Posts Tagged chronic stroke

[Abstract] Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a randomised-clinical-trial.

Abstract

OBJECTIVE:

The objective of this study was the evaluation of the clinical and neurophysiological effects of intensive robot-assisted hand therapy compared to intensive occupational therapy in the chronic recovery phase after stroke.

METHODS:

50 patients with a first-ever stroke occurred at least six months before, were enrolled and randomised into two groups. The experimental group was provided with the Amadeo™ hand training (AHT), whereas the control group underwent occupational therapist-guided conventional hand training (CHT). Both of the groups received 40 hand training sessions (robotic and conventional, respectively) of 45 min each, 5 times a week, for 8 consecutive weeks. All of the participants underwent a clinical and electrophysiological assessment (task-related coherence, TRCoh, and short-latency afferent inhibition, SAI) at baseline and after the completion of the training.

RESULTS:

The AHT group presented improvements in both of the primary outcomes (Fugl-Meyer Assessment for of Upper Extremity and the Nine-Hole Peg Test) greater than CHT (both p < 0.001). These results were paralleled by a larger increase in the frontoparietal TRCoh in the AHT than in the CHT group (p < 0.001) and a greater rebalance between the SAI of both the hemispheres (p < 0.001).

CONCLUSIONS:

These data suggest a wider remodelling of sensorimotor plasticity and interhemispheric inhibition between sensorimotor cortices in the AHT compared to the CHT group.

SIGNIFICANCE:

These results provide neurophysiological support for the therapeutic impact of intensive robot-assisted treatment on hand function recovery in individuals with chronic stroke.

 

via Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a … – PubMed – NCBI

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[Abstract] Backward walking observational training improves gait ability in patients with chronic stroke: randomised controlled pilot study.

Abstract

Backward walking has a positive effect on gait ability. Action observational training is an effective treatment method for stroke neurological disorders. This randomised comparator-controlled pilot study aimed to evaluate the feasibility of backward walking observational training on the gait ability of chronic stroke patients. Fourteen chronic stroke participants were randomly allocated to the experimental group (backward walking observation; n = 7) and control group (landscape observation; n = 7). Both groups performed conventional therapy 5 days/week; then the backward walking observation and landscape observation + backward walking training groups performed the observational training 3 days/week for 4 weeks. The primary outcome was measured dynamic gait index, 10-m walking test, and timed up and go test time. Both groups showed significant increases in dynamic gait index, 10-m walking test, and timed up and go test time. The experimental group showed more significant improvements in dynamic gait index (P = 0.04, η = 0.336), 10-m walking test (P = 0.04, η = 0.306), and timed up and go test time (P = 0.03, η = 0.334) than the control group. This pilot study demonstrated that conventional therapy with backward walking observational training improves gait ability. Our findings suggest that observing an action may have a positive effect on chronic stroke patients.

 

via Backward walking observational training improves gait ability in patients with chronic stroke: randomised controlled pilot study. – PubMed – NCBI

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[WEB SITE] Neurotechnology-Aided Rehab Holds Promise for Chronic Stroke Patients

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neurotechnol

Personalized neurotechnology-aided rehabilitation of the arm could improve recovery in severe chronic stroke patients, according to a study published recently in the journal Brain.

Neurotechnology-based therapies, including brain-machine interfaces, robotics, and brain stimulation among others, will lead to largest treatment effects and success if they are tailored to the needs of individual patients, and used in combination, according to the authors from the Wyss Center for Bio and Neuroengineering, Swiss Federal Institute of Technology Lausanne (EPFL), Scuola Superiore Sant’Anna, University of Geneva Faculty of Medicine and Clinique Romande de Réadaptation.

In their study, they call for longitudinal clinical studies to show the rehabilitation benefits of individual therapies as well as the use of multiple complementary therapies used in combination over long time periods.

“Our findings show that neurotechnology-aided upper limb rehabilitation is promising for severe chronic stroke patients,” says lead author Dr. Martina Coscia, Staff Engineer at the Wyss Center, in a media release.

“However, we also found that the ‘one size fits all’ approach doesn’t lead to the best outcome. We suggest a move towards a personalized combination of neurotechnology-based stroke rehabilitation therapies, ideally in a home-based environment where prolonged therapy is more feasible than in a clinic.

“We believe that by sequentially introducing stroke therapies according to individual progress, we could allow patients to continue their recovery beyond what is possible today.”

One of the most common consequences of stroke is impaired upper arm function, which has a direct impact on daily tasks and quality of life. Rehabilitation therapies generally have the largest effect in the first three months after stroke. After this time, patients are considered chronic and the likelihood of further natural recovery is limited; this is especially true for those most severely affected.

“What we would like to see in the future are long-term trials in which multiple neurotechnology-based therapies are used within the same patient,”  Professor Friedhelm Hummel from EPFL (Director, Defitech Chair of Clinical Neuroengineering) and the University of Geneva Medical School, shares in the release.

“We believe that this synergistic approach could uncover previously undiscovered treatment pathways for chronic stroke patients.”

In their study, the authors compared effectiveness data from 64 clinical studies on upper limb neurotechnology-aided treatments in chronic stroke patients. The interventions analyzed in the paper included robotics, functional electrical stimulation of muscles, brain stimulation, and brain-computer interfaces as well as their use in combination.

The interdisciplinary research team is now starting a clinical trial to test these ideas. The trial uses a new experimental design with a personalized therapy approach using brain-computer interfaces, robotics, functional electrical stimulation, and brain stimulation specifically chosen to maximize treatment effects in each individual patient. The goal is to keep incrementally improving recovery by using new personalized, neurotechnology-based therapies in combination. The trial will start in Switzerland in summer 2019.

[Source(s): Wyss Center for Bio and Neuroengineering, Science Daily]

 

via Neurotechnology-Aided Rehab Holds Promise for Chronic Stroke Patients – Rehab Managment

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[ARTICLE] The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis – Full Text

Abstract

Objective. The aim of this study was to perform a meta-analysis to examine whether virtual reality (VR) training is effective for lower limb function as well as upper limb and overall function in chronic stroke patients. Methods. Three databases, OVID, PubMed, and EMBASE, were used to collect articles. The search terms used were “cerebrovascular accident (CVA),” “stroke”, and “virtual reality”. Consequently, twenty-one studies were selected in the second screening of meta-analyses. The PEDro scale was used to assess the quality of the selected studies. Results. The total effect size for VR rehabilitation programs was 0.440. The effect size for upper limb function was 0.431, for lower limb function it was 0.424, and for overall function it was 0.545. The effects of VR programs on specific outcomes were most effective for improving muscle tension, followed by muscle strength, activities of daily living (ADL), joint range of motion, gait, balance, and kinematics.Conclusion. The VR training was effective in improving the function in chronic stroke patients, corresponding to a moderate effect size. Moreover, VR training showed a similar effect for improving lower limb function as it did for upper limb function.

1. Introduction

Stroke is a major cause of death in the modern world; it also causes sensory, motor, cognitive, and visual impairments and restricts performance of activities of daily living (ADL) [1]. Motor impairments are observed in 80% of stroke patients, and these can include loss of balance and gait [2]. These problems are important targets of rehabilitation, because they reduce the ability of individuals to perform ADL and this result in impaired community activities [34].

Most studies on balance and gait rehabilitation have shown positive effects. However, training-based methods often become tiresome are resource-intensive and require specialized facilities or equipment. Therefore, there is a demand for economical and safe methods of rehabilitation [2].

Virtual reality (VR) is defined by “the use of interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear and feel similar to real world objects and events.” Participants interact with projected images, maneuver virtual objects and perform activities programmed into the task, giving the user a sense of immersion in the simulated environment. Various forms of feedback are provided through the environment, the most common being visual and auditory, to enhance enjoyment and motor learning through real-time feedback and immediate results [5]. VR training using these features has recently been widely used in the field of stroke rehabilitation [3]. VR training aims to improve neural plasticity by providing a safe and enriched environment to perform functional task-specific activities with increased repetitions, intensity of practice, and motivation to comply with the intervention [1].

In the field of stroke rehabilitation, VR training is reported to be mostly effective at increasing upper limb joint range of motion, improving sensation, muscle strengthening, reducing pain, and improving functional processesRecently, various VR programs have been developed and implemented for the lower limbs as well as the upper limbs, and their effects are being tested. VR training for stroke patients has been shown to be safe and cost-effective at improving lower limb function, specifically improving balance, stair climbing speed, ankle muscle strength, range of motion, and gait speed [1]. Compared with existing treatment methods, it may be more effective at improving dynamic balance control and preventing falls in subacute and chronic stroke patients [6].

Treatment methods using VR provide a virtual environment for ADLs that are difficult to perform in a hospital, and therefore, it could be very effective at improving both upper limb and lower limb function. However, because the lower limbs have to support the weight of the body, various elements are required, including muscle strength and balance to control body weight, joint movements, and cognitive ability to integrate these other elements. Although studies related to VR training have been increasing in recent years, VR intervention has been used more extensively to improve upper limb function, which is relatively easier to apply than lower limb function.

Furthermore, doubts could be raised as to whether VR treatment methods for the lower limbs can improve these elements; these doubts related to lack of VR equipment or programs, as well as safety issues or dizziness during treatment. For this reason, we aimed to perform a meta-analysis as a scientific method to test the effects of uncertain treatment methods using statistical methods, in order to examine whether VR training is effective for lower limb function as well as upper limb function. […]

Continue —>  The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis

 

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[Abstract + Related Articles] Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use in Chronic Stroke

Abstract

Importance: Rehabilitation interventions for chronic stroke are largely impairment based, with results confined to the level of impairment instead of function. In contrast, cognitive strategy training interventions have demonstrated clinically meaningful improvements in functional outcomes. Integration of these approaches has yet to be explored.

Objective: To evaluate acceptability, recruitment, and retention rate and determine which outcome measures best capture the effect of the intervention.

Design: Single-group, pre–post design.

Setting: Research laboratory.

Participants: Adults with chronic stroke and hemiparesis (N = 10).

Intervention: A 12-wk intervention integrating cognitive strategy training with upper extremity motor training. Two weekly sessions used Kinect-based virtual reality to encourage high numbers of upper extremity movement repetitions. The third weekly session focused on the use of cognitive strategies with practice of client-centered goals.

Outcomes and Measures: Upper extremity motor performance was measured with the Fugl–Meyer Assessment. Occupational performance on trained and untrained goals was measured via the Performance Quality Rating Scale and the Canadian Occupational Performance Measure. Outcome data were gathered preintervention, postintervention, and at 3-mo follow-up.

Results: The intervention was perceived as acceptable. Recruitment rate was 15%, and retention rate was 100%. Large effects were found on outcomes of upper extremity motor performance, occupational performance, and participation at follow-up.

Conclusion and Relevance: MetacogVR is feasible for adults with chronic stroke. The effect of MetacogVR is best captured through measures of upper extremity motor performance, occupational performance, and participation.

What This Articles Adds: Traditional, impairment-based approaches to chronic stroke rehabilitation may require integration with cognitive-strategy training to affect performance on meaningful goals.

Related Articles

 

via Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use in Chronic Stroke | American Journal of Occupational Therapy

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[ARTICLE] Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme – Full Text

Abstract

Objective Persistent difficulty in using the upper limb remains a major contributor to physical disability post-stroke. There is a nihilistic view about what clinically relevant changes are possible after the early post-stroke phase. The Queen Square Upper Limb Neurorehabilitation programme delivers high-quality, high-dose, high-intensity upper limb neurorehabilitation during a 3-week (90 hours) programme. Here, we report clinical changes made by the chronic stroke patients treated on the programme, factors that might predict responsiveness to therapy and the relationship between changes in impairment and activity.

Methods Upper limb impairment and activity were assessed on admission, discharge, 6 weeks and 6 months after treatment, with modified upper limb Fugl-Meyer (FM-UL, max-54), Action Research Arm Test (ARAT, max-57) and Chedoke Arm and Hand Activity Inventory (CAHAI, max-91). Patient-reported outcome measures were recorded with the Arm Activity Measure (ArmA) parts A (0–32) and B (0–52), where lower scores are better.

Results 224 patients (median time post-stroke 18 months) completed the 6-month programme. Median scores on admission were as follows: FM-UL = 26 (IQR 16–37), ARAT=18 (IQR 7–33), CAHAI=40 (28-55), ArmA-A=8 (IQR 4.5–12) and ArmA-B=38 (IQR 24–46). The median scores 6 months after the programme were as follows: FM-UL=37 (IQR 24–48), ARAT=27 (IQR 12–45), CAHAI=52 (IQR 35–77), ArmA-A=3 (IQR 1–6.5) and ArmA-B=19 (IQR 8.5–32). We found no predictors of treatment response beyond admission scores.

Conclusion With intensive upper limb rehabilitation, chronic stroke patients can change by clinically important differences in measures of impairment and activity. Crucially, clinical gains continued during the 6-month follow-up period.

Introduction

Stroke remains common1 and persistent difficulty in using the upper limb is a major contributor to ongoing physical disability.2 The general consensus remains that most spontaneous recovery of the upper limb occurs over the first 3 months after stroke and current levels of rehabilitation result in little improvement after that, particularly at the level of impairment.3 Improving outcomes through higher dose (time in rehabilitation or number of repetitions) and intensity (dose per session) of rehabilitation is an attractive option.4 However, clinical trials of higher dose upper limb rehabilitation have generally not produced the magnitude of improvement that will change clinical practice,5 whether delivered in the early6 or chronic stages post-stroke.7–9 A common factor in these trials is that the dose (in hours) of additional therapy remained relatively low (18–36 hours). Despite scepticism that stroke patients could tolerate much higher doses,8 one study managed to deliver 300 hours of upper limb therapy to chronic stroke patients over 12 weeks and reported changes in measures of both impairment and activity that were far greater than those in lower dose studies.10 Three hundred hours represents an order of magnitude higher than any dose of rehabilitation offered in previous upper limb rehabilitation trials and deserves further consideration. However, this idea is challenging because of the logistics of setting up such a trial in healthcare settings where the ethic of high-dose, high-intensity rehabilitation is not supported. In this context, it is important to report the findings of clinical services that are able to deliver higher doses than conventionally seen. The Queen Square Upper Limb (QSUL) Neurorehabilitation programme is a single-centre clinical service that provides 90 hours of timetabled treatment focusing on the post-stroke upper limb in chronic (>6 months post-stroke) stroke patients. Here, we report (i) outcomes for patients admitted to this programme at the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust (UCLH), including 6-month follow-up data to look at whether any clinical benefits were maintained, (ii) the characteristics of the patients admitted and any predictors of response and (iii) the relationship between changes in impairment and activity.[…]

Continue —> https://jnnp.bmj.com/content/90/5/498

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[ARTICLE] Feasibility and clinical experience of implementing a myoelectric upper limb orthosis in the rehabilitation of chronic stroke patients: A clinical case series report – Full Text

Abstract

Individuals with stroke are often left with persistent upper limb dysfunction, even after treatment with traditional rehabilitation methods. The purpose of this retrospective study is to demonstrate feasibility of the implementation of an upper limb myoelectric orthosis for the treatment of persistent moderate upper limb impairment following stroke (>6 months). Methods: Nine patients (>6 months post stroke) participated in treatment at an outpatient Occupational Therapy department utilizing the MyoPro myoelectric orthotic device. Group therapy was provided at a frequency of 1–2 sessions per week (60–90 minutes per session). Patients were instructed to perform training with the device at home on non-therapy days and to continue with use of the device after completion of the group training period. Outcome measures included Fugl-Meyer Upper Limb Assessment (FM) and modified Ashworth Scale (MAS). Results: Patients demonstrated clinically important and statistically significant improvement of 9.0±4.8 points (p = 0.0005) on a measure of motor control impairment (FM) during participation in group training. It was feasible to administer the training in a group setting with the MyoPro, using a 1:4 ratio (therapist to patients). Muscle tone improved for muscles with MAS >1.5 at baseline. Discussion: Myoelectric orthosis use is feasible in a group clinic setting and in home-use structure for chronic stroke survivors. Clinically important motor control gains were observed on FM in 7 of 9 patients who participated in training.

Fig 1

Introduction

Stroke is a leading cause of long term disability in the United States[1]. Traditional rehabilitation does not restore normal motor control for all stroke survivors, and upwards of 50% live with persistent upper limb dysfunction[2]. This leads to diminished functional independence and quality of life[3]. Motor learning-based interventions have shown promise[4]. However in today’s health care milieu, for those with chronic motor deficits, provision of the intensive rehabilitation necessary to provide motor learning-based interventions is challenging. Therefore, new treatment methods are needed under these constraints.

An emerging technology that warrants further investigation is myoelectric control which harnesses the user’s EMG signal to power a custom fabricated orthotic device. When the user activates a target muscle, the EMG signal from that muscle signals a motor to produce a desired movement. Myoelectric control has been studied in different populations[5], but its study in stroke has been limited. One commercially available upper limb myoelectric device is the MyoPro motion-G (Cambridge, MA). The MyoPro motion-G provides assistance to the weak upper limb and allows the patient to perform movement they otherwise are unable to complete. Preliminary evidence suggests it may be effective in improving motor control[69] and one study showed improvement in self-reported function and perception of recovery[10]. This device has been utilized in the occupational therapy (OT) clinic at our medical center for 5 years. The purpose of this study is to demonstrate feasibility of administering treatment with the MyoPro using a group therapy design in a cohort of patients with chronic stroke whose progress with standard OT had plateaued.[…]

Continue —> Feasibility and clinical experience of implementing a myoelectric upper limb orthosis in the rehabilitation of chronic stroke patients: A clinical case series report

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[Abstract] Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a randomised-clinical-trial

Highlights

  • Robotic hand training can be helpful in improving hand motor recovery.
  • Amadeo™ induces large modulations of sensorimotor rhythms and connectivity.
  • Robotic training yields improvement of hand motor performance by restoring hand motor control.

 

Abstract

Objective

The objective of this study was the evaluation of the clinical and neurophysiological effects of intensive robot-assisted hand therapy compared to intensive occupational therapy in the chronic recovery phase after stroke.

Methods

50 patients with a first-ever stroke occurred at least six months before, were enrolled and randomised into two groups. The experimental group was provided with the Amadeo™ hand training (AHT), whereas the control group underwent occupational therapist-guided conventional hand training (CHT). Both of the groups received 40 hand training sessions (robotic and conventional, respectively) of 45 min each, 5 times a week, for 8 consecutive weeks. All of the participants underwent a clinical and electrophysiological assessment (task-related coherence, TRCoh, and short-latency afferent inhibition, SAI) at baseline and after the completion of the training.

Results

The AHT group presented improvements in both of the primary outcomes (Fugl-Meyer Assessment for of Upper Extremity and the Nine-Hole Peg Test) greater than CHT (both p<0.001). These results were paralleled by a larger increase in the frontoparietal TRCoh in the AHT than in the CHT group (p<0.001) and a greater rebalance between the SAI of both the hemispheres (p<0.001).

Conclusions

These data suggest a wider remodelling of sensorimotor plasticity and interhemispheric inhibition between sensorimotor cortices in the AHT compared to the CHT group.

Significance

These results provide neurophysiological support for the therapeutic impact of intensive robot-assisted treatment on hand function recovery in individuals with chronic stroke.

 

via Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a randomised-clinical-trial – ScienceDirect

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[Abstract] Brain-Machine Interface in Chronic Stroke: Randomized Trial Long-Term Follow-up

Background. Brain-machine interfaces (BMIs) have been recently proposed as a new tool to induce functional recovery in stroke patients.

Objective. Here we evaluated long-term effects of BMI training and physiotherapy in motor function of severely paralyzed chronic stroke patients 6 months after intervention.

Methods. A total of 30 chronic stroke patients with severe hand paresis from our previous study were invited, and 28 underwent follow-up assessments. BMI training included voluntary desynchronization of ipsilesional EEG-sensorimotor rhythms triggering paretic upper-limb movements via robotic orthoses (experimental group, n = 16) or random orthoses movements (sham group, n = 12). Both groups received identical physiotherapy following BMI sessions and a home-based training program after intervention. Upper-limb motor assessment scores, electromyography (EMG), and functional magnetic resonance imaging (fMRI) were assessed before (Pre), immediately after (Post1), and 6 months after intervention (Post2).

Results. The experimental group presented with upper-limb Fugl-Meyer assessment (cFMA) scores significantly higher in Post2 (13.44 ± 1.96) as compared with the Pre session (11.16 ± 1.73; P = .015) and no significant changes between Post1 and Post2 sessions. The Sham group showed no significant changes on cFMA scores. Ashworth scores and EMG activity in both groups increased from Post1 to Post2. Moreover, fMRI-BOLD laterality index showed no significant difference from Pre or Post1 to Post2 sessions.

Conclusions. BMI-based rehabilitation promotes long-lasting improvements in motor function of chronic stroke patients with severe paresis and represents a promising strategy in severe stroke neurorehabilitation.

via Brain-Machine Interface in Chronic Stroke: Randomized Trial Long-Term Follow-up – Ander Ramos-Murguialday, Marco R. Curado, Doris Broetz, Özge Yilmaz, Fabricio L. Brasil, Giulia Liberati, Eliana Garcia-Cossio, Woosang Cho, Andrea Caria, Leonardo G. Cohen, Niels Birbaumer, 2019

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[ARTICLE] Effectiveness of Robot-Assisted Upper Limb Training on Spasticity, Function and Muscle Activity in Chronic Stroke Patients Treated With Botulinum Toxin: A Randomized Single-Blinded Controlled Trial

Abstract

Background: The combined use of Robot-assisted UL training and Botulinum toxin (BoNT) appear to be a promising therapeutic synergism to improve UL function in chronic stroke patients.

Objective: To evaluate the effects of Robot-assisted UL training on UL spasticity, function, muscle strength and the electromyographic UL muscles activity in chronic stroke patients treated with Botulinum toxin.

Methods: This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with UL spastic hemiparesis. The experimental group (n = 16) received robot-assisted UL training and BoNT treatment. The control group (n = 16) received conventional treatment combined with BoNT treatment. Training protocols lasted for 5 weeks (45 min/session, two sessions/week). Before and after rehabilitation, a blinded rater evaluated patients. The primary outcome was the Modified Ashworth Scale (MAS). Secondary outcomes were the Fugl-Meyer Assessment Scale (FMA) and the Medical Research Council Scale (MRC). The electromyographic activity of 5 UL muscles during the “hand-to-mouth” task was explored only in the experimental group and 14 healthy age-matched controls using a surface Electromyography (EMGs).

Results: No significant between-group differences on the MAS and FMA were measured. The experimental group reported significantly greater improvements on UL muscle strength (p = 0.004; Cohen’s d = 0.49), shoulder abduction (p = 0.039; Cohen’s d = 0.42), external rotation (p = 0.019; Cohen’s d = 0.72), and elbow flexion (p = 0.043; Cohen’s d = 1.15) than the control group. Preliminary observation of muscular activity showed a different enhancement of the biceps brachii activation after the robot-assisted training.

Conclusions: Robot-assisted training is as effective as conventional training on muscle tone reduction when combined with Botulinum toxin in chronic stroke patients with UL spasticity. However, only the robot-assisted UL training contributed to improving muscle strength. The single-group analysis and the qualitative inspection of sEMG data performed in the experimental group showed improvement in the agonist muscles activity during the hand-to-mouth task.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03590314

Introduction

Upper limb (UL) sensorimotor impairments are one of the major determinants of long-term disability in stroke survivors (). Several disturbances are the manifestation of UL impairments after stroke (i.e., muscle weakness, changes in muscle tone, joint disturbances, impaired motor control). However, spasticity and weakness are the primary reason for rehabilitative intervention in the chronic stages (). Historically, spasticity refers to a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks resulting from hyperexcitability of the stretch reflex () while weakness is the loss of the ability to generate the normal amount of force.

From 7 to 38% of post-stroke patients complain of UL spasticity in the first year (). The pathophysiology of spasticity is complicated, and new knowledge has progressively challenged this definition. Processes involving central and peripheral mechanisms contribute to the spastic movement disorder resulting in abnormal regulation of tonic stretch reflex and increased muscle resistance of the passively stretched muscle and deficits in agonist and antagonist coactivation (). The resulting immobilization of the muscle at a fixed length for a prolonged time induces secondary biomechanical and viscoelastic properties changes in muscles and soft tissues, and pain (). These peripheral mechanisms, in turn, leads to further stiffness, and viscoelastic muscle changes (). Whether the muscular properties changes may be adaptive and secondary to paresis are uncertain. However, the management of UL spasticity should combine treatment of both the neurogenic and peripheral components of spasticity ().

UL weakness after stroke is prevalent in both acute and chronic phases of recovery (). It is a determinant of UL function in ADLs and other negative consequences such as bone mineral content (), atrophy and altered muscle pattern of activation. Literature supports UL strengthening training effectiveness for all levels of impairment and in all stages of recovery (). However, a small number of trials have been performed in chronic subgroup patients, and there is still controversy in including this procedure in UL rehabilitation ().

Botulinum toxin (BoNT) injection in carefully selected muscles is a valuable treatment for spastic muscles in stroke patients improving deficits in agonist and antagonist coactivation, facilitating agonist recruitment and increasing active range of motion (). However, improvements in UL activity or performance is modest (). With a view of improving UL function after stroke, moderate to high-quality evidence support combining BoNT treatment with other rehabilitation procedures (). Specifically, the integration of robotics in the UL rehabilitation holds promise for developing high-intensity, repetitive, task-specific, interactive treatment of upper limb (). The combined use of these procedures to compensate for their limitations has been studied in only one pilot RCT reporting positive results in UL function (Fugl-Meyer UL Assessment scale) and muscular activation pattern (). With the limits of the small sample, the results support the value of combining high-intensity UL training by robotics and BoNT treatment in patients with UL spastic paresis.

Clinical scales are currently used to assess the rehabilitation treatment effects, but these outcome measures may suffer from some drawbacks that can be overcome by instrumental assessment as subjectivity, limited sensitivity, and the lack of information on the underlying training effects on motor control (). Instrumental assessment, such as surface electromyography (sEMG) during a functional task execution allows assessing abnormal activation of spastic muscles and deficits of voluntary movements in patients with stroke.

Moreover, the hand-to-mouth task is representative of Activities of Daily Life (ADL) such as eating and drinking. Kinematic analysis of the hand-to-mouth task has been widely used to assess UL functions in individuals affected by neurological diseases showing adequate to more than adequate test-retest reliability in healthy subjects (). The task involves flexing the elbow a slightly flexing the shoulder against gravity, and it is considered to be a paradigmatic functional task for the assessment of spasticity and strength deficits on the elbow muscles (). Although sEMG has been reported to be a useful assessment procedure to detect muscle activity improvement after rehabilitation, limited results have been reported ().

The primary aim of this study was to explore the therapeutic synergisms of combined robot-assisted upper limb training and BoNT treatment on upper limb spasticity. The secondary aim was to evaluate the treatment effects on UL function, muscle strength, and the electromyographic activity of UL muscles during a functional task.

The combined treatment would contribute to decrease UL spasticity and improve function through a combination of training effects between BoNT neurolysis and the robotic treatment. A reduction of muscle tone would parallel improvement in muscle strength ought to the high-intensity, repetitive and task-specific robotic training. Since spasticity is associated with abnormal activation of shortening muscles and deficits in voluntary movement of the UL, the sEMG assessment would target these impairments ().

Materials and Methods

Trial Design

A single-blind RCT with two parallel group is reported. The primary endpoint was the changes in UL spasticity while the secondary endpoints were changes in UL function, muscle strength and the electromyographic activity of UL muscles during a functional task. The study was conducted according to the tenets of the Declaration of Helsinki, the guidelines for Good Clinical Practice, and the Consolidated Standards of Reporting Trials (CONSORT), approved by the local Ethics Committee “Nucleo ricerca clinica–Research and Biostatistic Support Unit” (prog n.2366), and registered at clinical trial (NCT03590314).

Patients

Chronic post-stroke patients with upper-limb spasticity referred to the Neurorehabilitation Unit (AOUI Verona) and the Physical Medicine and Rehabilitation Section, “OORR” Hospital (University of Foggia) were assessed for eligibility.

Inclusion criteria were: age > 18 years, diagnosis of ischemic or hemorrhagic first-ever stroke as documented by a computerized tomography scan or magnetic resonance imaging, at least 6 months since stroke, Modified Ashworth Scale (MAS) score (shoulder and elbow) ≤ 3 and ≥1+ (), BoNT injection within the previous 12 weeks of at least one of muscles of the affected upper limb, Mini-Mental State Examination (MMSE) score ≥24 () and Trunk Control Test score = 100/100 ().

Exclusion criteria were: any rehabilitation intervention in the 3 months before recruitment, bilateral cerebrovascular lesion, severe neuropsychologic impairment (global aphasia, severe attention deficit or neglect), joint orthopedic disorders.

All participants were informed regarding the experimental nature of the study. Informed consent was obtained from all subjects. The local ethics committee approved the study.

Interventions

Each patient underwent a BoNT injection in the paretic limb. The dose of BoNT injected into the target muscle was based on the severity of spasticity in each case. Different commercial formulations of BoNT were used according to the pharmaceutical portfolio contracts of our Hospitals (Onabotulinumtoxin A, Abobotulinumtoxin A, and Incobotulinumtoxin A). The dose, volume and number of injection sites were set accordingly. A Logiq ® Book XP portable ultrasound system (GE Healthcare; Chalfont St. Giles, UK) was used to inject BoNT into the target muscle.

Before the start of the study authors designed the experimental (EG) and the control group (CG) protocols. Two physiotherapists, one for each group, carried out the rehabilitation procedures. Patients of both groups received ten individual sessions (45 min/session, two sessions/week, five consecutive weeks). Treatments were performed in the rehabilitative gym of the G. B. Rossi University Hospital Neurological Rehabilitation Unit, or “OORR” Hospital.

Robot-Assisted UL Training

The Robot-assisted UL Training group was treated using the electromechanical device Armotion (Reha Technology, Olten, Switzerland). It is an end-effector device that allows goal-directed arm movements in a bi-dimensional space with visual feedback. It offers different training modalities such as passive, active, passive-active, perturbative, and assistive modes. The robot can move, drive or oppose the patient’s movement and allows creating a personalized treatment, varying parameters such as some repetitions, execution speed, resistance degree of motion. The exercises available from the software are supported by games that facilitate the functional use of the paretic arm (). The robot is equipped with a control system called “impedance control” that modulates the robot movements for adapting to the motor behavior of the patient’s upper limb. The joints involved in the exercises were the shoulder and the elbow, is the wrist fixed to the device.

The Robot-assisted UL Training consisted of passive mobilization and stretching exercises for affected UL (10 min) followed by robot-assisted exercises (35 min). Four types of exercises contained within the Armotion software and amount of repetitions were selected as follows: (i) “Collect the coins” (45–75 coins/10 min), (ii) “Drive the car” (15–25 laps/10 min), (iii) “Wash the dishes” (40–60 repetitions/10 min), and (iv) “Burst the balloons” (100–150 balloons/5 min) (Figure 1). All exercises were oriented to achieving several goals in various directions, emphasizing the elbow flexion-extension and reaching movement. The robot allows participants to execute the exercises through an “assisted as needed” control strategy. For increment the difficulty, we have varied the assisted and non-assisted modality, increasing the number of repetitions over the study period.

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Figure 1
The upper limb robot-assisted training setting.

Conventional Training

The conventional training consisted of UL passive mobilization and stretching (10 min) followed by UL exercises (35 min) that incorporated single or multi-joint movements for the scapula, shoulder, and elbow, performed in different positions (i.e., supine and standing position). The increase of difficulty and progression of intensity were obtained by increasing ROM, repetitions and performing movements against gravity or slight resistance (). Training parameters were recorded on the patient’s log. […]

 

Continue —>  Effectiveness of Robot-Assisted Upper Limb Training on Spasticity, Function and Muscle Activity in Chronic Stroke Patients Treated With Botulinum Toxin: A Randomized Single-Blinded Controlled Trial

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