Posts Tagged chronic
[Abstract] The Impact of Shoulder Abduction Loading on Volitional Hand Opening and Grasping in Chronic Hemiparetic Stroke
Background. Up to 60% of individuals with moderate to severe chronic hemiparetic stroke experience excessive involuntary wrist/finger flexion that constrains functional hand movements including hand opening. It’s not known how stroke-induced brain injury impacts volitional hand opening and grasping forces as a result of the expression of abnormal coupling between shoulder abduction and wrist/finger flexion or the flexion synergy.
Objective. The goal of this study is to understand how shoulder abduction loading affects volitional hand opening and grasping forces in individuals with moderate to severe chronic hemiparetic stroke.
Methods. Thirty-six individuals (stroke, 26; control, 10) were recruited for this study. Each participant was instructed to perform maximal hand opening and grasping forces while the arm was either fully supported or lifted with a weight equal to 25% or 50% of the participant’s maximal shoulder abduction torque. Hand pentagon area, defined as the area formed by the tips of thumb and fingers, was calculated during hand opening. Forces were recorded during grasping.
Results. In individuals with moderate stroke, increasing shoulder abduction loading reduced the ability to maximally open the hand. In individuals with severe stroke, who were not able to open the hand, grasping forces were generated and increased with shoulder abduction loading. Stroke individuals also showed a reduced ability to control volitional grasping forces due to the enhanced expression of flexion synergy.
Conclusions. Shoulder abduction loading reduced the ability to volitionally open the hand and control grasping forces after stroke. Neural mechanisms and clinical implications of these findings are discussed.
[ARTICLE] Short-term effects of physiotherapy combining repetitive facilitation exercises and orthotic treatment in chronic post-stroke patients – Full Text PDF
[Purpose] This study investigated the short-term effects of a combination therapy consisting of repetitive facilitative exercises and orthotic treatment.
[Subjects and Methods] The subjects were chronic post-stroke patients (n=27; 24 males and 3 females; 59.3 ± 12.4 years old; duration after onset: 35.7 ± 28.9 months) with limited mobility and motor function. Each subject received combination therapy consisting of repetitive facilitative exercises for the hemiplegic lower limb and gait training with an ankle-foot orthosis for 4 weeks. The Fugl-Meyer assessment of the lower extremity, the Stroke Impairment Assessment Set as a measure of motor performance, the Timed Up & Go test, and the 10-m walk test as a measure of functional ambulation were evaluated before and after the combination therapy intervention.
[Results] The findings of the Fugl-Meyer assessment, Stroke Impairment Assessment Set, Timed Up & Go test, and 10-m walk test significantly improved after the intervention. Moreover, the results of the 10-m walk test at a fast speed reached the minimal detectible change threshold (0.13 m/s).
[Conclusion] Short-term physiotherapy combining repetitive facilitative exercises and orthotic treatment may be more effective than the conventional neurofacilitation therapy, to improve the lower-limb motor performance and functional ambulation of chronic post-stroke patients.
The mobility of many stroke survivorsislimited, and most identify walking as a top priority for rehabilitation1) . One way to manage ambulatory difficulties is with an ankle-foot orthosis (AFO) or a foot-drop splint, which aims to stabilize the foot and ankle while weight-bearing and lift the toes while stepping1) . In stroke rehabilitation, various approaches, including robotic assistance, strength training, and task-related/virtual reality techniques, have been shown to improve motor function2) . The benefits of a high intensity stroke rehabilitation program are well established, and although no clear guidelines exist regarding the best levels of intensity in practice, the need for its incorporation into a therapy program is widely acknowledged2) . Repetitive facilitative exercises (RFE), which combine a high repetition rate and neurofacilitation, are a recently developed approach to rehabilitation of stroke-related limb impairment2–5) . In the RFE program, therapists use muscle spindle stretching and skin-generated reflexes to assist the patient’s efforts to move an affected joint5) . Previous studies have shown that an RFE program improved lower-limb motor performance (Brunnstrom Recovery Stage, foot tapping, and lower-limb strength) and the 10-m walk test in patients with brain damage3) . An AFO is an assistive device to help stroke patients with hemiplegia walk and stand. A properly prescribed AFO can improve gait performance and control abnormal kinematics arising from coordination deficits6) . Gait training with an AFO has been also reported to improve gait speed and balance in post-stroke patients7, 8) . Therefore, we hypothesized that short-term physiotherapy combining RFE and orthotic treatment would improve both lower-extremity motor performance and functional ambulation. The present study aimed to confirm the efficacy of a combination therapy consisting of RFE for the hemiplegic lower limb and gait training with AFO.
[Abstract] Combined tDCS and Vision Restoration Training in Subacute Stroke Rehabilitation: A Pilot Study
Visual field defects after posterior cerebral artery stroke can be improved by vision restoration training (VRT), but when combined with transcranial direct current stimulation (tDCS) which alters brain excitability, vision recovery can be potentiated in the chronic stage. To date the combination of VRT and tDCS has not been evaluated in post-acute stroke rehabilitation.
To determine whether combined tDCS and VRT can be effectively implemented in the early recovery phase following a stroke, we wished to explore the feasibility, safety and efficacy of an early intervention.
Open-label pilot study including a case series of seven tDCS/VRT versus a convenience sample of seven control patients (clinicalTrials.gov ID: NCT02935413).
Patients with homonymous visual field defects following a posterior cerebral artery stroke.
Seven homonymous hemianopia patients were prospectively treated with 10 sessions of combined tDCS (2mA, 10 daily sessions of 20 min) and VRT at 66 (±50) days on average post-stroke. Visual field recovery was compared with retrospective data of 7 controls, whose defect sizes and age of lesions were matched to the experimental subjects and who had received standard rehabilitation with compensatory eye movement and exploration training.
All seven patients of the treatment group completed the treatment protocol. Safety and acceptance were excellent, and patients reported occasional skin itching beneath the electrodes as the only minor side effect. Irrespective of their treatment, both groups (treatment and control) showed improved visual fields as documented by an increased mean sensitivity threshold in dB (decibel) in standard static perimetry. Recovery was significantly greater (p<.05) in tDCS/VRT patients (36.73 ± 37.0%) than in controls (10.74 ± 8.86).
In this open-label pilot study, tDCS/VRT in sub-acute stroke was safe, with excellent applicability and acceptance of the treatment. Preliminary effectiveness calculations show that tDCS/VRT may be superior to standard vision training procedures. A confirmatory, larger-sample, controlled, randomized and double-blind trial is now underway to compare real- vs. sham-tDCS supported visual field training in the early vision rehabilitation phase.
[Abstract] A portable and cost-effective upper extremity rehabilitation system for individuals with upper limb motor deficits
[Review Article] Effect of Virtual Reality on Postural and Balance Control in Patients with Stroke: A Systematic Literature Review – Full Text PDF
Objective. To critically evaluate the studies that were conducted over the past 10 years and to assess the impact of virtual reality on static and dynamic balance control in the stroke population.
Method. A systematic review of randomized controlled trials published between January 2006 and December 2015 was conducted. Databases searched were PubMed, Scopus, and Web of Science. Studies must have involved adult patients with stroke during acute, subacute, or chronic phase. All included studies must have assessed the impact of virtual reality programme on either static or dynamic balance ability and compared it with a control group. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies.
Results. Nine studies were included in this systematic review. The PEDro scores ranged from 4 to 9 points. All studies, except one, showed significant improvement in static or dynamic balance outcomes group.
Conclusions. This review provided moderate evidence to support the fact that virtual reality training is an effective adjunct to standard rehabilitation programme to improve balance for patients with chronic stroke. The effect of VR training in balance recovery is less clear in patients with acute or subacute stroke. Further research is required to investigate the optimum training intensity and frequency to achieve the desired outcome
[Abstract] Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. – PubMed
Mirror therapy (MT) has been proposed to improve the motor function of chronic individuals with stroke with mild to moderate impairment. With regards to severe upper limb paresis, MT has shown to provide limited motor improvement in the acute or sub-acute phase. However, no previous research has described the effects of MT in chronic individuals with stroke with severely impaired upper limb function.
The aim of this study was to determine the effectiveness of MT on chronic stroke survivors with severe upper-limb impairment in comparison with passive mobilization.
A randomized controlled trial.
Rehabilitative outpatient unit.
A total of 31 chronic subjects poststroke with severely impaired upper limb function were randomly assigned to either an experimental group (N.=15), or a control group (N.=16).
Twenty-four intervention sessions were performed for both groups. Each session included 45-minute period of MT (experimental group) or passive mobilization (control group), administered three days a week. Participants were assessed before and after the intervention with the Wolf Motor Function Test, the Fugl-Meyer Assessment, and the Nottingham Sensory Assessment.
Improvement in motor function was observed in both groups on the time (P=0.002) and ability (P=0.001) subscales of the Wolf Motor Function Test. No differences were detected in kinesthesis or stereognosis. However, the experimental group showed a significant improvement in tactile sensation that was mainly observed as an increased sensitivity to light touches.
In comparison with passive mobilization, MT in chronic stroke survivors with severely impaired upper-limb function may provide a limited but positive effect on light touch sensitivity while providing similar motor improvement.
CLINICAL REHABILITATION IMPACT:
MT is a therapeutic approach that can be used in the rehabilitation of severely impaired upper limb in chronic stroke survivors, specifically to address light touch sensitivity deficits.
We present a novel multi-user virtual reality (VR) environment for post-stroke rehabilitation that can be used independently in the home to improve upper extremity motor function. This project represents a collaborative multidisciplinary approach to upper extremity therapy that reinvents engagement with health, social communication and well-being for stroke survivors. This work is in the pre-clinical phase of an ongoing interdisciplinary research effort at the Rehabilitation Institute of Chicago which involves a team of artists, engineers, researchers and occupational therapists. This work bridges art, science and healthcare research. Our project attempts to extend traditional occupational therapy and make virtual reality art accessible for all people. It inspires a playful and natural social interaction in the comfort of the home setting for stroke survivors with hemiparesis by furthering social engagement through the rehabilitation exercises. It fosters interaction and collaboration between individual users and encourages the exchange of user-generated content. At the same time, the system captures continuous kinematic data, which can be used to better tailor therapy to the individual.
[Case Study] Effect of mental practice using inverse video of the unaffected upper limb in a subject with chronic hemiparesis after stroke -Full Text PDF
[Purpose] The aim of this case study was to investigate whether a method of mental practice (MP) using an inverse video of a subject’s unaffected limb to complement the vividness of motor imagery (MI) would be effective for improving affected upper limb function.
[Subjects and Methods] The participant was 60-year-old male in the chronic stage of stroke recovery with left sided hemiparesis. The design of the study was AB method of Single-System-Design. He performed the MP as a home program with DVD. The intervention lasted 30 minutes a session, twice a day, 5 times a week, over 6 weeks. The DVD was created using inverse video of his unaffected upper limb. Primary outcome measures were used the Fugl-Meyer Assessment for upper limb (FMA) and the Motor Activity Log (MAL) 3 times each baseline, intervention and follow-up. The subjective vividness of MI was assessed by the Visual Analog Scale (VAS).
[Results] FMA and MAL score during intervention was improved significantly comparing to baseline, and maintained in withdrawal. VAS score was improved in withdrawal comparing to baseline.
[Conclusion] Results suggested that effect of mental practice for stroke patients increased by vividness of motor imagery was improved by the inverse video.
Recent studies have shown that mental practice (MP) is which motor imagery (MI) is performed repeatedly can improve motor functions in patients after stroke; these effects have been demonstrated in clinical studies using randomized controlled trials1–5). An important aspect in mental practice is how vividly an individual can perform MI. To complement the vividness of MI, previous clinical studies used audio or visual guides during intervention and reported improvement of upper limb function and ADL1, 3).
However, there are some studies that vividness of MI differs depending on the specific features of the tasks and the subject’s ability to MI6, 7). Prior study reported that the vividness of MI was correlated with corticospinal excitability during MI8) and effect of MP was influenced by the vividness of MI. Particularly, in patients with severe sensory disturbance after stroke, excitability of the corticospinal tract of the affected side and ability for MI were significantly lower than in healthy controls and patients with pure motor strokes9). Therefore, it is more difficult for patients with sensory disturbance to perform MI vividly, which hinders demonstration of a significant effect of MP. Furthermore, since the effectiveness of MP differs depending on the method used to support MI, there is currently no effective and reproducible clinical method of MP. Therefore, this case study investigated whether a method of MP using an inverse video of a subject’s unaffected limb to complement the vividness of MI would be effective for improving affected upper limb function. In this study, we examined effects of how this MP using single-case design. …
[Αbstract] Using robot fully assisted functional movements in upper-limb rehabilitation of chronic stroke patients: preliminary results. – PubMed
Eur J Phys Rehabil Med. 2016 Nov 9. [Epub ahead of print]
BACKGROUND: Robotic rehabilitation is promising to promote function in stroke patients. The assist as needed training paradigm has shown to stimulate neuroplasticity but often cannot be used because stroke patients are too impaired to actively control the robot against gravity.
AIM: To verify whether a rehabilitation intervention based on robot fully assisted Reaching against gravity (RCH) and Hand-to-Mouth (HTM) can promote upper-limb function in chronic stroke.
DESIGN: Cohort study.
SETTING: Chronic stroke outpatients referring to the Robotic Rehabilitation Lab of a Rehabilitation Centre.
POPULATION: Ten chronic stroke patients with mild to moderate upper-limb hemiparesis.
METHODS: Patients underwent 12 sessions (3 per week) of robotic treatment using an end- effector robot Every session consisted of 20 minutes each of RCH and HtM; movements were fully assisted, but patients were asked to try to actively participate. The Fugl-Meyer Assessment (FMA) was the primary outcome measure; Medical Research Council and Modified Ashworth Scale were the secondary outcome measures.
RESULTS: All patients, but one, show functional improvements (FMA section A-D, mean increment 7.2±3.9 points, p<0.008).
CONCLUSION: This preliminary study shows that a robotic intervention based on functional movements, fully assisted, can be effective in promoting function in chronic stroke patients. These results are promising considering the short time of the intervention (1 month) and the time from the stroke event, which was large (27±20 months). A larger study, comprehensive of objective instrumental measures, is necessary to confirm the results.
CLINICAL REHABILITATION IMPACT: This intervention could be extended even to subacute stroke and other neurological disorders.
A decision support mobile app to help facilitate safety and independent living among TBI patients after returning home from a treatment facility is being developed in collaboration between researchers from Alabama-based Shepherd Center and ChartAssist LLC.
To assist with decision-making, the mobile app will be engineered to help improve the assessment of functional mobility, household activities, sleep, and safety risk.
Such decisions include making differential diagnostic assessments, selecting the most appropriate home- and community-based services and supports, measuring progress, and updating healthcare and supervision needs, according to the researchers, in a media release from Shepherd Center.
The app will also feature the ability to provide multidisciplinary treatment recommendations for TBI patients, as well as to set goals and track outcomes.
“I am thankful to have the opportunity to work with Shepherd Center and Dr Ron Seel, director of brain injury research, to help people with TBI and their families,” says Daniel Joye, president of ChartAssist, in the release. “The need for a decision support app is clear, and our company’s work on multidisciplinary rehabilitation in the mental health community is a great fit for helping people with brain injuries, their families and rehabilitation professionals.”
“I was quickly impressed by the innovative software development work that ChartAssist has done in the mental health community, “ states Ron Seel, PhD, the O. Wayne Rollins Director of Brain Injury Research at Shepherd Center, per the release.
“The software that ChartAssist has developed to facilitate person-centered, multidisciplinary rehabilitation assessment and treatment has broad applicability to helping people with brain injuries, who share many of the same chronic cognitive, behavioral, physical and health conditions experienced by people with mental health disabilities. Leveraging this work to develop secure, user-friendly, evidence-based decision support applications is a natural fit and could greatly improve people’s lives.”
Grants from the National Institute on Disability, Independent Living and Rehabilitation Research, as well as the Shepherd Center Foundation, provided the seed money to develop the app.
[Source: Shepherd Center]