- Motor imagery (MI) is a beneficial intervention for stroke rehabilitation.
- MI shows superior to routine methods of treatment or training in improving walking and motor function.
- Effects of MI on walking and motor function are not affected by treatment duration.
Posts Tagged Balance
The use of virtual and augmented reality for rehabilitation has become increasingly popular and has received much attention in scientific publications (over 1,000 papers). This white paper aims to summarize the scientific background and efficacy of using virtual and augmented reality for balance and gait training. For many patients with movement disorders, balance and gait training is an important aspect of their rehabilitation process and physical therapy treatment. Indications for such training include, among others, stroke, Parkinson’s disease, multiple sclerosis, cerebral palsy, vestibular disorders, neuromuscular diseases, low back pain, and various orthopedic complaints, such as total hip or knee replacement. Current clinical practice for balance training include exercises, such as standing on one leg, wobble board exercises and standing with eyes closed. Gait is often trained with a treadmill or using an obstacle course. Cognitive elements can be added by asking the patient to simultaneously perform a cognitive task, such as counting down by sevens. Although conventional physical therapy has proven to be effective in improving balance and gait,1,2 there are certain limitations that may compromise treatment effects. Motor learning research has revealed some important concepts to optimize rehabilitation: an external focus of attention, implicit learning, variable practice, training intensity, task specificity, and feedback on performance.3 Complying with these motor learning principles using conventional methods is quite challenging. For example, there are only a limited number of exercises, making it difficult to tailor training intensity and provide sufficient variation. Moreover, performance measures are not available and thus the patient usually receives little or no feedback. Also, increasing task specificity by simulating everyday tasks, such as walking on a crowded street, can be difficult and time consuming. Virtual and augmented reality could provide the tools needed to overcome these challenges in conventional therapy. The difference between virtual and augmented reality is that virtual reality offers a virtual world that is separate from the real world, while augmented reality offers virtual elements as an overlay to the real world (for example virtual stepping stones projected on the floor). In the first part of this paper we will explain the different motor learning principles, and how virtual and augmented reality based exercise could help to incorporate these principles into clinical practice. In the second part we will summarize the scientific evidence regarding the efficacy of virtual reality based balance and gait training for clinical rehabilitation.
[ARTICLE] Effect of upper extremity coordination exercise during standing on the paretic side on balance, gait ability and activities of daily living in persons with stroke – Full Text PDF
Objective: The purpose of this study was to determine the effect of upper extremity coordination exercise (UECE) during standing on the paretic side on balance, gait ability and activities of daily living (ADL) in persons with stroke.
Design: A randomized controlled trial.
Methods: A total of 27 patients with hemiplegic diagnosis after stroke were divided into two groups. Fourteen patients were in the study group and 13 patients were in the control group. The study group received conventional physical therapy and UECE during standing on the paretic side. The control group received conventional physical therapy and simple upper extremity exercise (SUEE). Subjects in both groups were given upper extremity training for 30 minutes per day, five times a week for 4 weeks. Initial evaluation was performed before treatment and reevaluated 4 weeks later to compare the changes of balance, gait ability and ADL (Korean version of modified Barthel index, K-MBI).
Results: Both groups showed a significant effect for balance, gait ability and ADL (p<0.05). In the Independent t-test, between both groups showed a significant effect for balance and gait ability except ADL (p<0.05).
Conclusions: In this paper, we investigated the changes in balance, walking, and ADL through UECE. We found significant changes in the study group and the control group. Results of the present study indicated that UECE during standing on the paretic side for 4 weeks had an effect on balance, gait ability and ADL (K-MBI) in persons with hemiplegia after stroke.
[ARTICLE] Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review – Full Text
Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user’s movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.
A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.
In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.
The review demonstrates that individuals’ movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.
Virtual reality (VR) in neurorehabilitation has emerged as a fairly recent approach that shows great promise to enhance the integration of virtual limbs in one`s body scheme  and motor learning in general . Virtual Rehabilitation is a “group [of] all forms of clinical intervention (physical, occupational, cognitive, or psychological) that are based on, or augmented by, the use of Virtual Reality, augmented reality and computing technology. The term applies equally to interventions done locally, or at a distance (tele-rehabilitation)” . The main objectives of intervention for facilitating motor learning within this definition are to (1) provide repetitive and customized high intensity training, (2) relay back information on patients’ performance via multimodal feedback, and (3) improve motivation [2, 4]. VR therapies or interventions are based on real-time motion tracking and computer graphic technologies displaying the patients’ behaviour during a task in a virtual environment.
The interaction of the user and Virtual environment can be described as a perception and action loop . This motor performance is displayed in the virtual environment and subsequently, the system provides multimodal feedback related to movement execution. Through external (e.g. vision) and internal (proprioception) senses the on-line sensory feedback is integrated into the patient’s mental representation. If necessary, the motor plan is corrected in order to achieve the given goal .
A previous Cochrane Review from Laver, George, Thomas, Deutsch, and Crotty  on Virtual Reality for stroke rehabilitation showed positive effects of VR intervention for motor rehabilitation in people post-stroke. However, grouped analysis from this review on recommendation for VR intervention provides inconclusive evidence. The author further comments that “[…] virtual reality interventions may vary greatly […], it is unclear what characteristics of the intervention are most important” (, p. 14).
Virtual rehabilitation system provides three different types of information to the patient: movement visualisation, performance feedback and context information . During a motor task the patient’s movements are captured and represented in the virtual environment (movement visualisation). According to the task success, information about the accomplished goal or a required movement alteration is transmitted through one or several sensory modalities (performance feedback). Finally, these two VR features are embedded in a virtual world (context information) that can vary from a very realistic to an abstract, unrealistic or reduced, technical environment.
Performance feedback often relies on theories of motor learning and is probably the most studied information type within VR-based motor rehabilitation. Moreover, context information is primarily not designed with a therapeutic purpose. Movement observation, however, plays an important role for central sensory stimulation therapies, such as mirror therapy or mental training. The observation or imagination of body movements facilitates motor recovery [7, 8, 9] and provides new possibilities for cortical reorganization and enhancement of functional mobility. Thus, it appears that movement visualisation may also play an important role in motor rehabilitation [10, 11, 12], although this aspect is yet to be systematically investigated .
The main goal of the present review is to identify various movement visualisation groups in VR-based motor interventions for lower extremities, by means of a systematic literature search. Secondarily, the included studies are further analysed for their effect on motor learning. This will help guide future research in rehabilitation using VR.
An interim analysis of the review published in 2013 showed six MV groups for upper and lower extremity training and additional two MV groups directed only towards lower extremity training. In this paper, we analysed only studies involving lower limb training, leading to a revision and expansion of the previously published MV groups findings [13, 14, 15].
[Abstract] Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: a randomized controlled study
- •The effect of sit-to-stand training combined with TENS was evaluated in stroke patients with spastic plantar flexor.
- •TENS followed by sit-to-stand training may improve spasticity, muscle strength and balance.
- •Clinician should consider TENS application prior to sit to stand training for stroke patients with spastic plantar flexor.
Sit-to-stand is a fundamental movement of human being for performing mobility and independent activity. However, Stroke people symptoms experience difficulty in conducting the sit-to-stand due to paralysis and especially ankle spasticity. Recently, transcutaneous electrical- stimulation (TENS) is used to reduce pain but also to manage spasticity.
The purpose of this study was to determine
- whether TENS would lead to ankle spasticity reduction and (
- whether sit-to-stand training combined with TENS would improve spasticity, muscle strength and balance ability in stroke patients.
Forty-stroke patients were recruited and were randomly divided into two groups: TENS group (n = 20) and sham group (n = 20). All participants underwent 30-sessions of sit-to-stand training (for 15-minutes, five-times per week for 6-weeks). Prior to each training session, 30-minutes of TENS over the peroneal nerve was given in TENS group, whereas sham group received non-electrically stimulated TENS for the same amount of time. Composite-Spasticity-Score was used to assess spasticity level of ankle plantar-flexors. Isometric strength in the extensor of hip, knee and ankle were measured by handhelddynamometer. Postural-sway distance was measured using a force platform.
The spasticity score in the TENS group (2.6 ± 0.8) improved significantly greater than the sham group (0.7 ± 0.8, p < 0.05). The muscle strength of hip extensor in the TENS group (2.7 ± 1.1 kg) was significantly higher than the sham group (1.0 ± 0.8 kg, p < 0.05). Significant improvement in postural-sway was observed in the TENS group compared to the sham group (p < 0.05).
Thus, sit-to-stand training combined with TENS may be used to improve the spasticity, balance function and muscle strength in stroke patients.
Source: Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: a randomized controlled study – Gait & Posture
[ARTICLE] Effects of Virtual Reality Exercise Program on Balance, Emotion and Quality of Life in Patients with Cognitive Decline
[Abstract] Effect of elastic bandage on postural control in subjects with chronic ankle instability: a randomised clinical trial
Purpose: To report the immediate and prolonged (one week) effects of elastic bandage (EB) on balance control in subjects with chronic ankle instability.
Material and methods: Twenty-eight individuals successfully completed the study protocol, of whom 14 were randomly assigned to the EB group (7 men, 7 women) and 14 were assigned to the non-standardised tape (NST) group (9 men, 5 women). To objectively measure postural sway we used computerised dynamic posturography (CDP) with sensory organisation test (SOT) and unilateral stance (US) test. We analysed the following SOT parameters: the composite SOT score, the composite SOT strategy and the SOT condition 2 and its strategy. In addition, we studied the centre of gravity (COG) sway velocity with open eyes and close eyes during the US test.
Results: Repeated measures ANOVA showed a significant effect for time in composite SOT score (F= 34.98; p= <0.01), composite SOT strategy (F= 12.082; p= 0.02), and COG sway with open eyes (F= 3.382; p= 0.039) in EB group and NST group. Therefore, there were improvements in balance control after bandage applications (defined as better scores in SOT parameters and decreased COG sway in US test). However, no differences between groups were observed in the most relevant parameters.
Conclusions: This study did not observe differences between EB and NST during the follow-up in the majority of measurements. Several outcome measures for SOT and US tests improved in both groups immediately after bandage applications and after one week of use. EB of the ankle joint has no advantage as compared to the non-standardised tape.
Implications for rehabilitation
- Elastic bandage (EB) of the ankle joint has no advantage as compared to the non-standardised tape.
- The effects of the bandages could be due to a greater subjective sense of security.
- It is important to be prudent with the use of bandage, since a greater sense of safety could also bring with it a greater risk of injury.
- The application of the bandage on subjects with chronic ankle instability (CAI) should be prolonged and used alongside other physiotherapy treatments.
[commentary] Gait and balance training using virtual reality is more effective for improving gait and balance ability after stroke than conventional training without virtual reality.
Virtual reality technology, consisting of computer simulations to artificially generate sensory information in the form of a virtual environment that is interactive and perceived as similar to the real world, is recognised as a novel intervention tool in stroke rehabilitation. This timely systematic review addressed the effectiveness of virtual reality training on gait and balance using commonly assessed clinical outcome measures. The meta-analyses conducted on these outcomes all favoured virtual reality training when the time-dose was matched between balance and gait training, with and without virtual reality. Virtual reality-based rehabilitation should thus be considered to be more than an adjunct to conventional gait training, which is recommended by a recent update on stroke rehabilitation best practice.1
While virtual reality offers the opportunity to create unique and customisable interventions that are unavailable or readily accomplished in the real world, its clinical implementation may be challenging. Diverse virtual reality tools exist; they range from computer games (eg, Wii, Kinect) to high-end, immersive, and costly systems.2 The realism and ecological validity of a virtual environment could enhance training efficiency in virtual reality-based rehabilitation. A useful framework3 to guide clinical decision-making consists of three essential phases: (1) interaction between the user and the virtual environment, taking into account the personal and environmental characteristics; (2) transfer of skills learned from the virtual environment to the real world; and (3) participation in the real world and its affordances as a result of rehabilitation. The transfer of virtual reality-based gait and balance training to actual community ambulation should thus be considered. It should be assessed with mobility outcomes recorded in the community and during negotiation of actual environmental challenges, such as slopes and obstacles. Outcomes of participation, motivation and adherence to training should also be evaluated.
Provenance: Invited. Not peer-reviewed.
© 2017 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Stroke survival rates have improved a lot over the last few years. Stroke was once the third leading cause of death in the United States, but it fell to fourth place in 2008 and fifth place in 2013. Today, strokes claim an average of 129,000 American lives every year. Reducing stroke deaths in America is a great improvement, but we still have a long way to go in improving the lives of stroke survivors.
Stagnant recovery rates and low quality of life for stroke survivors are unfortunately very common. Just 10% of stroke survivors make a full recovery. Only 25% of all survivors recover with minor impairments. Nearly half of all stroke survivors continue to live with serious impairments requiring special care, and 10% of survivors live in nursing homes, skilled nursing facilities, and other long-term healthcare facilities. It’s easy to see why stroke is the leading cause of long-term disability in the United States. By 2030, it’s estimated that there could be up to 11 million stroke survivors in the country.
Traditionally, stroke rehabilitation in America leaves much to be desired in terms of recovery and quality of life. There is a serious gap between stroke patients being discharged and transitioning to physical recovery programs. In an effort to improve recovery and quality of life, the American Heart Association has urged the healthcare community to prioritize exercise as an essential part of post-stroke care.
Unfortunately, too few healthcare professionals prescribe exercise as a form of therapy for stroke, despite its many benefits for patients. Many stroke survivors are not given the skills, confidence, knowledge, or tools necessary to follow an exercise program. However, that can change.
With the right recovery programs that prioritize exercise for rehabilitation, stroke survivors can “relearn” crucial motors skills to regain a high quality of life. Thanks to a phenomenon known as neuroplasticity, even permanent brain damage doesn’t make disability inevitable.
A stroke causes loss of physical function because it temporarily or permanently damages the parts of the brain responsible for those functions. The same damage is also responsible for behavioral and cognitive changes, which range from memory and vision problems to severe depression and anger. Each of these changes correspond to a specific region of the brain that was damaged due to stroke.
For example, damage in the left hemisphere of your brain will cause weakness and paralysis on the right side of your body. If a stroke damages or kills brain cells in the right hemisphere, you may struggle to understand facial cues or control your behavior. However, brain damage due to stroke is not necessarily permanent.
Published on January 17, 2017
By Jessica Finnegan, PT, MPT, NCS
This is an exciting time in the world of neurologic physical therapy. Rehabilitation technologies are emerging and research is ongoing to determine the efficacy of these products. In the current healthcare environment, rehabilitation stays are becoming shorter and physical therapists (PTs) must find a way to prioritize which interventions will be most beneficial to their patients. This article discusses several rehabilitation technologies with the hope of helping PTs integrate them into their plans of care to improve mobility in patients recovering from stroke and other neurological disorders.
Convenience, Safety, and Early Mobility
Intensive, repetitive mobility-task training is recommended for all patients with impaired gait after stroke.1 In the past, mobilizing a patient with dense hemiparesis may have required two to three skilled therapists. This has obvious implications for staff efficiency and productivity. In addition, musculoskeletal injuries are commonly reported by healthcare providers and are often associated with manual patient handling.2 Workplace injuries can be a threat to the health and careers of PTs and should be avoided. Darragh and colleagues explored physical and occupational therapists’ experience with safe-patient-handling (SPH) equipment, such as ceiling lifts, floor lifts, and more. This equipment is becoming more widely available, allowing early mobilization of patients with fewer skilled staff members present and reduced risk of injury to the therapist. In this study, therapeutic uses of SPH equipment included transfer training, functional ambulation, and bed mobility.
Therapists also reported using SPH devices to address impaired attention, visual perception, and neglect. Overall, therapists who used SPH equipment “experienced increased options in therapy, accomplished more, and mobilized patients earlier in their recovery.” They also remarked that they needed to co-treat or solicit help from other professionals less frequently, which should improve productivity overall.3…