The objective of this study was to investigate the effectiveness of functional electrical stimulation (FES) applied to the wrist and finger extensors for wrist flexor spasticity in hemiplegic patients.
Background: Developing countries like India are facing a double burden of communicable and non-communicable diseases. Stroke is one of the leading causes of death and disability in India. The estimated adjusted prevalence rate of stroke range, 84-262/100,000 in rural and 334-424/ 100,000 in urban areas. Depression is characterized by persistent feelings of sadness accompanied by feelings of hopelessness, worthlessness and helplessness. Depressed patients can experiences loss of energy or fatigue, inability to concentrate and decreased interest in daily living activity with changes in sleep and weight, and thoughts of death and suicide.
Objectives: To measure the prevalence of depression in chronic stroke patients.
Study design: Observational study
Methods: A total of 85 participants were recruited in this observational study. Each participant was given BDI scale.
Results: About 85 participants, 52.9% were moderately depressed, 18.85% of severely depressed, 16.5 % of mild mood disturbance, and 11.85% of borderline depressed chronic stroke patients.
Conclusion: This study concluded that prevalence of depression ranges from moderate to severe percentage in chronic stroke patients.
Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness.
Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards.
All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x- = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x- = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance.
This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.
Frequent use of improvised explosive devices (IEDs) in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) resulted in traumatic brain injury (TBI) being called the signature injury of recent conflicts.1 According to Department of Defense (DoD) reports, 379,519 service members received a TBI diagnosis from 2000 to 2017.2 Traumatic brain injuries are a subtype of acquired brain injury (ABI), which refers to any post-natal brain injury.3 Acquired brain injuries commonly present with symptoms of cognitive and motor impairment, and emotional instability that may persist for years and affect performance of activities of daily living (ADLs).4,5 Though survival rates of mild TBI (mTBI) are high, the resulting diminished quality of life calls for a greater focus on long-term TBI rehabilitative care.6
Another category of ABI, Cerebral Vascular Accident (CVA), often presents with similar impairments, such as diminished memory, upper extremity weakness and spasms, and depression.7–9 Moreover, those who have experienced a TBI are also at higher risk of CVA than those who have not.10,11 The majority of neurological recovery after TBI and CVA typically occurs within the first 6 months of injury, but training factors such as intensity, repetition, duration, patient motivation, and patient engagement may impact long-term treatment effectiveness on individuals in the chronic phase.12–16
Traditional rehabilitation protocols for individual’s post-ABI, such as proprioceptive neuromuscular facilitation (PNF), are widely recognized but underutilized by therapists.17 Additionally, hands-on interventions, while well known, have limited evidence supporting their success with chronic ABI rehabilitation.18 With technological advancements it may be possible to link the traditional therapies with progressive opportunities, while also increasing patient engagement and decreasing provider burden.
One method of post-ABI rehabilitation with growing clinical acceptance is virtual reality (VR). Virtual reality is defined as a synthetic world that responds in real time to changes in user input, creating a constantly-engaging environment in which users participate.19 Virtual rehabilitation utilizes VR in a variety of clinically relevant domains,20 and offers a unique platform for ABI rehabilitation by engaging patients in appropriately challenging tasks.21 It provides the needed intensity of care, can unify treatment in an integrative rehabilitation, and can involve bimanual interactions engaging both hemispheres.22 A review of studies evaluating improvements in cognitive domains (e.g., executive function) indicates that computer-based cognitive rehabilitation programs which are tailored to the participant’s abilities often produce greater results compared to non-personalized cognitive rehabilitation computer programs.23
The BrightBrainer Virtual Rehabilitation (BBVR) program is a computer-based VR platform that utilizes real-time bimanual interaction for the purpose of increasing cognitive engagement compared to simple mouse, or single finger touch interaction. Bilateral training has been found to promote improved motor functioning for people who have experienced ABI, above and beyond unilateral training.24,25 This system facilitates split attention training (focusing), task sequencing (alternating actions between arms), hand-eye coordination, and dual tasking through use of simultaneous cognitive and motor challenges. Though the BBVR system was originally developed for geriatric patients with CVA, the use of adaptable games, bimanual tasks, and repetition may make it translatable as a tool for ABI treatment in a military population.26
While literature on VR therapy post-ABI is abundant, many of the systems either focus only on rehabilitation of one aspect of post-ABI deficits,27 or are too physically large to implement in most clinics.28 The BBVR system is unique because it combines cognitive and physical training in a compact, adaptive VR system which can be implemented largely unobtrusively into clinical space. This pilot study implemented the BBVR system within a Military Treatment Facility’s (MTF) outpatient occupational therapy clinic as a 6-week intervention for participants with ABI. The primary aim was to evaluate the feasibility of integrating the BBVR system into the clinic for both 1-on-1 provider-participant interaction and concurrent treatment in which 1 provider oversees 2 participants at a time. The 3 secondary aims were: (1) to evaluate the preliminary clinical effectiveness of the BBVR system in terms of motor function, cognitive performance, and behavioral/emotional symptoms; (2) to evaluate the dose-response effect of the BBVR system; and (3) to evaluate the correlation between participant-level BBVR game performance and longitudinal change in clinical outcomes.
BACKGROUND: Lower limb support ability is important for steady and efficient mobility, but previous data commonly involved training during double stance positions, with or without external feedback, using a complex and costly machine.
AIM: To compare the effects of stepping training with or without external feedback in relation to the lower limb support ability of the affected limb on the functional ability necessary for independence in individuals with stroke.
DESIGN: A single-blinded, randomised controlled trial.
SETTING: Tertiary rehabilitation centres.
POPULATION: Ambulatory participants with stroke who walked independently over at least 10 meters with or without walking devices.
METHODS: Thirty-six participants were randomly arranged to be involved in a program of stepping training with or without external feedback related to the lower limb support ability of the affected limb (18 participants/group) for 30 minutes, followed by overground walking training for 10 minutes, 5 days/week over 4 weeks. The outcomes, including the lower limb support ability of the affected legs during stepping, functional ability and spatial walking data, were assessed prior to training, immediately after the first training session, and after 2- and 4- week training.
RESULTS: Participants demonstrated significant improvement in the amount of lower limb support ability, immediately after the first training with external feedback. Then, these participants showed further improvement in both the amount and duration of lower limb support ability, as well as the timed up and go data after 2 and 4 weeks of training (p < 0.05). This improvement was not found following control training.
CONCLUSIONS: The external feedback relating to lower limb support ability during stepping training effectively improved the movement stability and complex motor activity of ambulatory individuals with stroke who had long post-stroke time (approximately 3 years).
CLINICAL REHABILITATION IMPACT: Stepping training protocols and feedback can be easily applied in various settings using the amount of body-weight from an upright digital bathroom scale. Thus, the findings offer an alternative rehabilitation strategy for clinical, community and home-based settings for stroke individuals.
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via Stepping training with external feedback relating to lower limb support ability effectively improved complex motor activity in ambulatory patients with stroke: a randomized controlled trial – European Journal of Physical and Rehabilitation Medicine 2019 Oct 15 – Minerva Medica – Journals
Stroke constitutes a major public health problem affecting millions of people worldwide with considerable impacts on socio-economics and health-related costs. It is the second cause of death (Langhorne et al., 2011), and the third cause of disability-adjusted life-years worldwide (Feigin et al., 2014): ∼8.2 million people were affected by stroke in Europe in 2010, with a total cost of ∼€64 billion per year (Olesen et al., 2012). Due to ageing societies, these numbers might still rise, estimated to increase 1.5–2-fold from 2010 to 2030 (Feigin et al., 2014).
Improving upper limb functioning is a major therapeutic target in stroke rehabilitation (Pollock et al., 2014; Veerbeek et al., 2017) to maximize patients’ functional recovery and reduce long-term disability (Nichols-Larsen et al., 2005; Veerbeek et al., 2011; Pollock et al., 2014). Motor impairment of the upper limb occurs in 73–88% first time stroke survivors and in 55–75% of chronic stroke patients (Lawrence et al., 2001). Constraint-induced movement therapy (CIMT), but also standard occupational practice, virtual reality and brain stimulation-based interventions for sensory and motor impairments show positive rehabilitative effects in mildly and moderately impaired stroke victims (Pollock et al., 2014; Raffin and Hummel, 2018). However, stroke survivors with severe motor deficits are often excluded from these therapeutic approaches as their deficit does not allow easily rehabilitative motor training (e.g. CIMT), treatment effects are negligible and recovery unpredictable (Byblow et al., 2015; Wuwei et al., 2015; Buch et al., 2016; Guggisberg et al., 2017).
Recent neurotechnology-supported interventions offer the opportunity to deliver high-intensity motor training to stroke victims with severe motor impairments (Sivan et al., 2011). Robotics, muscular electrical stimulation, brain stimulation, brain computer/machine interfaces (BCI/BMI) can support upper limb motor restoration including hand and arm movements and induce neuro-plastic changes within the motor network (Mrachacz-Kersting et al., 2016; Biasiucci et al., 2018).
The main hurdle for an improvement of the status quo of stroke rehabilitation is the fragmentary knowledge about the physiological, psychological and social mechanisms, their interplay and how they impact on functional brain reorganization and stroke recovery. Positive stimulating and negatively blocking adaptive brain reorganization factors are insufficiently characterized except from some more or less trivial determinants, such as number and time of treatment sessions, pointing towards the more the better (Kwakkel et al., 1997). Even the long accepted model of detrimental interhemispheric inhibition of the overactive contralesional brain hemisphere on the ipsilesional hemisphere is based on an oversimplification and lack of differential knowledge and is thus called into question (Hummel et al., 2008; Krakauer and Carmichael, 2017; Morishita and Hummel, 2017).
Here, we take a pragmatic approach of comparing effectiveness data, keeping this lack of knowledge of mechanisms in mind and providing novel ideas towards precision medicine-based approaches to individually tailor treatments to the characteristics and needs of the individual patient with severe chronic stroke to maximize rehabilitative outcome.[…]
Objective: The purpose of this study was to evaluate the Role of Practice and Mental Imagery on Hand function improvement in stroke survivors
Method: We conducted systematic review of the previous studies and searched electronic databases for the years 1995 to 2016, studies were selected according to inclusion criteria, and critical appraisal was done for each study and summarized the use of mental practice for the improvement in hand function in stroke survivors.
Results: Studies differed in the various aspects like intervention protocols, outcome measures, design, and patient’s characteristics. The total number of practice hours to see the potential benefits from mental practice varied widely. Results suggest that mental practice has potential to improve the upper extremity function in stroke survivors.
Conclusion: Although the benefits of mental practice to improve upper extremity function looks promising, general guidelines for the clinical use of mental practice is difficult to make. Future research should explore the dosage, factors affecting the use of Mental Practice, effects of Mental Therapy alone without in combination with other interventions.
Up to 85% stroke survivors experience hemi paresis resulting in impaired movement of the arm, and hand as reported by Nakayama et al. Loss of arm function adversely affects quality of life and functional motor recovery in affected upper extremity.
Sensorimotor deficits in the upper limb, such as weakness, decreased speed of movement, decreased angular excursion and impaired temporal coordination of the joints impaired upper-limb and trunk coordination.
Treatment interventions such as materials-based occupations constraint-induced movement therapy modified constraint-induced movement therapy and task-related or task-specific training are common training methods for remediating impairments and restoring function in the upper limb.
For the improvement of upper and lower functions, physical therapy provides training for functional improvement and fine motor. For most patients such rehabilitation training has many constraints of time, place and expense, accordingly in recent studies, clinical methods such as mental practice for improvement of the upper and lower functions have been suggested.
Mental practice is a training method during which a person cognitively rehearses a physical skill using motor imagery in the absence of overt, physical movements for the purpose of enhancing motor skill performance. For example, a review of the duration of mental movements found temporal equivalence for reaching; grasping; writing; and cyclical activities, such as walking and running.
Evidence for the idea that motor imagery training could enhance the recovery of hand function comes from several lines of research: the sports literature; neurophysiologic evidence; health psychology research; as well as preliminary findings using motor imagery techniques in stroke patients.
Much interest has been raised by the potential of Motor Practice of Motor task, also called “Motor Imagery” as a neuro rehabilitation technique to enhance Motor Recovery following Stroke.
Mental Practice is a training method during which a person cognitively rehearsals a physical skill using Motor Imagery in the absence of Physical movements for the purpose of enhancing Motor skill performance.
The merits of this intervention are that the patient concentration and motivation can be enhanced without regard to time and place and the training is possible without expensive equipment.
Researchers have speculated about its utility in neurorehabilitation. In fact, several review articles examining the impact of mental practice have been published. Two reviews examined stroke outcomes in general and did not limit their review to upper-extremity–focused outcomes. Both articles included studies that were published in 2005 or earlier.
Previous reviews, however, did not attempt to rate the studies reviewed in terms of the level of evidence. Thus, in this review, we determined whether mental practice is an effective intervention strategy to remediate impairments and improve upper-limb function after stroke by examining and rating the current evidence. […]
The objective of this study was to investigate the effectiveness of functional electrical stimulation (FES) applied to the wrist and finger extensors for wrist flexor spasticity in hemiplegic patients.
Thirty stroke patients treated as inpatients were included in the study. Patients were randomly divided into study and control groups. FES was applied to the study group. Wrist range of movement, the Modified Ashworth Scale (MAS), Rivermead Motor Assessment (RMA), Brunnstrom (BS) hand neurophysiological staging, Barthel Index (BI), and Upper Extremity Function Test (UEFT) are outcome measures.
There was no significant difference regarding range of motion (ROM) and BI values on admission between the groups. A significant difference was found in favor of the study group for these values at discharge. In the assessment within groups, there was no significant difference between admission and discharge RMA, BS hand, and UEFT scores in the control group, but there was a significant difference between the admission and discharge values for these parameters in the study group. Both groups showed improvement in MAS values on internal assessment.
It was determined that FES application is an effective method to reduce spasticity and to improve ROM, motor, and functional outcomes in hemiplegic wrist flexor spasticity.
The aim of this study was to examine the effect of the side of brain lesion on the ipsilesional hand function of stroke survivors.
Twenty-four chronic stroke survivors, equally allocated in 2 groups according to the side of brain lesion (right or left), and 12 sex- and age-matched healthy controls performed the Jebsen-Taylor Hand Function Test (JTHFT), the Nine-Hole Peg Test (9HPT), the maximum power grip strength (PwGSmax) test, and the maximum pinch grip strength (PnGSmax) test. Only the ipsilesional hand of the stroke survivors and both hands (left and right) of the controls were assessed.
PwGS max and PnGS max were similar among all tested groups. Performances in JTHFT and 9HPT were affected by the brain injury. Individuals with left brain damage showed better performance in 9HPT than individuals with right brain damage, but performance in JTHFT was similar.
Individuals after a brain injury have the capacity to produce maximum strength preserved when using their ipsilesional hand. However, the dexterity of their hands and digits is affected, in particular for stroke individuals with right brain lesion.