Posts Tagged chronic stroke

[Abstract + References] The Efficiency, Efficacy, and Retention of Task Practice in Chronic Stroke

Abstract

In motor skill learning, larger doses of practice lead to greater efficacy of practice, lower efficiency of practice, and better long-term retention. Whether such learning principles apply to motor practice after stroke is unclear. Here, we developed novel mixed-effects models of the change in the perceived quality of arm movements during and following task practice. The models were fitted to data from a recent randomized controlled trial of the effect of dose of task practice in chronic stroke. Analysis of the models’ learning and retention rates demonstrated an increase in efficacy of practice with greater doses, a decrease in efficiency of practice with both additional dosages and additional bouts of training, and fast initial decay following practice. Two additional effects modulated retention: a positive “self-practice” effect, and a negative effect of dose. Our results further suggest that for patients with sufficient arm use post-practice, self-practice will further improve use.

References

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[ARTICLE] Pushing the Rehabilitation Boundaries: Hand Motor Impairment Can Be Reduced in Chronic Stroke – Full Text

Abstract

Background. Stroke is one of the most common causes of physical disability worldwide. The majority of survivors experience impairment of movement, often with lasting deficits affecting hand dexterity. To date, conventional rehabilitation primarily focuses on training compensatory maneuvers emphasizing goal completion rather than targeting reduction of motor impairment. 

Objective. We aim to determine whether finger dexterity impairment can be reduced in chronic stroke when training on a task focused on moving fingers against abnormal synergies without allowing for compensatory maneuvers. 

Methods. We recruited 18 chronic stroke patients with significant hand motor impairment. First, participants underwent baseline assessments of hand function, impairment, and finger individuation. Then, participants trained for 5 consecutive days, 3 to 4 h/d, on a multifinger piano-chord-like task that cannot be performed by compensatory actions of other body parts (e.g., arm). Participants had to learn to simultaneously coordinate and synchronize multiple fingers to break unwanted flexor synergies. To test generalization, we assessed performance in trained and nontrained chords and clinical measures in both the paretic and the nonparetic hands. To evaluate retention, we repeated the assessments 1 day, 1 week, and 6 months post-training. 

Results. Our results showed that finger impairment assessed by the individuation task was reduced after training. The reduction of impairment was accompanied by improvements in clinical hand function, including precision pinch. Notably, the effects were maintained for 6 months following training. 

Conclusion. Our findings provide preliminary evidence that chronic stroke patient can reduce hand impairment when training against abnormal flexor synergies, a change that was associated with meaningful clinical benefits.

Introduction

Stroke is one of the leading causes of death and disability globally,1,2 resulting in a wide range of physical, emotional, and cognitive consequences.3 Among the most common physical sequela of stroke are hemiparesis and spasticity, two forms of motor impairment that affect daily living and overall quality of life in approximately 80% of survivors.3 Hand impairment, in particular, is often present in the chronic stage after stroke, frequently manifesting itself as both a decrease in finger strength, loss of dexterity (negative signs), and abnormal hand flexion synergy, characterized by a pattern of involuntary motor activation resulting in finger and hand flexion (positive signs).4,5 Indeed, one of the most prominent deficits in hand dexterity is increased finger enslaving, or unintended force produced by the uninstructed fingers. This hand function abnormality is thought to be a direct result of lesions to the motor cortex and corticospinal tract,5,6,7,8,9 as these are known to be critical for the control of independent finger movements (i.e., finger individuation).5,1013

Previously, we have shown that stroke patients recover both finger individuation and strength relying on separable recovery processes.5 Recovery asymptotes after the first 3 to 6 months, although typically remains far from the level of performance of healthy individuals, especially for the individuation component. Over the past few years, different training and rehabilitation strategies have assessed the effect of finger and hand training as well as virtual reality environments in chronic stroke patients in an attempt to improve deficits in dexterous movement.1420 Some of these works reported positive gains in clinical measures of hand dexterity. However, these studies cannot distinguish between compensatory maneuvers versus true impairment reduction as the mechanism underlying clinical benefits. Specifically, these studies did not fully assess force control in the finger individuation tasks,14,1820 used gross measures of hand dexterity and did not report a detailed individuation metric,14,16 and/or did not report post-training long-term retention of clinical outcomes or retention of improvement in finger individuation.14,18,20 In the present study, we use a direct and quantitative measure of finger dexterity5.

The goal of this study was to discern whether true hand motor impairment can be reduced in the chronic phase after stroke following personalized multidimensional training targeting finger dexterity that minimizes the use of compensatory maneuvers to facilitate performance. To this end, we modified a previously published piano-chord-like task13,21 to train finger dexterity by asking participants to practice in an intense manner against their baseline flexion synergy. Task difficulty during practice was adjusted for each participant based on baseline ability, controlling for individual differences in initial weakness and performance. Participants cannot perform this task by recruiting actions beyond their fingers. We tested both the short- and long-term retention of trained and nontrained hand-chord postures. We quantified hand dexterity by measuring finger individuation and also gauged the impact of the training on clinical outcome measures of impairment, activity, and participation. We hypothesized that intensive training focused on moving fingers against abnormal synergies while minimizing compensatory movements, would improve the ability of patients with chronic stroke to individuate their fingers and perform functional tasks better.

Materials and Methods

Participants

We recruited a cohort of eighteen participants with ischemic stroke and hemiparesis (5 female, 13 male; age 61.3 ± 2.1 years, mean ± SEM). We administered multiple screening assessments during the pretest session to determine participant eligibility. We included participants if they met the following inclusion criteria: (1) age 21 years and older; (2) ischemic stroke at least 6 months prior (time poststroke of 49.7 ± 11.4 months, mean ± SEM), confirmed by computed tomography, magnetic resonance imaging, or neurological report; (3) residual unilateral upper extremity weakness; (4) ability to give informed consent and understand the tasks involved; (5) appearance of flexion synergy in the hand, evaluated by observation of a trainee and/or neurologist; and (6) the ability to extend fingers ≥5° from resting position, as evaluated by a stroke specialist. We excluded participants with one or more of the following criteria: (1) cognitive impairment, as seen by a score of <20/30 on the Montreal Cognitive Assessment (MoCA); (2) history of a physical or neurological condition that interferes with study procedures or assessment of motor function (e.g., severe arthritis, severe neuropathy, Parkinson’s disease); (3) inability to sit in a chair and perform upper limb exercises for one hour at a time; (4) participation in another upper extremity rehabilitative therapy study during the study period; (5) terminal illness; (6) social and/or personal circumstances that interfere with the ability to return for therapy sessions and follow-up assessments; (7) pregnancy; and (8) severe visuospatial neglect, as seen by a score of <44/54 on the Star Cancellation Test. Among the screened patients, 3 patients were excluded from the study. One participant had hemorrhagic stroke, one showed cognitive-related issues in understanding the task and could not sign the informed consent, and the third patient did not show residual unilateral upper extremity weakness. For detailed participant characteristics, see Table 1.

Table 1. Patient Characteristics in the Trained Cohort.a

Table 1. Patient Characteristics in the Trained Cohort.aView larger version

Apparatus to Measure and Train Finger Dexterity

We tested participants’ hand function using an ergonomic device, designed and published previously5, that measures isometric forces produced by each finger (Figure 1A). The hand-shaped keyboard was comprised of 10 keys with force transducers (FSG-15N1A, Honeywell; dynamic range 0-50 N) underneath each key at the position of the fingertips. Downward flexion force exerted at each fingertip was measured at a sampling rate of 200 Hz. The data were digitized using National Instruments USB-621x devices interfacing with MATLAB (The MathWorks, Inc) Data Acquisition Toolbox. Visual stimuli were presented on a computer monitor (22 inches), run by custom software written in MATLAB environment using the Psychophysics Toolbox (Psychtoolbox).22


                        figure
Figure 1. Experimental apparatus and protocol. (A) Ergonomic hand device. Force sensors beneath each key measured the force exerted by each finger in real time. (B) Computer screen showing the instructional stimulus, which indicates both which fingers to press and how much force to produce (height of the green bar). (C) All possible combinations of 2-finger and 3-finger chords tested at baseline and in all post-training sessions. (D) Experimental protocol. During the pre-test, clinical assessments and baseline performance on maximal voluntary contraction force (MVF), individuation, and chord tasks (all possible combinations) were assessed in both hands. During the 5 days of training, participants practiced 6 chords (3 two-finger and 3 three-finger) with the paretic hand (420 trails per day). During post-tests, clinical assessments and performance were reassessed in both hands.

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Source: https://journals.sagepub.com/doi/full/10.1177/1545968320939563

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[ARTICLE] Timing-dependent effects of transcranial direct current stimulation with mirror therapy on daily function and motor control in chronic stroke: a randomized controlled pilot study – Full Text

Abstract

Background

The timing of transcranial direct current stimulation (tDCS) with neurorehabilitation interventions may affect its modulatory effects. Motor function has been reported to be modulated by the timing of tDCS; however, whether the timing of tDCS would also affect restoration of daily function and upper extremity motor control with neurorehabilitation in stroke patients remains largely unexplored. Mirror therapy (MT) is a potentially effective neurorehabilitation approach for improving paretic arm function in stroke patients. This study aimed to determine whether the timing of tDCS with MT would influence treatment effects on daily function, motor function and motor control in individuals with chronic stroke.

Methods

This study was a double-blinded randomized controlled trial. Twenty-eight individuals with chronic stroke received one of the following three interventions: (1) sequentially combined tDCS with MT (SEQ), (2) concurrently combined tDCS with MT (CON), and (3) sham tDCS with MT (SHAM). Participants received interventions for 90 min/day, 5 days/week for 4 weeks. Daily function was assessed using the Nottingham Extended Activities of Daily Living Scale. Upper extremity motor function was assessed using the Fugl-Meyer Assessment Scale. Upper extremity motor control was evaluated using movement kinematic assessments.

Results

There were significant differences in daily function between the three groups. The SEQ group had greater improvement in daily function than the CON and SHAM groups. Kinematic analyses showed that movement time of the paretic hand significantly reduced in the SEQ group after interventions. All three groups had significant improvement in motor function from pre-intervention to post-intervention.

Conclusion

The timing of tDCS with MT may influence restoration of daily function and movement efficiency of the paretic hand in chronic stroke patients. Sequentially applying tDCS prior to MT seems to be advantageous for enhancing daily function and hand movement control, and may be considered as a potentially useful strategy in future clinical application.

Introduction

Stroke remains one of the leading causes of long-term disability [1]. Most stroke patients have difficulties performing every day activities due to paresis of upper limbs, which results in impaired activities of daily living (ADL) and reduced quality of life [23]. Identifying strategies that can facilitate functional recovery is thus an important goal for stroke rehabilitation. In recent years, several neurorehabilitation approaches have been developed to augment functional recovery, for example repetitive, task-oriented training and non-invasive brain stimulation (NIBS) [45]. Repetitive, task-oriented training emphasizes repetitive practice of task-related arm movements to facilitate motor relearning and restore correct movement patterns [6]. On the other hand, non-invasive brain simulation aims to maximize brain plasticity by externally applying electrical stimulation to modulate cortical excitability [7]. Since these two types of approaches individually have been shown to improve stroke recovery, it has been proposed that a synergistic approach that combines both of them may further augment overall treatment effects [89].

Mirror therapy (MT) is one type of repetitive task-oriented training that has been widely used in clinical and research settings [10]. During MT training, a mirror is positioned in between the paretic and non-paretic arm. The paretic arm is behind the mirror and participants can only see the non-paretic arm and its mirror reflection. Participants are required to focus their attention on the mirror reflection and imagine it is the paretic arm while performing bilateral movements as simultaneously as possible. This mirrored visual feedback is hypothesized to restore the efferent-afferent loop that is damaged after stroke and facilitate re-learning of correct movement patterns [11]. MT has been demonstrated to reduce arm impairment and improve sensorimotor function and quality of life in individuals with stroke [10,11,12,13].

Transcranial direct current stimulation (tDCS) is a commonly used NIBS technique in stroke rehabilitation. tDCS applies weak direct current to the scalp to modulate brain excitability [14]. This weak direct current gradually changes neural membrane potentials to facilitate depolarization (excitation) or hyper-polarization (inhibition) of the neurons to enhance plasticity of the brain [15]. tDCS has been demonstrated to modulate neural networks and enhance motor learning in stroke patients [716,17,18]. Although tDCS can be used alone, it is often combined with other rehabilitation approaches to boost responses of the brain to therapies [81920]. A recent meta-analysis further showed that combining tDCS with rehabilitation interventions could produce greater treatment effects on recovery of motor function than tDCS alone in stroke patients [21].

Combining tDCS with MT is a potentially promising approach to not only augment neural responses of the brain but also increase treatment benefits of MT. Nevertheless, one crucial factor that needs to be considered when combining tDCS with MT is the timing of tDCS [22]. tDCS can be applied prior to MT (i.e., offline tDCS) or concurrently with MT (i.e., online tDCS). To our knowledge, only two studies have examined the synergistic effects of combined tDCS with MT in chronic stroke patients [2324]. Cho et al. (2015) applied tDCS prior to MT or motor training without mirror reflection. They found significant improvements in manual dexterity and grip strength in the combined tDCS with MT group, suggesting that sequentially applying tDCS prior to MT could improve motor function. By contrast, Jin et al. (2019) delivered tDCS prior to or concurrently with MT and found advantageous effects on hand function in the concurrent tDCS with MT group. The conflicting results between these two studies indicated further needs to explore the interaction effects of the timing of tDCS with MT to determine the optimal combination strategy.

The important factor to consider when examining the effects of combined tDCS with MT is the treatment outcomes, especially for outcomes that are related to daily activities. ADL such as the basic ADL and complex instrumental ADL (IADL) are essential for independent living and well-being of stroke patients. Therefore, restoring daily function should be one of the priority goals of stroke rehabilitation. However, the previous two studies only examined the effects of combined tDCS with MT on motor function [2324]. No studies to date have examined the timing-dependent effects of tDCS with MT on daily function in chronic stroke patients. Whether the timing of tDCS can affect restoration of daily function with MT remains uncertain.

In addition to daily function, investigating arm movement kinematics changes with respect to the timing of tDCS with MT is also critical for determining the optimal combination strategy. Movement kinematics of the arms can provide information of whether true behavioral changes or compensation strategies occur during training [2526]. However, the two previous studies included only clinical motor function measurements [2324]. While these clinical measurements can inform clinicians/researchers of motor function changes, they may not necessarily capture spatial and temporal characteristics of movement as well as motor control strategies changes after the combined interventions [2627]. Assessing movement kinematics changes with respect to the timing of tDCS with MT would help to unravel the benefits of combined approach on motor control of the paretic arm.

The purpose of this study was to examine the timing-dependent effects of tDCS with MT on daily function, upper extremity motor function and motor control in chronic stroke patients. The tDCS was applied sequentially prior to MT (i.e., sequentially combined tDCS with MT group, SEQ) or concurrently with MT (i.e., concurrently combined tDCS with MT, CON). The sham tDCS with MT was used as the control condition. In addition to motor function outcomes, we further included the ADL/IADL measurement and movement kinematics assessments. We hypothesized that the SEQ and COM groups would demonstrate differential improvements in daily function, motor function and motor control.[…]

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Source: https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-020-00722-1

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[Abstract + References] Post-stroke fatigue: how it relates to motor fatigability and other modifiable factors in people with chronic stroke

Abstract

Post-stroke fatigue (PSF) is a common symptom associated with disability and decreased quality of life. Distinction can be made between perceived fatigue and fatigability. The first aim of this study was to evaluate the prevalence of perceived fatigue and fatigability amongst patients with chronic stroke and to explore how these two parameters relate. The second aim was to study the relationship between modifiable factors (sleep disorders, anxiety, depression and activities of daily living) and fatigue in this population. Sixty-two patients with chronic stroke (> 6 months) were included. Perceived fatigue was evaluated using the Fatigue Severity Scale (FSS). Motor fatigability was assessed with the percent change in meters walked from first to last minute of the 6-min Walk Test and an isometric muscular fatigability test. Subjects also completed self-report questionnaires assessing anxiety and depression (Hospital Anxiety and Depression Scale—HADS), sleep quality (Pittsburgh Sleep Quality Index—PSQI) and activity limitations (ACTIVLIM-stroke). Seventy-one percent of participants presented PSF. There was no correlation between the FSS and motor fatigability. FSS significantly correlated with HADS-Anxiety (ρ = 0.53, P < 0.001), HADS-depression (ρ = 0.63, P < 0.001), PSQI (ρ = 0.51, P < 0.001) and ACTIVLIM (ρ = − 0.30, P < 0.05). A linear regression model showed that the HADS-Depression, the PSQI and the ACTIVLIM explained 46% of the variance of the FSS. A high proportion of chronic stroke patients presents PSF, with no relation between their fatigue and fatigability. Perceived fatigue is associated with potentially modifiable factors: anxious and depressive symptoms, poor sleep quality and activity limitations.

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via Post-stroke fatigue: how it relates to motor fatigability and other modifiable factors in people with chronic stroke | SpringerLink

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[Abstract] Improving abnormal gait patterns by using a Gait Exercise Assist Robot (GEAR) in chronic stroke subjects: A randomized, controlled, pilot trial

Abstract

Background

Although the Gait Exercise Assist Robot (GEAR) has been reported to effectively improve gait of hemiplegic patients, no study has investigated its use in chronic stroke patients. It is possible to facilitate gait reorganization by gait training with less compensation using the GEAR even in chronic stroke patients.

Research question

What are the effects of GEAR training on the abnormal gait patterns of chronic stroke subjects?

Methods

Subjects were randomly assigned to either the GEAR group (n = 8) or the treadmill group (n = 11). Each group underwent 20 sessions (40 min/day, 5 days/week). The changes in the 10 types of abnormal gait patterns were evaluated using a three-dimensional motion analysis system and the Global Rating of Change (GRC) scale before and after the intervention, and at 1-month and 3-month follow-up assessment.

Results

In the GEAR group, hip hiking at a 1-month follow-up assessment was markedly lesser than that before the intervention, and the excessive hip external rotation at 3-month follow-up assessment was notably lesser than that after the intervention, but the change in excessive hip external rotation was in the normal range. In the treadmill group, knee extensor thrust at a 1-month follow-up assessment was strikingly lesser than that before the intervention, but the difference was in the normal range. In the GEAR group, the GRC scale scores were considerably higher after the intervention, at a 1-month, and 3-month follow-up assessment than those before the intervention. But, in the treadmill group, only the GRC scale score at a 1-month follow-up assessment was visibly higher than that before the intervention.

Significance

Gait training using the GEAR may be more effective than treadmill-training in improving the swing phase in chronic stroke subjects.

via Improving abnormal gait patterns by using a Gait Exercise Assist Robot (GEAR) in chronic stroke subjects: A randomized, controlled, pilot trial – ScienceDirect

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[Abstract] Stepping After Stroke: Walking Characteristics in People With Chronic Stroke Differ on the Basis of Walking Speed, Walking Endurance, and Daily Steps

Abstract

Background

What contributes to free-living walking after stroke is poorly understood. Studying the characteristics of walking may provide further details that guide interventions.

Objective

The objectives of this study were to examine how the walking characteristics of bouts per day, median steps per bout, maximum steps per bout, and time spent walking differ in individuals with various walking speeds, walking endurance, and daily steps and to identify cutoffs for differentiating ambulators who were active versus inactive.

Design

This study involved a cross-sectional analysis of data from the Locomotor Experience Applied Post-Stroke trial.

Methods

Participants were categorized by walking speed, walking endurance (via the 6-minute walk test), and daily steps (via 2 consecutive days of objective activity monitoring). Differences in walking characteristics were assessed. Linear regression determined which characteristics predicted daily step counts. Receiver operating characteristic curves and areas under the curve were used to determine which variable was most accurate in classifying individuals who were active (≥5500 daily steps).

Results

This study included 252 participants with chronic stroke. Regardless of categorization by walking speed, walking endurance, or daily steps, household ambulators had significantly fewer bouts per day, steps per bout, and maximum steps per bout and spent less time walking compared with community ambulators. The areas under the curve for maximum steps per bout and bouts per day were 0.91 (95% confidence interval = 0.88 to 0.95) and 0.83 (95% confidence interval = 0.78 to 0.88), respectively, with cutoffs of 648 steps and 53 bouts being used to differentiate active and inactive ambulation.

Limitations

Activity monitoring occurred for only 2 days.

Conclusions

Walking characteristics differed based on walking speed, walking endurance, and daily steps. Differences in daily steps between household and community ambulators were largely due to shorter and fewer walking bouts. Assessing and targeting walking bouts may prove useful for increasing stepping after stroke.

via Stepping After Stroke: Walking Characteristics in People With Chronic Stroke Differ on the Basis of Walking Speed, Walking Endurance, and Daily Steps | Physical Therapy | Oxford Academic

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[Abstract] Compensating Hand Function in Chronic Stroke Patients Through the Supernumerary Robotic Finger – Book Chapter

Abstract

A novel solution to compensate hand grasping abilities is proposed for chronic stroke patients. The goal is to provide the patients with a wearable supernumerary robotic finger that can be worn on the paretic forearm by means of an elastic band. The proposed prototype is a modular articulated device that can adapt its structure to the grasped object shape. The extra-finger and the paretic hand act like the two parts of a gripper cooperatively holding an object. We evaluated the feasibility of the approach with four chronic stroke patients performing a qualitative test, the Frenchay Arm Test. In this proof of concept study, the use of the supernumerary robotic finger has increased the total score of the patients of 2 points in a 5 points scale. The subjects were able to perform the two grasping tasks included in the test that were not possible without the robotic extra-finger. Adding a robotic opposing finger is a very promising approach that can significantly improve the functional compensation of the chronic stroke patient during everyday life activities.

 

via Compensating Hand Function in Chronic Stroke Patients Through the Supernumerary Robotic Finger | SpringerLink

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[Abstract] Can robotic gait rehabilitation plus Virtual Reality affect cognitive and behavioural outcomes in patients with chronic stroke? A randomized controlled trial involving three different protocols

Abstract

Background

The rehabilitation of cognitive and behavioral abnormalities in individuals with stroke is essential for promoting patient’s recovery and autonomy. The aim of our study is to evaluate the effects of robotic neurorehabilitation using Lokomat with and without VR on cognitive functioning and psychological well-being in stroke patients, as compared to traditional therapy.

Methods

Ninety stroke patients were included in this randomized controlled clinical trial. The patients were assigned to one of the three treatment groups, i.e. the Robotic Rehabilitation group undergoing robotic rehab with VR (RRG+VR), the Robotic Rehabilitation Group (RRG-VR) using robotics without VR, and the Conventional Rehabilitation group (CRG) submitted to conventional physiotherapy and cognitive treatment.

Results

The analysis showed that either the robotic training (with and without VR) or the conventional rehabilitation led to significant improvements in the global cognitive functioning, mood, and executive functions, as well as in activities of daily living. However, only in the RRG+VR we observed a significant improvement in cognitive flexibility and shifting skills, selective attention/visual research, and quality of life, with regard to the perception of the mental and physical state.

Conclusion

Our study shows that robotic treatment, especially if associated with VR, may positively affect cognitive recovery and psychological well-being in patients with chronic stroke, thanks to the complex interation between movement and cognition.

Source: https://www.sciencedirect.com/science/article/abs/pii/S1052305720304122

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[BLOG POST] Yes! There is Hope for Chronic Stroke!

A stroke is usually considered chronic at the six-month mark. This article reviews research on chronic stroke recovery and promising therapy treatment approaches that target improving limb function, even for an “old” stroke.

By Natalie Miller, Clinical Manager / Occupational Therapist. More posts by Natalie Miller.

27 MAR 2020 • 5 MIN READ

Yes! There is Hope for Chronic Stroke

What is a chronic stroke?

The term chronic stroke typically refers to a time frame of at least six months after the initial stroke incident occurred. As a person enters this stage and moves onward to years of stroke survival, he may start to encounter all new frustrations related to recovery, especially regarding motor recovery and use of the affected arm.

In the medical world, “most significant” recovery of movement is generally considered to happen within the first six months, with spontaneous recovery slowing after that time. There is a push for high-intensity and high-frequency of therapy while the stroke is still fairly fresh, in order to capitalize on the “critical window” of the highest responsiveness to treatment.

That doesn’t mean we should stop addressing motor recovery after six months. What if we still focus on intensive therapy early on in stroke rehab, but also find ways to promote motor recovery six or more months later? What if we don’t stop searching for new strategies to improve, or at the very least, not lose function of the weaker arm?

chronic

Can I still improve function if I am in the chronic stage of stroke?

Our understanding of the brain and its capabilities is constantly evolving. We used to think that adult brains couldn’t change at all after a certain age! Emerging research evidence suggests there are ways to challenge and improve the chronic stroke brain months and even years down the road. One large-scale study involving outcomes from 219 stroke survivors suggested the critical window for motor recovery may be as long as 18 months! Another recent case study highlighted motor recovery in a stroke survivor who was 23 years post-stroke!

What types of rehabilitation are effective for people with chronic stroke?

Stroke research suggests the following treatments are promising for individuals who are at least six months post-stroke:

  1. Mental Practice with Motor Imagery
  2. Constraint Induced Movement Therapy (CIMT)
  3. Virtual Reality (VR)
  4. Preventing Learned Non-Use

Mental Practice with Motor Imagery

This is a type of treatment where a specific movement is rehearsed mentally. Done best with a pre-recorded audio set, the person listens carefully as a task is described in detail. The details usually include every aspect of that task, including how the five senses may be experienced while performing it, as well as the exact movements that would be needed to complete the task. For example, if the task were “drinking a cup of water,” the recording would describe how to reach out with the arm, extend the fingers, feel the weight of the cup, experience the temperature and the liquid as it touches the mouth, and the exactness of the motion to set it back down gently.

Studies have shown that with this type of repetitive visualization and practice, actual movement and functional use of the arm can improve, such that an arm that was once fairly “useless” can now actually pick up a water cup and bring it to the mouth. The best part is, research also shows that this can be an effective treatment 12 months and beyond since when the stroke actually happened!

reach-for-glass

Constraint Induced Movement Therapy (CIMT)

This is a type of treatment that involves blocking the stronger arm (usually with a cast or mitt) to promote engagement of the hemiplegic, or weaker arm. The more a person uses the weaker arm, the less they are at risk of “learned non-use.” By “forcing” the weaker arm to participate more, and even to be the primary or only source of function, it has a lot more chance to stay the same or get better, even years after the stroke happened. In fact, patients in Constraint Induced studies reported and showed increased use of their arms during normal activities, even if their strokes happened years before!

Virtual Reality (VR)

Virtual reality is another name for video games! This type of treatment may be immersive (using a headset) or non-immersive, with a participant engaging in a game on a screen. VR technology focusing on strengthening and improving limb function is becoming more prevalent in clinics and in homes. These programs are able to quantify arm or leg movement to control gameplay and provide immediate performance feedback.

Research supports the use of VR therapy to enhance motor recovery for adults with acute and chronic stroke. Virtual reality technology can also improve motivation in addition to movement outcomes, helping users stick with their self-training programs and continue using their affected side. Research shows that chronic stroke patients often find self-training programs that use video games to be user friendly and enjoyable.

weight

Avoiding “learned non-use.”

We now know more about this phenomenon that affects many stroke survivors – especially those who are years out from a stroke. The stronger arm starts to take over to just get things accomplished, probably because there is a lot of positive feedback for using the stronger arm (It’s faster! It’s easier! I can just get it done!) and a lot of negative feedback for using the stroke-affected arm (It’s so frustrating! It takes me forever using it!). Research is showing that if people can still find motivation and dedication to actually trying to use the weaker arm, it is possible to still regain function – even years later.

The bottom line: don’t give up!

There IS hope. We can’t predict the exact amount of movement or strength that could come back, or what exactly you will be able to do with your affected arm or hand. But we are producing more research that is pointing us in the direction of believing recovery is still possible after that six month critical window. Don’t give up!

References:

Ballester, BR, et al. (2019). A critical time window for recovery extends beyond one-year post-stroke. Journal of Neurophysiology, 122: 350-357. doi: 10.1152/jn.00762.2018
Soros, P, et al. (2017). Motor recovery beginning 23 years after ischemic stroke. Journal of Neurophysiology, 118(2): 778-781. doi: 10.1152/jn.00868.2016
Page, S, Levine, P, and Leonard, A. (2007). Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke, 38(4): 1293-1297. doi: 10.1161/01.STR.0000260205.67348.2b
Kunkel, A, et al. (1999). Constraint-induced movement therapy for motor recovery in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 80, 624-628. doi:10.1016/s0003-9993(99)90163-6
5. Taub, E, et al. (1993). Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74, 347-354.
Subramanian, SK, et al. (2013). Arm motor recovery using a virtual reality intervention in chronic stroke: Randomized control trial. Neurorehabilitation and Neural Repair, 27(1), 13-23. doi: 10.1177/1545968312449695.

Source: https://us.blog.neofect.com/chronic-stroke-is-there-any-hope/

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[Abstract] Development and Clinical Evaluation of Web-based Upper-limb Home Rehabilitation System using Smartwatch and Machine-learning model for Chronic Stroke Survivors: Development, Usability, and Comparative Study

ABSTRACT

Background:

Human activity recognition (HAR) technology has been advanced with the development of wearable devices and the machine learning (ML) algorithm. Although previous researches have shown the feasibility of HAR technology for home rehabilitation, there has not been enough evidence based on clinical trial.

Objective:

We intended to achieve two goals: (1) To develop a home-based rehabilitation (HBR) system, which can figure out the home rehabilitation exercise of patient based on ML algorithm and smartwatch; (2) To evaluate clinical outcomes for patients with chronic stroke using the HBR system.

Methods:

We used off-the-shelf smartwatch and the convolution neural network (CNN) of ML algorithm for developing our HBR system. It was designed to be able to share the time data of home exercise of individual patient with physical therapist. To figure out the most accurate way for detecting exercise of chronic stroke patients, we compared accuracy results with dataset of personal/total data and accelerometer only/gyroscope/accelerometer combined with gyroscope data. Using the system, we conducted a preliminary study with two groups of stroke survivors (22 participants in HBR group and 10 participants in a control group). The exercise compliance was periodically checked by phone calls in both groups. To measure clinical outcomes, we assessed the Wolf motor function test (WMFT), Fugl-meyer assessment of upper extremity (FMA-UE), grip power test, Beck’s depression index and range of motion (ROM) of the shoulder joint at 0 (baseline), 6 (mid-term), 12 weeks (final) and 18 weeks(6 weeks after the final assessment without HBR system).

Results:

The ML model created by personal data(99.9%) showed greater accuracy than total data(95.8%). The movement detection accuracy was the highest in accelerometer combined with gyroscope data (99.9%) compared to gyroscope(96.0%) or accelerometer alone(98.1%). With regards to clinical outcomes, drop-out rates of control and experimental group were 4/10 (40%) and 5/22 (22%) at 12 weeks and 10/10 (100%) and 10/22 (45%) at 18 weeks, respectively. The experimental group (N=17) showed a significant improvement in WMFT score (P=.02) and ROM (P<.01). The control group (N=6) showed a significant change only in shoulder internal rotation (P=.03).

Conclusions:

This research found that the homecare system using the commercial smartwatch and ML model can facilitate the participation of home training and improve the functional score of WMFT and shoulder ROM of flexion and internal rotation for the treatment of patients with chronic stroke. We recommend our HBR system strategy as an innovative and cost-effective homecare treatment modality. Clinical Trial: Preliminary study (Phase I)


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