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[ARTICLE] Effects of Biaxial Ankle Strengthening on Muscle Co-contraction during Gait in Chronic Stroke Patients: A Randomized Controlled Pilot Study – Full Text

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Highlights

• Introduced comprehensive Ankle Movement Training(AMT) for stroke patients.

• AMT improved ankle muscle strength and co-contraction during gait in stroke patients.

• Emphasizing a significant consequence of AMT on gait recovery in stroke patients.

Abstract

Introduction

Ankle dysfunction in patients with stroke is a common but serious cause of balance and gait impairments. However, comprehensive paretic ankle training seldom exists. Thus, we investigated the effects of a bi-axial ankle muscle training program using visual feedback as a means to improve ankle strength and performance of functional activities in patients with stroke.

Methods

This study was a randomized controlled pilot trial with concealed allocation and assessor blinding and intention-to-treat analysis. Twenty-five patients with stroke and difficulty in walking (e.g., foot drop) or ankle muscle weakness receiving inpatient rehabilitation were included. The experimental group underwent ankle muscle training consisting of passive stretching, control of ankle muscles, and active-resistive strengthening using visual feedback for 40 min per day, 5 times per week for 4 weeks. The control group underwent ankle-related physical therapy, including ankle range-of-motion exercises. The amount of time for training was equal between the two groups. The outcome measurements were isometric ankle contraction force to assess the strength of ankle muscles, ankle proprioception, Fugl–Meyer lower extremity score, Berg balance scale score, walking speed, and ankle co-contraction index to assess muscle efficiency during gait.

Results

The analysis revealed significant between-group differences in the ankle muscle strength in each direction (P < 0.05), Fugl–Meyer score (P < 0.01), and stance-phase co-contraction index (P < 0.05). After training, the experimental group displayed significant within-group differences in the strength of the ankle muscles in each direction (P < 0.01), ankle proprioception (P < 0.05), and walking speed (P < 0.05).

Conclusions

Our findings demonstrate the significant short-term effects of ankle muscle training on strength, walking speed, and muscle efficiency in patients with chronic stroke.

Abbreviations

AMTankle muscle trainingFM-LFugl–Meyer lower extremityBBSBerg balance scaleCIco-contraction indexROMrange of motion

Keywords

AnkleStrengtheningCoactivationFeedbackGaitStroke

1. INTRODUCTION

One of the most notable lower limb impairments after the development of central nervous system disorders, such as stroke, is the inability of the ankle joint to yield normal levels of muscle force. In a functional task, such as locomotion, muscle weakness of the ankle muscles is associated with reduced plantar flexion at the end of the stance phase and reduced dorsiflexion at the swing phase [1]. In particular, reduced forward propulsion owing to weakness of the plantar flexors can reduce the walking speed, and decreased dorsiflexion can lead to injurious falls [2]. Weakness of the ankle muscles in patients with stroke is more prominent than impairments of other proximal lower muscles; thus, affected patients often continuously need ankle–foot orthoses after discharge, which may inhibit their performance of daily activities in the long term [3].

There are a few targeted ankle muscle-stretching and -strengthening training programs or devices for patients with stroke [4]. Ankle muscle-stretching devices help increase ankle mobility (i.e., range of motion [ROM]), and ankle muscle-strengthening programs help improve muscle strength affected by reductions in muscle mass or inadequate voluntary activation that requires muscle contractions [5]. Previously, robot-assisted gait training has helped yield a simple repeated gait pattern movement, which was effective for improving the gait speed and aerobic function, but has seldom improved gait symmetry or ankle functions [6]. The anklebot is a rehabilitation robotics tool aiming to enhance ankle motor control using a target-based video game with visual feedback. The repetitive ankle dorsi-plantar flexions while seated were effective in improving the movement velocity, smoothness, and accuracy and the heel strikes during gait among moderately to highly functional patients with stroke [4]. Children with cerebral palsy have shown improvements in ankle biomechanics and lower limb motor control after receiving an intelligent intervention of passive stretching and active strengthening using a robotic training system [7]. However, previous studies have not considered the effect of ankle joint functionality on mobility and strength. Therefore, ankle muscle training (AMT) protocols should include comprehensive and effective ankle muscle-stretching and -strengthening rehabilitation training to improve ankle functions.

Appropriate control of muscle contraction in a target joint requires proper sensory information on its interaction with the rest of the body and with the environment. The proprioceptive feedback to motoneurons presents information on changes in the threshold muscle lengths or joint angles, thus setting the spatial activation range [8]. Therefore, the proprioceptive feedback and muscle coordination should be considered in ankle movement training in patients with stroke for improving ankle motor control. Proprioception has been defined as the ability to integrate sensory signals from various mechanoreceptors to determine body position and movement in space [9]. Because the ankle–foot complex, which provides essential proprioceptive feedback to enable adjustment of the ankle position and movements of the upper body, is the only body part that comes into contact with the ground, ankle proprioception plays a crucial role in balance control [10]. Therefore, it is important to improve AMT in consideration of the continuous interaction between the external environment and the ankle proprioceptive feedback for the proper control of ankle muscle contraction in patients with stroke.

Effectively enhancing ankle muscle strength and contraction control can increase the performance of activities while standing. There are a number of evidence stating that ankle muscle strength is correlated with gait velocity and temporal symmetry [2]. However, in a study on highly functional patients with stroke, impairments in ankle motor control, not ankle muscle strength, have been reported to predict functional deficits in walking [11]. In another study, both decreased ankle muscle strength and motor control independently contributed to gait impairment in patients with stroke [12]. As a factor that interferes with ankle motor control, abnormal muscle co-contraction between the ankle dorsiflexors and plantar flexors interferes with walking performance [13]. Further, the decreased muscle coordination with respect to the timing of muscle contraction is also caused by a decrease in ankle sensory function. Thus, ankle motor control involves more complex factors, such as muscle weakness, abnormal muscle activities, inadequate muscle co-activation, sensory and visual deficits, and noncontractile soft-tissue tightness. Therefore, protocols of AMT and assessments should consider these factors rather than providing simple single-directional repetitive movements.

Therefore, to provide comprehensive AMT for patients with stroke of various functional levels, we developed an AMT program using a custom ankle rehabilitation device that would apply three processes: passive stretching, control of ankle muscle contraction, and active-resistive strengthening. The aim of this study was to evaluate the effects of our AMT program on ankle muscle strength, ankle proprioception, balance ability, walking speed, and ankle muscle co-contraction during a gait cycle in patients with chronic stroke; we hypothesized that the proposed AMT program will affect their ankle muscle strength, ankle proprioception, balance ability, walking speed, and ankle muscle co-contraction.[…]

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[Abstract] Development of a Home-based Hand Rehabilitation Training and Compensation Feedback System

Abstract

Stroke survivors often show a limited recovery in the hand function even after the recovery period (3-6 months after stroke) and at-home hand rehabilitation is common due to the long-term nature of hand rehabilitation and the limited medical resources. We designed a home-based hand rehabilitation training and compensation feedback system. A low-cost simple orthosis glove, a set of hand rehabilitation training games and a compensation detection and feedback module were designed and developed in this system. A preliminary test was carried out on the system and the results showed that the training section (the orthosis glove and the hand rehabilitation training games) of the system was friendly to the subjects and the subjects were more receptive to the system and the compensation detection and feedback module had a promising performance. This system can not only provide high intensity and incentive hand rehabilitation training, but also guide the stroke patients to correct wrong upper body postures during the training process, which can achieve better rehabilitation results. The system has the potential to become an effective home-based hand rehabilitation training and compensation feedback system.

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[Abstract + References] Preliminary Results of a Brain-Computer Interface System based on Functional Electrical Stimulation and Avatar Feedback for Lower Extremity Rehabilitation of Chronic Stroke Patients

Abstract

Brain-Computer Interfaces (BCI) show important rehabilitation effects for patients after stroke. Previous studies have also shown improvements for patients that are in a chronic stage and/or have severe hemiparesis, and are particularly challenging for conventional rehabilitation techniques. For this pilot study three stroke patients in chronic phase with hemiparesis in the lower extremity were recruited. BCI system was based on the Motor Imagery (MI) with Functional Electrical Stimulation (FES) and Avatar feedback. The results show improvements in gait and balance measured with 10 Meter Walk Test (10MWT) and Timed Up and Go Test (TUG). Walking speed for 10MWT when walking speed was measured in fast velocity improved in average for 0.16 m/s. Improvements were also measured in ankle dorsiflexion movement ability measured with Range of Motion (ROM). The findings of the current study demonstrate this kind of rehabilitation approach could be effective. However further studies are needed including more patients.

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[Abstract] Current evidence on virtual reality and its potential usefulness in post-stroke neurorehabilitation

INTRODUCTION. Virtual reality therapy (VRT) constitutes a powerful and motivating tool for stroke patients to actively participate in the process of neurorehabilitation, providing augmented performance feedback, with the aim of achieving better therapeutic results owing to the enhancing of neuroplasticity mechanisms.

AIM. To report the most relevant data about the applications of VRT in the post-stroke neurorehabilitation. DEVELOPMENT. We conducted a PubMed search for articles, latest books, leading clinical practice guidelines, and scientific societies, regarding such applications.

CONCLUSIONS. Different performed randomized clinical trials (RCT) show that VRT safely facilitates in a statistically significant way motor and functional recovery of upper limb, gait, balance, quality of life related to health, and activities of daily living, together with conventional therapy, but have no clearly demonstrated overall superiority to conventional therapy. In this regard, underlying specific mechanisms remain elusive at this stage. Future RCT should define the good responder stroke patient profile based on the VRT used in conjunction with conventional therapy, allowing the generation of neurorehabilitation approaches that combine a customized immersive VRT with the clinical experience of the therapists, to maximize the results. It is necessary to carry out well-designed RCT, including larger samples of appropriately selected stroke subjects, to draft a consensus document that allows recommending, with a greater level of evidence and on a widespread basis, the implementation of VRT as add-on therapy in post-stroke neurorehabilitation. As well as to determine if the beneficial effects are maintained in the long term and to clarify the most suitable treatment schedule.


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[Abstract] Virtual Reality based Therapy Modules for Rehabilitation of Upper-limb Movements of Stroke Patients: A Trial Study – Full Text PDF

Abstract

Traditional physical therapeutic sessions for stroke inflicted patients include- mobilisation, strengthening and stretching exercises of the affected limb. These methods proved to be advantageous in regaining lost strength, but seemed to be boring and less engaging. Virtual Reality techniques of rehabilitation are involving and excite patient’s interest to participate. This research is based on improving upper extremity functions of left or right hemiplegic patients using Virtual Reality based therapy modules. The system was tried upon 5 stroke patients who were regular visitors in the occupational therapy department of the hospital, between age group: 25–50 years whose upper limb motion was restricted. After practicing on a regular basis, the subjects attained easy arm movement and reduced shoulder flexion.

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Source: http://nopr.niscair.res.in/handle/123456789/55427

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[Abstract] DESC glove: Prototyping a novel wearable device for post-stroke hand rehabilitation

Abstract

The human brain integrates tactile sensory information from the fingertips to efficiently manipulate objects. Sensory impairments due to neurological disorders, e.g. stroke, largely reduce hand dexterity and the ability to perform daily living activities. Several feedback augmentation techniques have been investigated for rehabilitative purposes with promising outcomes. However, they often require the use of unpractical, expensive, or complex devices. In this work we propose the delivery of vibrotactile feedback based on the Discrete Event-driven Sensory feedback Control (DESC) to promote motor learning in post stroke rehabilitation. For this purpose, we prototyped a novel wearable device, namely the DESC glove. It consisted of a soft glove instrumented with PolyVinylidene Fluoride (PVDF) sensors at the fingertips and eccentric-mass vibration actuators to be worn on the forearm. We proceeded with the characterization of the device, which resulted in promising outcomes. The DESC glove was tested with ten healthy participants subsequently in a pick and lift timed task. The effects of augmented vibrotactile feedback were assessed comparing it to a baseline, consisting of wearing the device unpowered. The results of this pilot study showed a decrease in the time necessary to perform the task, a reduction in the time delay from load force to grip force activation and a diminishing of the grip force applied on the object, which led to a lower breakage rate in the intervention condition. These promising outcomes encourage further experiments with stroke survivors to validate the effectiveness of the device to improve hand dexterity and promote stroke rehabilitation.

via DESC glove | TU Delft Repositories

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[ARTICLE] Feedback Design in Targeted Exercise Digital Biofeedback Systems for Home Rehabilitation: A Scoping Review – Full Text PDF

Digital biofeedback systems (DBSs) are used in physical rehabilitation to improve outcomes by engaging and educating patients and have the potential to support patients while doing targeted exercises during home rehabilitation. The components of feedback (mode, content, frequency and timing) can influence motor learning and engagement in various ways. The feedback design used in DBSs for targeted exercise home rehabilitation, as well as the evidence underpinning the feedback and how it is evaluated, is not clearly known. To explore these concepts, we conducted a scoping review where an electronic search of PUBMED, PEDro and ACM digital libraries was conducted from January 2000 to July 2019. The main inclusion criteria included DBSs for targeted exercises, in a home rehabilitation setting, which have been tested on a clinical population. Nineteen papers were reviewed, detailing thirteen different DBSs. Feedback was mainly visual, concurrent and descriptive, frequently providing knowledge of results. Three systems provided clear rationale for the use of feedback. Four studies conducted specific evaluations of the feedback, and seven studies evaluated feedback in a less detailed or indirect manner. Future studies should describe in detail the feedback design in DBSs and consider a robust evaluation of the feedback element of the intervention to determine its efficacy.

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via Feedback Design in Targeted Exercise Digital Biofeedback Systems for Home Rehabilitation: A Scoping Review – Sensors – X-MOL

 

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[Abstract] Myoelectric Computer Interface Training for Reducing Co-Activation and Enhancing Arm Movement in Chronic Stroke Survivors: A Randomized Trial

Background. Abnormal muscle co-activation contributes to impairment after stroke. We developed a myoelectric computer interface (MyoCI) training paradigm to reduce abnormal co-activation. MyoCI provides intuitive feedback about muscle activation patterns, enabling decoupling of these muscles.

Objective. To investigate tolerability and effects of MyoCI training of 3 muscle pairs on arm motor recovery after stroke, including effects of training dose and isometric versus movement-based training.

Methods. We randomized chronic stroke survivors with moderate-to-severe arm impairment to 3 groups. Two groups tested different doses of isometric MyoCI (60 vs 90 minutes), and one group tested MyoCI without arm restraint (90 minutes), over 6 weeks. Primary outcome was arm impairment (Fugl-Meyer Assessment). Secondary outcomes included function, spasticity, and elbow range-of-motion at weeks 6 and 10.

Results. Over all 32 subjects, MyoCI training of 3 muscle pairs significantly reduced impairment (Fugl-Meyer Assessment) by 3.3 ± 0.6 and 3.1 ± 0.7 (P < 10−4) at weeks 6 and 10, respectively. Each group improved significantly from baseline; no significant differences were seen between groups. Participants’ lab-based and home-based function also improved at weeks 6 and 10 (P ≤ .01). Spasticity also decreased over all subjects, and elbow range-of-motion improved. Both moderately and severely impaired patients showed significant improvement. No participants had training-related adverse events. MyoCI reduced abnormal co-activation, which appeared to transfer to reaching in the movement group.

Conclusions. MyoCI is a well-tolerated, novel rehabilitation tool that enables stroke survivors to reduce abnormal co-activation. It may reduce impairment and spasticity and improve arm function, even in severely impaired patients.

 

via Myoelectric Computer Interface Training for Reducing Co-Activation and Enhancing Arm Movement in Chronic Stroke Survivors: A Randomized Trial – Emily M. Mugler, Goran Tomic, Aparna Singh, Saad Hameed, Eric W. Lindberg, Jon Gaide, Murad Alqadi, Elizabeth Robinson, Katherine Dalzotto, Camila Limoli, Tyler Jacobson, Jungwha Lee, Marc W. Slutzky, 2019

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[Abstract] Virtual Reality for Upper Limb Rehabilitation in Subacute and Chronic Stroke: A Randomized Controlled Trial – Archives of Physical Medicine and Rehabilitation

Η εικόνα ίσως περιέχει: κείμενο

Highlights

• Combined reinforced feedback in virtual environment with conventional rehabilitation treatment provides clinically meaningful improvements.

• Effectiveness of reinforced feedback in virtual environment is comparable for patients with ischemic and hemorrhagic stroke.

• Effectiveness of virtual therapy remains sensitive to time since stroke onset.

• Effectiveness of virtual therapy does not depend on age and sex.

Abstract

Objective

To evaluate the effectiveness of reinforced feedback in virtual environment (RFVE) treatment combined with conventional rehabilitation (CR) in comparison with CR alone, and to study whether changes are related to stroke etiology (ie, ischemic, hemorrhagic).

Design

Randomized controlled trial.

Setting

Hospital facility for intensive rehabilitation.

Participants

Patients (N=136) within 1 year from onset of a single stroke (ischemic: n=78, hemorrhagic: n=58).

Interventions

The experimental treatment was based on the combination of RFVE with CR, whereas control treatment was based on the same amount of CR. Both treatments lasted 2 hours daily, 5d/wk, for 4 weeks.

Main Outcome Measures

Fugl-Meyer upper extremity scale (F-M UE) (primary outcome), FIM, National Institutes of Health Stroke Scale (NIHSS), and Edmonton Symptom Assessment Scale (ESAS) (secondary outcomes). Kinematic parameters of requested movements included duration (time), mean linear velocity (speed), and number of submovements (peak) (secondary outcomes).

Results

Patients were randomized in 2 groups (RFVE with CR: n=68, CR: n=68) and stratified by stroke etiology (ischemic or hemorrhagic). Both groups improved after treatment, but the experimental group had better results than the control group (Mann-Whitney U test) for F-M UE (P<.001), FIM (P<.001), NIHSS (P≤.014), ESAS (P≤.022), time (P<.001), speed (P<.001), and peak (P<.001). Stroke etiology did not have significant effects on patient outcomes.

Conclusions

The RFVE therapy combined with CR treatment promotes better outcomes for upper limb than the same amount of CR, regardless of stroke etiology.

via Virtual Reality for Upper Limb Rehabilitation in Subacute and Chronic Stroke: A Randomized Controlled Trial – Archives of Physical Medicine and Rehabilitation

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[ARTICLE] Does motivation matter in upper-limb rehabilitation after stroke? ArmeoSenso-Reward: study protocol for a randomized controlled trial – Full Text

Abstract

Background

Fifty percent of all stroke survivors remain with functional impairments of their upper limb. While there is a need to improve the effectiveness of rehabilitative training, so far no new training approach has proven to be clearly superior to conventional therapy. As training with rewarding feedback has been shown to improve motor learning in humans, it is hypothesized that rehabilitative arm training could be enhanced by rewarding feedback. In this paper, we propose a trial protocol investigating rewards in the form of performance feedback and monetary gains as ways to improve effectiveness of rehabilitative training.

Methods

This multicentric, assessor-blinded, randomized controlled trial uses the ArmeoSenso virtual reality rehabilitation system to train 74 first-ever stroke patients (< 100 days post stroke) to lift their impaired upper limb against gravity and to improve the workspace of the paretic arm. Three sensors are attached to forearm, upper arm, and trunk to track arm movements in three-dimensional space while controlling for trunk compensation. Whole-arm movements serve as input for a therapy game. The reward group (n = 37) will train with performance feedback and contingent monetary reward. The control group (n = 37) uses the same system but without monetary reward and with reduced performance feedback. Primary outcome is the change in the hand workspace in the transversal plane. Standard clinical assessments are used as secondary outcome measures.

Discussion

This randomized controlled trial will be the first to directly evaluate the effect of rewarding feedback, including monetary rewards, on the recovery process of the upper limb following stroke. This could pave the way for novel types of interventions with significantly improved treatment benefits, e.g., for conditions that impair reward processing (stroke, Parkinson’s disease).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2328-2) contains supplementary material, which is available to authorized users.

 

Background

After stroke, 50% of survivors are left with impairments in arm function [12], which is associated with reduced health-related quality of life [3]. While there is evidence for a positive correlation between therapy dose and functional recovery [46], a higher therapy dose is challenging to implement, as it usually leads to an increase in costs commonly not covered by health insurances. However, when dose is matched, most randomized controlled trials introducing new types of rehabilitative interventions (e.g., robot-assisted therapy [7]) failed to show a superior effect compared to standard therapy. Thus, the need for improving therapy effectiveness remains. In search for elements of effective therapy, we hypothesize that performance feedback and monetary rewards can improve effectiveness.

It has been shown that reward enhances procedural [8] and motor-skill learning [910] and has a positive effect on motor adaptation [11]. Rewards mainly improve retention of motor skills and motor adaptations [911]. This effect was not explained by training duration (dose) as rewarded and non-rewarded groups underwent similar training schedules [811]. In a functional magnetic resonance imaging (fMRI) study, Widmer et al. reported that adding monetary rewards after good performance leads to better consolidation and higher ventral striatum activation than knowledge of performance alone [10]. The striatum is a key locus of reward processing [12], and its activity was shown to be increased by both intrinsic and extrinsic reward [13]. Being a brain structure that receives substantial dopaminergic input from the midbrain, ventral striatal activity can be seen as a surrogate marker for dopaminergic activity in the substantia nigra/ventral tegmental area [14]. In rodents, Hosp et al. found that dopaminergic projections from the midbrain also terminate directly in the primary motor cortex (M1) [15]. Dopamine in M1 is necessary for long-term potentiation of certain cortico-cortical connections and successful motor-skill learning [16]. As mechanisms of motor learning are also thought to play a role in motor recovery [17], rehabilitative interventions may benefit from neuroplasticity enhanced by reward.

Here, we describe a trial protocol to test the effect of enhanced feedback and reward on arm rehabilitation after stroke at matched training dose (time and intensity). We use the ArmeoSenso, a standardized virtual reality (VR)-based training system [18] that is delivered in two versions for two different study groups, one version with and one without reward and enhanced performance feedback.[…]

 

Continue —>  Does motivation matter in upper-limb rehabilitation after stroke? ArmeoSenso-Reward: study protocol for a randomized controlled trial

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Fig. 2
a Healthy subject using the ArmeoSenso training system. b Arm workspace assessment: gray cubic voxels arranged in the transverse plane reflecting 10 cm × 10 cm active workspace relative to the patient’s trunk

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