Posts Tagged Feedback

[Abstract] An Interactive System for Fine Motor Rehabilitation – Rehabilitation Nursing



One of the most important aspects in neuromotor rehabilitation is the need of feedback for patients. The rehabilitation system’s efficiency relies on the therapist’s judgment, who tells the patient whether he/she is performing the exercises correctly. This process may be quite subjective, because it depends on the therapist’s personal opinion. On the other hand, recent studies have shown that vibrotactile biofeedback can improve the effectiveness of interaction as it is a very helpful tool in the physiological process of neuromotor rehabilitation.


We designed an interactive system focused on rehabilitation of the upper limbs using active markers and image processing, which consists of drawing activities in both augment and virtual reality.


System gives to the user a correction through multimodal stimuli feedback (vibrotactile, visual and sound stimulus) and force measurement to let the patients know if they are not achieving the tasks’ goals.


The developed system could be used by nursing assistants to better help patients. The purpose of this system was assisting patients with injuries to shoulders, elbows or wrists, providing an audio-vibrotactile feedback as a factor of correction in the movements of the patient. To examine our system, 11 participants were asked to participate in an experiment where they performed activities focussed to strengthen their fine motor movements.

Conclusions and Clinical Relevance

Our results show that patients’ fine motor skills improved 10% on average by comparing their error rates throughout the sessions.

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Source: An Interactive System for Fine Motor Rehabilitation – Posada-Gómez – 2016 – Rehabilitation Nursing – Wiley Online Library

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[ARTICLE] Wristband Accelerometers to motiVate arm Exercise after Stroke (WAVES): study protocol for a pilot randomized controlled trial – Full Text



Loss of upper limb function affects up to 85 % of acute stroke patients. Recovery of upper limb function requires regular intensive practise of specific upper limb tasks. To enhance intensity of practice interventions are being developed to encourage patients to undertake self-directed exercise practice. Most interventions do not translate well into everyday activities and stroke patients continue to find it difficult remembering integration of upper limb movements into daily activities. A wrist-worn device has been developed that monitors and provides ‘live’ upper limb activity feedback to remind patients to use their stroke arm in daily activities (The CueS wristband). The aim of this trial is to assess the feasibility of a multi-centre, observer blind, pilot randomised controlled trial of the CueS wristband in clinical stroke services.


This pilot randomised controlled feasibility trial aims to recruit 60 participants over 15 months from North East England. Participants will be within 3 months of stroke which has caused new reduced upper limb function and will still be receiving therapy. Each participant will be randomised to an intervention or control group. Intervention participants will wear a CueS wristband (between 8 am and 8 pm) providing “live” feedback towards pre-set movement goals through a simple visual display and vibration prompts whilst undertaking a 4-week upper limb therapy programme (reviewed twice weekly by an occupational/physiotherapist). Control participants will also complete the 4-week upper limb therapy programme but will wear a ‘sham’ CueS wristband that monitors upper limb activity but provides no feedback. Outcomes will determine study feasibility in terms of recruitment, retention, adverse events, adherence and collection of descriptive clinical and accelerometer motor performance data at baseline, 4 weeks and 8 weeks.


The WAVES study will address an important gap in the evidence base by reporting the feasibility of undertaking an evaluation of emerging and affordable technology to encourage impaired upper limb activity after stroke. The study will establish whether the study protocol can be supported by clinical stroke services, thereby informing the design of a future multi-centre randomised controlled trial of clinical and cost-effectiveness.

Continue —> Wristband Accelerometers to motiVate arm Exercise after Stroke (WAVES): study protocol for a pilot randomized controlled trial | Trials | Full Text

Fig. 1 Study flow diagram

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Rehabilitation is the process of training for someone in order to recover or improve their lost functions caused by neurological deficits. The upper limb rehabilitation system provides relearning of motor skills that are lost due to any neurological injuries via motor rehabilitation training. The process of motor rehabilitation is a form of motor learning via practice or experience. It requires thorough understanding and examination of neural processes involved in producing movement and learning as well as the medical aspects that may affect the central nervous system (CNS) or peripheral nervous system (PNS) in order to develop an effective treatment system. Although there are numerous rehabilitation systems which have been proposed in literatures, a low cost upper limb rehabilitation system that maximizes the functional recovery by stimulating the neural plasticity is not widely available. This is due to lack of motivation during rehabilitation training, lack of real time biofeedback information with complete database, the requirement of one to one attention between physiotherapist and patient, the technique to stimulate human neural plasticity.

Therefore, the main objective of this thesis is to develop a novel low cost rehabilitation system that helps recovery not only from loss of physical functions, but also from loss of cognitive functions to fulfill the aforementioned gaps via multimodal technologies such as augmented reality (AR), computer vision and signal processing. In order to fulfill such ambitious objectives, the following contributions have been implemented.

Firstly, since improvements in physical functions are targeted, the Rehabilitation system with Biofeedback simulation (RehaBio) is developed. The system enhances user’s motivation via game based therapeutic exercises and biofeedback. For this, AR based therapeutic games are developed to provide eye-hand coordination with inspiration in motivation via immediate audio and visual feedback. All the exercises in RehaBio are developed in a safe training environment for paralyzed patients. In addition to that, realtime biofeedback simulation is developed and integrated to serve in two ways: (1) from the patient’s point of view, the biofeedback simulation motivates the user to execute the movements since it will animate the different muscles in different colors, and (2) from the therapist’s point of view, the muscle simulations and EMG threshold level can be evaluated as patient’s muscle performance throughout the rehabilitation process.

Secondly, a new technique that stimulates the human neural plasticity is proposed. This is a virtual human arm (VHA) model that driven by proposed continuous joint angle prediction in real time based on human biological signal, Electromyogram (EMG). The VHA model simulation aims to create the illusion environment in Augmented Realitybased Illusion System (ARIS).

Finally, a complete novel upper limb rehabilitation system, Augmented Reality-based Illusion System (ARIS) is developed. The system incorporates some of the developments in RehaBio and real time VHA model to develop the illusion environment. By conducting the rehabilitation training with ARIS, user’s neural plasticity will be stimulated to reestablish the neural pathways and synapses that are able to control mobility. This is achieved via an illusion concept where an illusion scene is created in AR environment to remove the impaired real arm virtually and replace it with VHA model to be perceived as part of the user’s own body. The job of the VHA model in ARIS is when the real arm cannot perform the required task, it will take over the job of the real one and will let the user perceive the sense that the user is still able to perform the reaching movement by their own effort to the destination point. Integration with AR based therapeutic exercises and motivated immediate intrinsic and extrinsic feedback in ARIS leads to serve as a novel upper limb rehabilitation system in a clinical setting.

The usability tests and verification process of the proposed systems are conducted and provided with very encouraging results. Furthermore, the developments have been demonstrated to the clinical experts in the rehabilitation field at Port Kembla Hospital. The feedback from the professionals is very positive for both the RehaBio and ARIS systems and they have been recommended to be used in the clinical setting for paralyzed patients.

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[Abstract] Virtual Reality to Assess and Treat Lower Extremity Disorders in Post-stroke Patients


Introduction: This article is part of the Focus Theme of Methods of Information in Medicine on “Methodologies, Models and Algorithms for Patients Rehabilitation”.

Objectives: To identify support of a virtual reality system in the kinematic assessment and physiotherapy approach to gait disorders in individuals with stroke.

Methods: We adapt Virtual Reality Rehabilitation System (VRRS), software widely used in the functional recovery of the upper limb, for its use on the lower limb of hemiplegic patients. Clinical scales have been used to relate them with the kinematic assessment provided by the system. A description of the use of reinforced feedback provided by the system on the recovery of deficits in several real cases in the field of physiotherapy is performed. Specific examples of functional tasks have been detailed, to be considered in creating intelligent health technologies to improve post-stroke gait.

Results: Both participants improved scores on the clinical scales, the kinematic parameters in leg stance on plegic lower extremity and walking speed > Minimally Clinically Important Difference (MCID).

Conclusion: The use of the VRRS software attached to a motion tracking capture system showed their practical utility and safety in enriching physiotherapeutic assessment and treatment in post-stroke gait disorders.

Source: Methods of Information in Medicine: December 10, 2015

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[ARTICLE] Robot-Assisted Reach Training for Improving Upper Extremity Function of Chronic Stroke – Full Text PDF/HTML


Stroke, as a major risk factor for chronic impairment of upper limb function, can severely restrict the activities of daily living. Recently, robotic devices have been used to enhance the functional upper extremity movement of stroke patients.

The purpose of the current study was to assess whether a robot-assisted reach training program using a whole arm manipulator (WAM) could improve upper extremity kinematic performance and functional movement for chronic stroke patients. Using a single-group design, this study followed 10 people with chronic stroke (6 men, 61.5 years; Mini-Mental State Examination score: 27.0; onset duration: 8.9 years). WAM with seven degrees of freedom for the shoulder, elbow, and wrist joints was used during robot-assisted reach exercises.

Subjects participated in the training program for 40 minutes per day, 2 times a week, for 4 weeks. The main outcome measures were upper extremity kinematic performance (movement velocity) for three directions and functional movement (Action Research Arm Test). Upper extremity kinematic performance and functional movement measures were performed three times: at baseline, during intervention (at 2 weeks), and post intervention. Upper extremity kinematic performance and functional movement showed improvement after two weeks (P < 0.05) and four weeks (P < 0.05) of training compared to baseline.

The findings of the current study demonstrated the positive effects of short-term robot-assisted reach training on upper extremity kinematic performance as well as functional movement in individuals with chronic stroke. In addition, the findings of the current study may provide valuable information for subsequent randomized controlled trials.

Source: Robot-Assisted Reach Training for Improving Upper Extremity Function of Chronic Stroke

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[Systematic Review] A Decade of Progress Using Virtual Reality for Poststroke Lower Extremity Rehabilitation: Systematic Review of the Intervention Methods – Full Text PDF

Objective. To develop a systematic review of the literature, to describe the different virtual reality (VR) interventions and interactive videogames applied to the lower extremity (LE) of stroke patients, and to analyse the results according to the most frequently used outcome measures.

Material and Methods. An electronic search of randomized trials between January 2004 and January 2014 in different databases (Medline, Cinahl, Web of Science, PEDro, and Cochrane) was carried out. Several terms (virtual reality, feedback, stroke, hemiplegia, brain injury, cerebrovascular accident, lower limb, leg, and gait) were combined, and finally 11 articles were included according to the established inclusion and exclusion criteria.

Results.The reviewed trials showed a high heterogeneity in terms of study design and assessment tools, which makes it difficult to compare and analyze the different types of interventions. However, most of them found a significant improvement on gait speed, balance and motor function, due to VR intervention.

Conclusions. Although evidence is limited, it suggests that VR intervention (more than 10 sessions) in stroke patients may have a positive impact on balance, and gait recovery. Better results were obtained when a multimodal approach, combining VR and
conventional physiotherapy, was used. Flexible software seems to adapt better to patients’ requirements, allowing more specific and individual treatments.

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[ARTICLE] Feedback Received While Practicing Everyday Activities During Rehabilitation After Stroke: An Observational Study


Background and Purpose

The provision of feedback is important for effective skill learning. The purpose of this study was to examine the nature of feedback provided during the practice of everyday activities (such as standing up, walking, and reaching and grasping objects) during stroke rehabilitation, both when the therapist was present and when the patient was practicing alone.


Design: A cross-sectional observational study of the feedback received during rehabilitation by people who had had a stroke was conducted. Forty unique patient–therapist dyads were observed during 30 minutes of actual practice of everyday activities with data collected through behavioural mapping. The following was recorded: the activity practiced, whether the therapist was present, whether feedback was provided verbally or by equipment, and the content of feedback. Participants: A sample of all therapists providing rehabilitation within one Australian health service and their patients who had had a stroke. Measures: Quantity, frequency, mode (verbal or equipment) and content (information feedback, motivational statements, unrelated or none) of feedback during the practice of everyday activities were determined.


For 68% of the time that patients were practicing activities, they received ≥1 occasion of feedback/minute. When the therapist was present, the frequency of motivational statements was more than four times greater, at 1.32 (SD 0.6) occasions/minute, than information feedback. For 25% of the time, the therapist was not present, and no feedback was provided.


Given the importance of specific content for learning, therapists could replace some motivational statements with information feedback. When practicing alone, information feedback could be provided by commercially available biofeedback or customized equipment. Copyright © 2014 John Wiley & Sons, Ltd.

via Feedback Received While Practicing Everyday Activities During Rehabilitation After Stroke: An Observational Study – Stanton – 2014 – Physiotherapy Research International – Wiley Online Library.

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[REVIEW] The Application of Cycling and Cycling Combined with Feedback in the Rehabilitation of Stroke Patients: A Review

Stroke is a leading cause of long-term disabilities, such as hemiparesis, inability to walk without assistance, and dependence of others in the activities of daily living. Motor function rehabilitation after stroke demands for methods oriented to the recovery of the walking capacity. Because of the similarities with walking, cycling leg exercise may present a solution to this problem.

The aim of this article is to review the state of the art applications of cycling leg exercise as a

  1. motor function rehabilitation method
  2. aerobic training method for stroke patients as well as the commonly used
  3. assessment tools.

The cycling characteristics and applications, the applied test protocols as well as the tools used to assess the state and the recovery of patients and types of cycling devices are presented. In addition, the potential benefits of the use of other therapies, like feedback, together with cycling are explored. The application of cycling leg exercise alone and combined with feedback in stroke rehabilitation approaches has shown promising results.

Positive effects on motor abilities were found in subacute and chronic patients. However, larger and normalized studies and assessments are needed because there is a high heterogeneity in the patients’ characteristics, protocols and metrics. This wil allow the comparison between different studies related with cycling.

via The Application of Cycling and Cycling Combined with Feedback in the Rehabilitation of Stroke Patients: A Review.

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[ARTICLE] Upper extremity rehabilitation of stroke: Facilitation of corticospinal excitability using virtual mirror paradigm – Full Text


Background: Several experimental studies in stroke patients suggest that mirror therapy and various virtual reality programs facilitate motor rehabilitation. However, the underlying mechanisms for these therapeutic effects have not been previously described.

Objectives: We attempted to delineate the changes in corticospinal excitability when individuals were asked to exercise their upper extremity using a real mirror and virtual mirror. Moreover, we attempted to delineate the role of visual modulation within the virtual environment that affected corticospinal excitability in healthy subjects and stroke patients.

Methods: A total of 18 healthy subjects and 18 hemiplegic patients were enrolled into the study. Motor evoked potential (MEP)s from transcranial magnetic stimulation were recorded in the flexor carpi radialis of the non-dominant or affected upper extremity using three different conditions: (A) relaxation; (B) real mirror; and (C) virtual mirror. Moreover, we compared the MEPs from the virtual mirror paradigm using continuous visual feedback or intermittent visual feedback.

Results: The rates of amplitude increment and latency decrement of MEPs in both groups were higher during the virtual mirror task than during the real mirror. In healthy subjects and stroke patients, the virtual mirror task with intermittent visual feedback significantly facilitated corticospinal excitability of MEPs compared with continuous visual feedback.

Conclusion: Corticospinal excitability was facilitated to a greater extent in the virtual mirror paradigm than in the real mirror and in intermittent visual feedback than in the continuous visual feedback, in both groups. This provides neurophysiological evidence supporting the application of the virtual mirror paradigm using various visual modulation technologies to upper extremity rehabilitation in stroke patients.

Keywords: Stroke; Corticospinal excitability; Transcranial magnetic stimulation; Virtual reality; Feedback

Read Article –> JNER | Full text | Upper extremity rehabilitation of stroke: Facilitation of corticospinal excitability using virtual mirror paradigm.

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[ARTICLE] Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology.


Purpose: This paper proposes a novel system (using the Nintendo Wii remote) that offers customised, non-immersive, virtual reality-based, upper-limb stroke rehabilitation and reports on promising preliminary findings with stroke survivors.

Method: The system novelty lies in the high accuracy of the full kinematic tracking of the upper limb movement in real-time, offering strong personal connection between the stroke survivor and a virtual character when executing therapist prescribed adjustable exercises/games. It allows the therapist to monitor patient performance and to individually calibrate the system in terms of range of movement, speed and duration.

Results: The system was tested for acceptability with three stroke survivors with differing levels of disability. Participants reported an overwhelming connection with the system and avatar. A two-week, single case study with a long-term stroke survivor showed positive changes in all four outcome measures employed, with the participant reporting better wrist control and greater functional use. Activities, which were deemed too challenging or too easy were associated with lower scores of enjoyment/motivation, highlighting the need for activities to be individually calibrated.

Conclusions: Given the preliminary findings, it would be beneficial to extend the case study in terms of duration and participants and to conduct an acceptability and feasibility study with community dwelling survivors.

Implications for Rehabilitation

  • Low-cost, off-the-shelf game sensors, such as the Nintendo Wii remote, are acceptable by stroke survivors as an add-on to upper limb stroke rehabilitation but have to be bespoked to provide high-fidelity and real-time kinematic tracking of the arm movement.
  • Providing therapists with real-time and remote monitoring of the quality of the movement and not just the amount of practice, is imperative and most critical for getting a better understanding of each patient and administering the right amount and type of exercise.
  • The ability to translate therapeutic arm movement into individually calibrated exercises and games, allows accommodation of the wide range of movement difficulties seen after stroke and the ability to adjust these activities (in terms of speed, range of movement and duration) will aid motivation and adherence – key issues in rehabilitation.
  • With increasing pressures on resources and the move to more community-based rehabilitation, the proposed system has the potential for promoting the intensity of practice necessary for recovery in both community and acute settings.

via Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology, Disability and Rehabilitation: Assistive Technology, Informa Healthcare.

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