g., for conditions that impair reward processing (stroke, Parkinson’s disease).
After stroke, 50% of survivors are left with impairments in arm function [1, 2], which is associated with reduced health-related quality of life . While there is evidence for a positive correlation between therapy dose and functional recovery [4, 5, 6], a higher therapy dose is challenging to implement, as it usually leads to an increase in costs commonly not covered by health insurances. However, when dose is matched, most randomized controlled trials introducing new types of rehabilitative interventions (e.g., robot-assisted therapy ) failed to show a superior effect compared to standard therapy. Thus, the need for improving therapy effectiveness remains. In search for elements of effective therapy, we hypothesize that performance feedback and monetary rewards can improve effectiveness.
It has been shown that reward enhances procedural  and motor-skill learning [9, 10] and has a positive effect on motor adaptation . Rewards mainly improve retention of motor skills and motor adaptations [9, 10, 11]. This effect was not explained by training duration (dose) as rewarded and non-rewarded groups underwent similar training schedules [8, 9, 10, 11]. In a functional magnetic resonance imaging (fMRI) study, Widmer et al. reported that adding monetary rewards after good performance leads to better consolidation and higher ventral striatum activation than knowledge of performance alone . The striatum is a key locus of reward processing , and its activity was shown to be increased by both intrinsic and extrinsic reward . Being a brain structure that receives substantial dopaminergic input from the midbrain, ventral striatal activity can be seen as a surrogate marker for dopaminergic activity in the substantia nigra/ventral tegmental area . In rodents, Hosp et al. found that dopaminergic projections from the midbrain also terminate directly in the primary motor cortex (M1) . Dopamine in M1 is necessary for long-term potentiation of certain cortico-cortical connections and successful motor-skill learning . As mechanisms of motor learning are also thought to play a role in motor recovery , rehabilitative interventions may benefit from neuroplasticity enhanced by reward.
Here, we describe a trial protocol to test the effect of enhanced feedback and reward on arm rehabilitation after stroke at matched training dose (time and intensity). We use the ArmeoSenso, a standardized virtual reality (VR)-based training system  that is delivered in two versions for two different study groups, one version with and one without reward and enhanced performance feedback. […]
Brain Computer Interfaces (BCI), is a modern technology which is currently revolutionizing the field of signal processing. BCI helped in the evolution of a new world where man and computer had never been so close. Advancements in cognitive neuro-sciences facilitated us with better brain imaging techniques and thus interfaces between machines and the human brain became a reality. Electroencephalography (EEG), which is the measurement and recording of electric signals using sensors arrayed across the scalp can be used for applications like prosthetic devices, applications in warfare, gaming, virtual reality and robotics upon signal conditioning and processing.
This paper is entirely based on Brain-Computer Interface with an objective of actuating a robotic arm with the help of device commands derived from EEG signals. This system unlike any other existing technology is purely non-invasive in nature, cost effective and is one of its kinds that can serve various requirements such as prosthesis. This paper suggests a low cost system implementation that can even serve as a reliable substitute for the existing technologies of prosthesis like BIONICS. […]
[ARTICLE] Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial – Full Text
To assess the feasibility of a randomized controlled trial to evaluate music therapy as a home-based intervention for arm hemiparesis in stroke.
A pilot feasibility randomized controlled trial, with cross-over design. Randomization by statistician using computer-generated, random numbers concealed in opaque envelopes.
Eleven people with stroke and arm hemiparesis, 3–60 months post stroke, following discharge from community rehabilitation.
Each participant engaged in therapeutic instrumental music performance in 12 individual clinical contacts, twice weekly for six weeks.
Feasibility was estimated by recruitment from three community stroke teams over a 12-month period, attrition rates, completion of treatment and successful data collection. Structured interviews were conducted pre and post intervention to establish participant tolerance and preference. Action Research Arm Test and Nine-hole Peg Test data were collected at weeks 1, 6, 9, 15 and 18, pre and post intervention by a blinded assessor.
A total of 11 of 14 invited participants were recruited (intervention n = 6, waitlist n = 5). In total, 10 completed treatment and data collection.
It cannot be concluded whether a larger trial would be feasible due to unavailable data regarding a number of eligible patients screened. Adherence to treatment, retention and interview responses might suggest that the intervention was motivating for participants.
A total of 80% of stroke cases result in hemiparesis,1 and half this number experience persistent lack of arm function.2 Effective interventions are lacking, and evidence to support those that are accessible is insufficient.3 A clear need has been identified for long-term support in the community for people with stroke, but services are limited and few studies have examined home-based interventions and provided sufficient detail of the protocols used.4
Music interventions may be beneficial for improving arm function following stroke,5,6 and a strong rhythmic stimulus embedded within music may enhance motor performance more than the use of a rhythmic stimulus alone without music.7 More research is needed to establish the effects of music interventions on arm function, and with the majority of rehabilitation being delivered in patients’ homes it is useful to determine the feasibility of home-based treatment delivery and research. This article reports on the feasibility of conducting a randomized controlled trial where a music intervention, for which there was a clear protocol based on published guidelines,8,9 was delivered in a variety of home environments.
Continue —> Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trialClinical Rehabilitation – Alexander J Street, Wendy L Magee, Andrew Bateman, Michael Parker, Helen Odell-Miller, Jorg Fachner, 2018
[WEB SITE] ‘Motivating alternative’: Virtual reality therapy just as effective as regular therapy after stroke.
“Virtual reality training may be a motivating alternative for people to use as a supplement to their standard therapy after a stroke,” study author Irish Brunner of Aarhus University said.
The study, published in Neurology, involved 120 people with an average age of 62 who had suffered a stroke on average about a month before the study started.
Each participant had a mild to severe muscle weakness about a month before the study started. All participants had mild to severe muscle weakness or impairment in their wrists, hands or upper arms.
They all received four to five hour-long training sessions per week for four weeks. They also had their harm and hand functions tested at the beginning of the study after the training ended and again three months after the study had begun.
Half of the participants had received standard physical and occupational therapy. Meanwhile, the other had virtual reality training that was designed for rehabilitation and could be adapted to the person’s abilities.
Those doing the virtual reality training used a screen and gloves with sensors to play several games that incorporated arm, hand and finger movements.
“Both groups had substantial improvement in their functioning, but there was no difference between the two groups in the results,” Brunner said.
These results suggest that either type of training could be used, depending on what the patient prefers.
Brunner noted that the virtual reality system was not an immersive experience.
“We can only speculate whether using virtual reality goggles or other techniques to create a more immersive experience would increase the effect of the training.”
Virtual reality training was as effective as, but not superior to, conventional therapy for improving arm and hand function after stroke when both were added to standard rehabilitation in the subacute phase of stroke recovery, researchers found.
In the phase III VIRTUES study, conducted at five rehabilitation hospitals in Europe, similar and significant improvements from baseline assessments of arm and hand mobility were seen at the end of the 4-week intervention and at 3-month follow-up, but there was no difference between the two groups in the results for any endpoints (P<0.001), Iris Brunner, PhD, of Aarhus University, Hammel Neurocenter in Denmark, and colleagues reported online in Neurology.
“These results suggest that either type of training could be used, depending on what the patient prefers,” Brunner said in a statement. “Virtual reality training may be a motivating alternative for people to use as a supplement to their standard therapy after a stroke.”
Improvement of upper extremity motor function performance on the Action Research Arm Test (ARAT) was similar with the virtual reality and conventional training after the 4-week intervention and at follow-up. Patients in virtual reality training improved their ARAT scores an average of 12 points (21%) from baseline to the postintervention assessment, and 17 points (30%) at 3-month follow-up, while those receiving conventional training improved 13 points (21%) at those respective assessments.
Likewise, no differences were seen between the virtual reality and conventional training groups in secondary endpoints, including the Box and Blocks Test, Functional Independence Measure, and Patient Global Impression of Change assessment.
The study involved 120 patients (average age 62) enrolled between March 2014 and April 2016 who had mild-to-severe upper extremity impairment in their wrists, hands, or upper arms as a result of suffering a stroke an average of one month before the study started.
For the add-on conventional or virtual reality therapy, participants had four to five hour-long training sessions per week for four weeks: 62 received conventional physical and occupational therapy, and 58 received virtual reality training that involved using a screen and gloves with sensors to play games that could be adapted to the person’s abilities.
Level of impairment had no differential effect on outcomes, which were similar for patients with mild/moderate impairment – defined as the ability to extend the wrist at least 20 degrees and the fingers at least 10 degrees from drop hand position – or severe impairment. On ARAT, improvements at 3-month follow-up in the mild/moderate group were 14 points (25%) with virtual reality (VR) training and 13 points (23%) with conventional therapy, while the severe group improved 23 points (40%) with VR and 23 points (40%) with conventional therapy.
While active training time was considerably increased among severely impaired participants using virtual reality training compared to those using conventional training, this was not reflected in a larger improvement in arm motor function, authors wrote. This reflects a study design limitation, they wrote: The addition of a third arm receiving only standard rehabilitation would have helped identify potential benefits of more intensive training and increased training time, as previously reported.
Danielle Levac, MD, PhD, PT, of Northeastern University in Boston, who was not involved in the study, agreed with Brunner and colleagues that future study should apply outcome measures that differentiate between recovery on an impairment level and compensation, given that training intensity within the first few months of a stroke is crucial for maximally exploiting the window of increased plasticity.
Also, neither patient engagement nor motivation — attributes through which VR systems are thought to increase adherence and potentially enhance motor learning — were “subjectively or objectively measured here, which seriously detracts from the author’s conclusions that VR constitutes ‘motivating’ training,” Levac told MedPage Today.
The numerous small studies that have demonstrated benefits of virtual reality training have used specially engineered rehab-specific systems, whereas a recent larger trial in subacute stroke patients that did not find superiority over conventional training used a commercial gaming system.
“It is the low cost and easy accessibility of off-the-shelf gaming systems that have made them so pervasive and attractive in clinical practice, despite the disadvantages for tailoring to individual patient needs noted by the authors,” Levac said.
Robert Teasell MD, of Western University in London, Ontario, and head of the Stroke Rehabilitation Writing Group for the Canadian Stroke Best Practice Recommendations, told MedPage Today that many small trials of virtual reality training have demonstrated a benefit in stroke patients.
“This study is important because it is comparatively larger, employs a multisite design, and has an active control group which gets an equal amount of ‘conventional’ therapy and not just ‘usual care,'” said Teasell, who was not involved in the study. “It demonstrates effectiveness – although not superiority – of virtual reality as a promising adjunct treatment.”
[ARTICLE] Arm rehabilitation in post stroke subjects: A randomized controlled trial on the efficacy of myoelectrically driven FES applied in a task-oriented approach – Full Text
Motor recovery of persons after stroke may be enhanced by a novel approach where residual muscle activity is facilitated by patient-controlled electrical muscle activation. Myoelectric activity from hemiparetic muscles is then used for continuous control of functional electrical stimulation (MeCFES) of same or synergic muscles to promote restoration of movements during task-oriented therapy (TOT). Use of MeCFES during TOT may help to obtain a larger functional and neurological recovery than otherwise possible.
Eighty two acute and chronic stroke victims were recruited through the collaborating facilities and after signing an informed consent were randomized to receive either the experimental (MeCFES assisted TOT (M-TOT) or conventional rehabilitation care including TOT (C-TOT). Both groups received 45 minutes of rehabilitation over 25 sessions. Outcomes were Action Research Arm Test (ARAT), Upper Extremity Fugl-Meyer Assessment (FMA-UE) scores and Disability of the Arm Shoulder and Hand questionnaire.
Sixty eight subjects completed the protocol (Mean age 66.2, range 36.5–88.7, onset months 12.7, range 0.8–19.1) of which 45 were seen at follow up 5 weeks later. There were significant improvements in both groups on ARAT (median improvement: MeCFES TOT group 3.0; C-TOT group 2.0) and FMA-UE (median improvement: M-TOT 4.5; C-TOT 3.5). Considering subacute subjects (time since stroke < 6 months), there was a trend for a larger proportion of improved patients in the M-TOT group following rehabilitation (57.9%) than in the C-TOT group (33.2%) (difference in proportion improved 24.7%; 95% CI -4.0; 48.6), though the study did not meet the planned sample size.
This is the first large multicentre RCT to compare MeCFES assisted TOT with conventional care TOT for the upper extremity. No adverse events or negative outcomes were encountered, thus we conclude that MeCFES can be a safe adjunct to rehabilitation that could promote recovery of upper limb function in persons after stroke, particularly when applied in the subacute phase.
Stroke is the leading cause of disability in adults in the world and can result in highly complex clinical situations. The insult often involves the sensory-motor system leading to hemiparesis and impairment of the upper limb in over 50% of survivors [1,2]. Although some structural recovery is possible, especially in the first months after stroke, only a small percentage of persons recover pre-morbid movement patterns and functionality .
Limitations in reaching and grasping have an important role in determining the level of independence of the person in their daily activities and the subsequent impact on their quality of life. Tailored goal oriented rehabilitation is therefore an essential factor in reducing impairment and augmenting functionality of a hemiplegic arm. A plurality of interventions may help the subject to restore participation and adapt to the new clinical status including task oriented therapy (TOT) that has been shown to be effective for motor recovery [4,5], as well as constraint induced movement therapy (CIMT) , biofeedback and robot assisted therapy [7–9]. Moreover, electrostimulation has been applied to improve muscle recruitment and aid motor recovery. Since resources and time in rehabilitation are limited it is important to identify and employ effective interventions .
The inability to use the arm in an efficient way may lead to non use of the arm and hand that can lead to changes also at the neural level . It is therefore essential that arm use is facilitated in meaningful activities. Approaches that assist the person during purposeful voluntarily activated movement could be important for inducing neuroplasticity and increasing function. Neuromuscular electrical stimulation (NMES) has been employed in rehabilitation of stroke patients either to generate muscle contraction or be a support during movements; however, with inconsistent results [11–20]. A prerequisite for neuroplasticity through training is the volitional intent and attention of the person and it therefore follows that the user should participate consciously in the rehabilitative intervention [21,22].
Through the use of EMG it is technically possible to register the myoelectric activity from voluntary contraction of a muscle while its motor nerve is being stimulated by electrical impulses . MeCFES is a method where the FES is directly controlled by volitional EMG activity. In contrast to EMG triggered FES, the controlling muscle is continuously controlling the stimulation intensity. Thus the resulting movement and intrinsic multisensory activation is synchronized with the active attention and intention of the subject and the muscle contraction can be gradually modulated by the subject himself facilitating motor learning and recovery of function. This has been demonstrated to be possible in spinal cord injured subjects [24,25] and a pilot study has shown that when the controlling and stimulated muscles are homologous or they are synergistic it may lead to a marked increase in motor function of the hemiparetic forearm of selected stroke patients . Motor learning principles required for CNS-activity-dependent plasticity, in fact, include task-oriented movements, muscle activation driving practice of movement, focused attention, repetition of desired movements, and training specificity [21,22,27]. The use of MeCFES during active challenging goal oriented movements should help the patient and the therapist overcome the effect of learned non use by turning attempts to move the arm into successful movements.
We hypothesize that applying MeCFES in a task oriented paradigm to assist normal arm movements during rehabilitation of the upper limb in persons with stroke will improve the movement quality and success and thus induce recovery at the body functions level (impairment) and the activity level (disability) of the International Classification of Function, Disability and Health (ICF)  superior to that induced by usual care task-oriented rehabilitation.[…]
Playing virtual reality games could be as effective as adding extra physical therapy sessions to a stroke patient’s rehab regimen, according to researchers.
“It is not a question of choosing one thing over the other, rather of having different training alternatives to provide variation,” says Iris Brunner, author of a study, published recently in Neurology, that explored a variety of medical uses for virtual reality.
“Virtual reality cannot replace physical therapy. But it can be experienced as a game, motivating patients to do an extra treatment session,” adds Brunner, associate professor with the University of Aarhus and Hammel Neurocenter, in Denmark.
Brunner and her team’s study included 120 stroke patients with mild to severe hand weakness, all of whom were randomly assigned to add 16 hour-long therapy sessions to their routine rehabilitation over a month. One group performed physical therapy, while the other group played a virtual reality game called YouGrabber, notes a media release from HealthDay.
In the game, Brunner explains, “the patients wear gloves with sensors, and their movements are tracked by an infrared camera and transferred to a virtual arm on screen.”
“In different scenarios, they can grasp objects that come toward them or pick carrots. In other games, patients steer a plane or a car with their movement. The therapist chooses the movements to be trained and the level of difficulty.”
Fifty patients in the physical therapy group and 52 in the virtual reality group completed the study and were evaluated after 3 months.
The researchers found no difference between the two groups with regard to the improvement in their hand and arm function.
“Patients who started out with moderately to mildly impaired arm and hand motor function achieved, on average, a level of good motor function,” Brunner states, while those with severe weakness were able to use their arms to make movements.
Patients with severe hand weakness appreciated how even small movements translated to the virtual arms on screen, she adds. And even the older patients liked the virtual reality game, she notes, possibly because the graphics are simpler than those in commercial video games.
Brunner concludes by noting that larger studies are needed to understand the potential value of virtual reality as a stroke recovery treatment.
Even if you haven’t moved your hand and arm in years due to a neuromuscular injury or disease, it is possible the MyoPro® may be able to help you use your arm and hand again.
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“We have accomplished half of the work, which is creating the engineering systems to test this work and now we have to develop the protocol for using it for rehabilitation to see how well it works,” said Alba Perez-Gracia, ISU chair and associate professor of mechanical engineering, and a lead researcher on the project.
The ISU researchers, who are working on this collaborative project with Texas A&M and California State University, Fullerton, first mapped arm motions and digitalized them and then have created a virtual world where people wearing a portable virtual-reality device can use the system as a therapeutic intervention. The researchers will soon be testing the new tool with human subjects.
Subjects wear a virtual reality headset and use it to complete tasks created for the virtual world. The virtual reality system picks up the actual movements of their own arm and displays it as a cartoon figure within the virtual world. The subject may then participate in the virtual world task that include picking up balls and throwing them at a target or stacking cubes using their right or left hand. In addition, the system has been developed to reflect the image of the arm being used.
For example, if a person is using the right arm to complete the task, the virtual reality system reflects the image so that the cartoon arm actions being portrayed look as if it is the left arm performing the task. This reflected image of arm function has the potential to be used as a therapeutic intervention because previous research has shown that observing an action activates the same area of the brain as performing the action.
“It is called the mirror neuron system,” said Nancy Devine, associate dean of the ISU School of Rehabilitation and Communications Sciences, who is a co-researcher on the project. “When you observe body movements, the cells in the brain that would produce that movement are active even though that arm isn’t being used.”
She said if you just look at brain activity, in some areas of the brain you can’t distinguish an active movement from an observed movement.
“So, if you take someone who has had a stroke and can’t use one arm, you can take their arm that is still working and reflect it to the other arm by putting them in this engaging virtual environment and we can be providing an exercise that is effective in helping rehabilitate the damaged areas,” Devine added.
Although the work on this specific project ends at the end of the academic year, ISU’s work on this type of project may continue.
“We have created the portable virtual-reality device that the patient can wear, which projects the motion happening for the patients,” Perez-Gracia said. “We hope it will be a starting point for future projects on using virtual reality and robotics for helping in rehabilitation and training of human motion.”
This research has been taking place at the ISU Robotics Laboratory and the Bioengineering laboratory at the Engineering Research Complex. On this project, Perez-Gracia and Devine have been working with the third researcher of the team, Marco P. Schoen, professor of mechanical engineering, Omid Heidari, a doctoral student in mechanical engineering, master of science students A.J. Alriyadh, Asib Mahmud, Vahid Pourgharibshahi and John Roylance, and undergraduate students Dillan Hoy, Madhuri Aryal and Merat Rezai. Eydie Kendall, assistant professor of physical and occupational therapy, also collaborated on the project.
“We have very good equipment here that we can do experiments with and that is very appealing,” said Heidari, who said the laboratory has become his second home. “Instead of just writing code on computers and stuff, we are actually doing something here that is very practical and very interesting. We did the motion capture, the kinematic part, and now we are working on finishing the virtual reality part of the project. We are getting closer to having a good model of what we want.”
HOCOMA REVOLUTIONIZING REHABILITATION
Conventional therapy today is limited—by time, by number of repetitions, by
the lack of reproducible movement quality and by the fact that it is strenuous for both therapists and patients. In other words: there is a disbalance between the therapy we know we should provide according to motor learning principles and all the factors that prevent us from reaching this goal.[…]