Posts Tagged hemiparesis

[Abstract] Adaptive Physical Activity for Stroke: An Early-Stage Randomized Controlled Trial in the United States

Background. As stroke survival improves, there is an increasing need for effective, low-cost programs to reduce deconditioning and improve mobility.

Objective. To conduct a phase II trial examining whether the community-based Italian Adaptive Physical Activity exercise program for stroke survivors (APA-Stroke) is safe, effective, and feasible in the United States.

Methods. In this single-blind, randomized controlled trial, 76 stroke survivors with mild to moderate hemiparesis >6 months were randomized to either APA-Stroke (N = 43) or Sittercise (N = 33). APA-Stroke is a progressive group exercise regimen tailored to hemiparesis that includes walking, strength, and balance training. Sittercise, a seated, nonprogressive aerobic upper body general exercise program, served as the control. Both interventions were 1 hour, 3 times weekly, in 5 community locations, supervised by exercise instructors.

Results. A total of 76 participants aged 63.9 ± 1.2 years, mean months poststroke 61.8 ± 9.3, were included. There were no serious adverse events; completion rates were 58% for APA-Stroke, 70% for Sittercise. APA-Stroke participants improved significantly in walking speed. Sample size was inadequate to demonstrate significant between-group differences. Financial and logistical feasibility of the program has been demonstrated. Ongoing APA classes have been offered to >200 participants in county Senior Centers since study completion.

Conclusion. APA-Stroke shows great promise as a low-cost, feasible intervention. It significantly increased walking speed. Safety and feasibility in the US context are demonstrated. A pivotal clinical trial is required to determine whether APA-Stroke should be considered standard of care.

via Adaptive Physical Activity for Stroke: An Early-Stage Randomized Controlled Trial in the United States – Mary Stuart, Alexander W. Dromerick, Richard Macko, Francesco Benvenuti, Brock Beamer, John Sorkin, Sarah Chard, Michael Weinrich, 2019

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[WEB SITE] Medical Device as Post-Stroke Spasticity Reducer Shows Promise

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An investigational, non-invasive medical device shows promise as a possible treatment for spasticity in patients who have experienced a stroke, Feinstein Institutes for Medical Research scientists report.

Their study, published in Springer Nature’s Bioelectronic Medicine, suggests that trans-spinal direct current stimulation and peripheral nerve direct current stimulation significantly reduced upper limb spasticity in participants who experienced a stroke.

Spasticity is a residual inability of the brain to control muscle tone. It increases muscle stiffness, which inhibits movement of the hands, arms, and legs; can affect the face and throat; and sometimes causes pain.

Efforts to treat upper limb spasticity have focused on intensive, repetitive, activity-dependent learning; however, it is common to experience residual spasticity despite aggressive therapy. When spasticity continues to worsen and causes pain, the standard-of-care is botox (botulinum toxin) injection, according to a media release from Feinstein Institutes for Medical Research.

“Spasticity is a persistent and common inhibitor of movement in patients with chronic stroke, and it has been a great hurdle as we continue to use intensive training to assist motor recovery,” says Bruce T. Volpe, MD, professor at the Feinstein Institutes and lead author of the paper, in the release.

“The surprise in these clinical results were the improved motor functions that apparently occurred with the focused treatment only of spasticity. We are eager to start a trial that couples motor training and anti-spasticity treatment.”

The treatment involves passing a direct electrical current across the spinal cord with a skin surface electrode, known as trans-spinal direct current stimulation (tsDCS), and adding a peripheral direct current stimulation (pDCS) in the paralyzed upper limb. There are additional benefits to patients when tsDCS is combined with pDCS.

Volpe, along with a team that includes Johanna Chang, MS, Alexandra Paget-Blanc, BS, and Maira Saul, MD, employed this device in patients with chronic stroke and hemiparesis to test whether treatment would decrease upper limb spasticity. The trial was a single-blind cross-over design study.

Twenty six participants were treated with five consecutive days of 20 minutes of active, paired tsDCS+pDCS. The participants received both active and sham stimulation conditions, but were not told the order of stimulation.

The device used in the trial was PathMaker Neurosystems Inc’s MyoRegulator, a non-invasive device designed to provide simultaneous, non-invasive stimulation intended to suppress hyperexcitable spinal neurons involved with spasticity.

The results demonstrated that the active treatment condition significantly reduced upper limb spasticity for up to five weeks and these patient responders saw significant improvements in motor function, the release explains.

[Source(s): Feinstein Institutes for Medical Research, PR Newswire]

 

via Medical Device as Post-Stroke Spasticity Reducer Shows Promise – Rehab Managment

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[Abstract + References] Investigation of the effects of mirror therapy on the spasticity, motor function and functionality of impaired upper limbs in chronic stroke patients

Background/Aims

Strokes lead to different levels of disability. During the chronic stage, hemiparesis, spasticity and motor deficits may cause loss of functional independence. Mirror therapy aims to reduce deficits and increase functional recovery of the impaired upper limb. This study aimed to evaluate the effects of mirror therapy on upper limb spasticity and motor function, as well as its impact on functional independence in chronic hemiparetic patients.

Methods

In this quasi-experimental study, eight chronic hemiparetic patients (age 55.5 ± 10.8 years) were assessed to determine their degree of spasticity (Modified Ashworth Scale), level of upper limb motor function (Fugl-Meyer Assessment) and functionality (Functional Independence Measure). All participants received 12 sessions of mirror therapy delivered three times per week, over a period of 4 weeks. Participants were re-evaluated post-intervention and these results were compared to their pre-intervention scores to determine the impact of mirror therapy.

Results

A decrease in spasticity was observed, with significant improvements in shoulder extensors (P=0.033) and a significant increase in motor function (P=0.002). The therapeutic protocol adopted did not have a significant effect on functional independence (P=0.105).

Conclusions

Mirror therapy led to improvements in upper limb spasticity and motor function in chronic hemiparetic stroke patients. No effects on functional independence were observed. Further research with a larger number of patients is needed to provide more robust evidence of the benefits of mirror therapy in chronic hemiparetic stroke patients.

 

References

via Investigation of the effects of mirror therapy on the spasticity, motor function and functionality of impaired upper limbs in chronic stroke patients | International Journal of Therapy and Rehabilitation

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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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[Abstract + References] Development of a Hand Rehabilitation Therapy System with Soft Robotic Glove – Conference paper

Abstract

The major cause of problems with hand motility in adults is due to work accidents, strokes, injuries and work accidents. The emergence of robotic gloves for hand rehabilitation therapy has been developed to assist with rehabilitation treatment. In this scientific paper, a robotic glove prosthesis is designed and developed for use in hand rehabilitation in patients with grip pathologies. There is talk of mechanical design and operation, and the glove is controlled by a mobile application that allows the physiotherapist to enter the settings for the patient or allow an expert system based on 15 rules to do so. The system is capable of generating reports for the patient, the physiotherapist or the caregiver to review. The developed system is portable, lightweight and easy to transport. The validation of the prototype was carried out with adult patients suffering from hemiparesis.

References

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    Chu, C.-Y., Patterson, R.M.: Soft robotic devices for hand rehabilitation and assistance: a narrative review. J. Neuroeng. Rehabil. 15(1), 9 (2018)CrossRefGoogle Scholar
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    Ueki, S., Kawasaki, H., Ito, S., Nishimoto, Y., Abe, M., Aoki, T., Ishigure, Y., Ojika, T., Mouri, T.: Development of a hand-assist robot with multi-degrees-of-freedom for rehabilitation therapy (2012). ieeexplore.ieee.orgCrossRefGoogle Scholar
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    Kutner, N., Zhang, R., Butler, A.J., Wolf, S.L., Alberts, J.L.: Quality-of-life change associated with robotic-assisted therapy to improve hand motor function in patients with subacute stroke: a randomized clinical trial (2010). academic.oup.com
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    Abdallah, I.B., Bouteraa, Y., Rekik, C.: Design and development of 3D printed myoelectric robotic exoskeleton for hand rehabilitation. Int. J. Smart Sens. Intell. Syst. 10(2), 341–366 (2017)Google Scholar
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    Cempini, M., Cortese, M., Vitiello, A.: A powered finger–thumb wearable hand exoskeleton with self-aligning joint axes (2015). ieeexplore.ieee.org
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    Heo, P., Gu, G.M., Lee, S., Rhee, K., Kim, J.: Current hand exoskeleton technologies for rehabilitation and assistive engineering. Int. J. Precis. Eng. Manuf. 13(5), 807–824 (2012)CrossRefGoogle Scholar
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    Jones, C., Wang, F., Morrison, R., Sarkar, N., Kamper, D.G.: Design and development of the cable actuated finger exoskeleton for hand rehabilitation following stroke (2014). ieeexplore.ieee.orgCrossRefGoogle Scholar
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    Polygerinos, P., Wang, Z., Galloway, K., Wood, R.J., Walsh, C.J.: Soft robotic glove for combined assistance and at-home rehabilitation. Elsevier (2015)Google Scholar
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    Maciejasz, P., Eschweiler, J., Gerlach-Hahn, K., Jansen-Troy, A., Leonhardt, S.: A survey on robotic devices for upper limb rehabilitation. J. Neuroeng. Rehabil. 11(1), 3 (2014)CrossRefGoogle Scholar
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    Avila Chaurand, R., Prado León, L.R., González Muñoz, E.L., and Universidad de Guadalajara: Centro de Investigaciones en Ergonomía., Dimensiones antropométricas de población latinoamericana. Universidad de Guadalajara, Centro Universitario de Arte, Arquitectura y Diseño, División de Tecnología y Procesos, Departamento de Producción y Desarrollo, Centro de Investigaciones en Ergonomía (2001)Google Scholar

via Development of a Hand Rehabilitation Therapy System with Soft Robotic Glove | SpringerLink

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[WEB SITE] Flint Rehab Introduces MiGo Wearable for Stroke Recovery

MiGo

Flint Rehab announces the launch of MiGo, a wearable activity tracker specifically designed for stroke survivors. The device makes its official debut at the 2019 Consumer Electronics Show in Las Vegas.

MiGo is designed to track upper extremity activity — in addition to walking — and is optimized for the movement patterns performed by individuals with stroke. The device is accompanied by a smartphone app that provides motivational support through digital coaching, progressive goal setting, and social networking with other stroke survivors, according to the company in a media release.

“Most wearable fitness trackers are designed to help people get into shape. MiGo is a new type of wearable that helps people regain their independence after a stroke,” says Dr Nizan Friedman, co-founder and CEO of Irvine, Calif-based Flint Rehab, in the release.

“Traditionally, innovation in medical technology has been limited by what insurance companies are willing to cover. As a consumer-level digital health technology, MiGo avoids these constraints, empowering stroke survivors to take their recovery into their own hands.”

A common outcome of stroke is hemiparesis, or impaired movement on one side of the body. One of the leading causes of this lifelong disability is a phenomenon called “learned non-use,” where stroke survivors neglect to use their impaired arm or leg, causing their brain to lose the ability to control those limbs altogether.

MiGo directly addresses the problem of learned non-use by motivating stroke survivors to use their impaired side as much as possible. Using deep-learning algorithms, MiGo accurately tracks how much the wearer is using their impaired side, providing them with an easy-to-understand rep count throughout the day.

MiGo also provides an intelligent activity goal that updates every day based on the wearer’s actual movement ability, ensuring every user stays continuously challenged at the level appropriate for them. Then, the device acts as the wearer’s personal cheerleader, giving them rewards and positive feedback right on their wrist as they work to hit their daily goal, the release explains.

“Suffering a stroke is a traumatic, life-changing event. Many survivors do not have the proper support network to deal with the event, and they may find it difficult to relate with friends and family who don’t understand what they are going through,” states Dan Zondervan, co-founder and vice president of Flint Rehab.

“Using the MiGo app, users can join groups to share their activity data and collaborate with other stroke survivors to achieve group goals. Group members can also share their experiences and offer encouraging support to each other — right in the app,” he adds.

For more information, visit Flint Rehab.

[Source(s0): Flint Rehab, Business Wire]

 

via Flint Rehab Introduces MiGo Wearable for Stroke Recovery – Rehab Managment

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[Abstract] A novel neurocognitive rehabilitation tool in the recovery of hemiplegic hand grip after stroke: a case report.

Abstract

Stroke has significant physical, psychological and social consequences. Recent rehabilitation approaches suggest that cognitive exercises with dual-task (sensory-motor) exercises positively influence the recovery and function of the hemiplegic hand grip. The purpose of this study was to describe a rehabilitation protocol involving the use of a new neurocognitive tool called “UOVO” for hand grip recovery after stroke. A 58-year-old right-handed male patient in the chronic stage of stroke, presenting with left-sided hemiparesis and marked motor deficits at the level of the left hand and forearm, was treated with the UOVO, a new rehabilitation instrument based on the neurocognitive rehabilitation theory of Perfetti. The patient was evaluated at T0 (before treatment), T1 (after treatment) and T2 (2 months of follow-up). At T2, the patient showed improvements of motor functions, shoulder, elbow and wrist spasticity, motility and performance. This case report explores the possibility of improving traditional rehabilitation through a neurocognitive approach with a dual-task paradigm (including motor and somato-sensory stimulation), specifically one involving the use of an original rehabilitation aid named UOVO, which lends itself very well to exercises proposed through the use of motor imagery. The results were encouraging and showed improvements in hemiplegic hand grip function and recovery. However, further studies, in the form of randomized controlled trials, will be needed to further explore and confirm our results.

 

via A novel neurocognitive rehabilitation tool in the recovery of hemiplegic hand grip after stroke: a case report. – PubMed – NCBI

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[ARTICLE] Mechanics and energetics of post-stroke walking aided by a powered ankle exoskeleton with speed-adaptive myoelectric control – Full Text

Abstract

Background

Ankle exoskeletons offer a promising opportunity to offset mechanical deficits after stroke by applying the needed torque at the paretic ankle. Because joint torque is related to gait speed, it is important to consider the user’s gait speed when determining the magnitude of assistive joint torque. We developed and tested a novel exoskeleton controller for delivering propulsive assistance which modulates exoskeleton torque magnitude based on both soleus muscle activity and walking speed. The purpose of this research is to assess the impact of the resulting exoskeleton assistance on post-stroke walking performance across a range of walking speeds.

Methods

Six participants with stroke walked with and without assistance applied to a powered ankle exoskeleton on the paretic limb. Walking speed started at 60% of their comfortable overground speed and was increased each minute (n00, n01, n02, etc.). We measured lower limb joint and limb powers, metabolic cost of transport, paretic and non-paretic limb propulsion, and trailing limb angle.

Results

Exoskeleton assistance increased with walking speed, verifying the speed-adaptive nature of the controller. Both paretic ankle joint power and total limb power increased significantly with exoskeleton assistance at six walking speeds (n00, n01, n02, n03, n04, n05). Despite these joint- and limb-level benefits associated with exoskeleton assistance, no subject averaged metabolic benefits were evident when compared to the unassisted condition. Both paretic trailing limb angle and integrated anterior paretic ground reaction forces were reduced with assistance applied as compared to no assistance at four speeds (n00, n01, n02, n03).

Conclusions

Our results suggest that despite appropriate scaling of ankle assistance by the exoskeleton controller, suboptimal limb posture limited the conversion of exoskeleton assistance into forward propulsion. Future studies could include biofeedback or verbal cues to guide users into limb configurations that encourage the conversion of mechanical power at the ankle to forward propulsion.

Trial registration

N/A.

Background

Walking after a stroke is more metabolically expensive, leading to rapid exhaustion, limited mobility, and reduced physical activity [1]. Hemiparetic walking is slow and asymmetric compared to unimpaired gait. Preferred walking speeds following stroke range between < 0.2 m s− 1 and ~ 0.8 m s− 1 [2] compared to ~ 1.4 m s− 1 in unimpaired adults, and large interlimb asymmetry has been documented in ankle joint power output [34]. The ankle plantarflexors are responsible for up to 50% of the total positive work needed to maintain forward gait [56]; therefore, weakness of the paretic plantarflexors is especially debilitating, and as a result, the paretic ankle is often a specific target of stroke rehabilitation [78910]. In recent years, ankle exoskeletons have emerged as a technology capable of improving ankle power output by applying torque at the ankle joint during walking in clinical populations [78] and healthy controls [11121314]. Myoelectric exoskeletons offer a user-controlled approach to stroke rehabilitation by measuring and adapting to changes in the user’s soleus electromyography (EMG) when generating torque profiles applied at the ankle [15]. For example, a proportional myoelectric ankle exoskeleton was shown to increase the paretic plantarflexion moment for persons post-stroke walking at 75% of their comfortable overground (OVG) speed [8]; despite these improvements, assistance did not reduce the metabolic cost of walking or improve percent paretic propulsion. The authors suggested exoskeleton performance could be limited because the walking speed was restricted to a pace at which exoskeleton assistance was not needed.

Exoskeleton design for improved function following a stroke would benefit from understanding the interaction among exoskeleton assistance, changes in walking speed, and measured walking performance. Increases in walking speed post-stroke are associated with improvements in forward propulsion and propulsion symmetry [16], trailing limb posture [1718], step length symmetries [1719], and greater walking economies [1719]. This suggests that assistive technologies need to account for variability in walking speeds to further improve post-stroke walking outcomes. However, research to date has evaluated exoskeleton performance at only one walking speed, typically set to either the participant’s comfortable OVG speed or a speed below this value [78]. At constant speeds, ankle exoskeletons have been shown to improve total ankle power in both healthy controls [11] and persons post-stroke [8], suggesting the joint powers and joint power symmetries could be improved by exoskeleton technology. Additionally, an exosuit applying assistance to the ankle was able to improve paretic propulsion and metabolic cost in persons post-stroke walking at their comfortable OVG speed [7]. Assessing the impact of exoskeleton assistance on walking performance across a range of speeds is the next logical step toward developing exoskeleton intervention strategies targeted at improving walking performance and quality of life for millions of persons post-stroke.

In order to assess the impact of exoskeleton assistance across a range of walking speeds in persons post-stroke, we developed a novel, speed-adaptive exoskeleton controller that automatically modulates the magnitude of ankle torque with changes in walking speed and soleus EMG. We hypothesized that: 1) Our novel speed-adaptive controller will scale exoskeleton assistance with increases in walking speed as intended. 2) Exoskeleton assistance will lead to increases in total average net paretic ankle power and limb power at all walking speeds. 3) Exoskeleton assistance will lead to metabolic benefits associated with improved paretic average net ankle and limb powers.

Methods

Exoskeleton hardware

We implemented an exoskeleton emulator comprised of a powerful off-board actuation and control system, a flexible Bowden cable transmission, and a lightweight exoskeleton end effector [20]. The exoskeleton end effector includes shank and foot carbon fiber components custom fitted to participants and hinged at the ankle. The desired exoskeleton torque profile was applied by a benchtop motor (Baldor Electric Co, USA) to the carbon-fiber ankle exoskeleton through a Bowden-cable transmission system. An inline tensile load cell (DCE-2500 N, LCM Systems, Newport, UK) was used to confirm the force transmitted by the exoskeleton emulator during exoskeleton assistance.

Speed-adaptive proportional myoelectric exoskeleton controller

Our exoskeleton controller alters the timing and magnitude of assistance with the user’s soleus EMG signal and walking speed (Fig. 1). The exoskeleton torque is determined from Eq. 1, in which participant mass (mparticipant) is constant across speeds, treadmill speed (V) is measured in real-time, the speed gain (Gspeed) is constant for all subjects and across speeds, the adaptive gain (Gadp) is constant for a gait cycle and calculated anew for each gait cycle, and the force-gated and normalized EMG (EMGGRFgated) is a continuously changing variable.

τexo (t)=mparticipant×V×Gspeed×Gadp×EMGGRFgatedτexo (t)=mparticipant×V×Gspeed×Gadp×EMGGRFgated
(1)
Fig. 1
Fig. 1

Novel speed-adaptive myoelectric exoskeleton controller measures and adapts to users’ soleus EMG signal as well as their walking speed in order to generate the exoskeleton torque profile. Raw soleus EMG signal is filtered and rectified to create an EMG envelope, and the created EMG envelope is then gated by anterior GRFs to ensure assistance is only applied during forward propulsion. The adaptive EMG gain is calculated as a moving average of peak force-gated EMG from the last five paretic gait cycles. The pre-speed gain control signal is the product of the force-gated EMG and the adaptive EMG gain. The speed gain is determined using real-time walking speed and computed as 25% of the maximum biological plantarflexion torque at that given walking speed. Exoskeleton torque is the result of multiplying the speed gain with the pre-speed gain control signal

[…]

Continue —> Mechanics and energetics of post-stroke walking aided by a powered ankle exoskeleton with speed-adaptive myoelectric control | Journal of NeuroEngineering and Rehabilitation | Full Text

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[Abstract] Effectiveness of Virtual Reality Using PS4 Gaming Technology in Stroke Rehabilitation for Improving Upper Limb Function-A Pilot Study

Background: Hemiparesis resulting in functional limitation of an upper extremity and lower limb is common among stroke survivors. Virtual reality is one of the way of improving motor function in stroke, limited evidence is available on the efficacy of virtual reality for stroke rehabilitaton.

Methods: In this pilot study 2 parallel groups involving stroke patients, we compared the feasibility, safety and efficacy of virtual reality using the sony PS4 gaming technology to evaluate upper limb motor improvement. The primary feasibility outcome was the total time receiving the intervention. The… primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with wolf motor function test and Spasticity Grading at 4 weeks after intervention. OUTCOME MEASURE: WOLF Motor function test and Box and Block test.

Result: This study shows that mean values obtained from WOLF motor function test showed no statistical significance and the mean values of Box and Block test showed statistical significance.

Conclusion: This study concludes that the PS4 gaming technology is a feasible, safe, and potentially effective intervention to enhance motor function recovery in patients with a recent stroke.

Indian Journals

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[REVIEW ARTICLE] Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach – Full Text

Robot-mediated therapy is an innovative form of rehabilitation that enables highly repetitive, intensive, adaptive, and quantifiable physical training. It has been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis. Multiple studies collated in a growing number of review articles showed the positive effects on motor impairment, less clearly on functional limitations. After describing the current status of robotic therapy after upper limb paresis due to stroke, this overview addresses basic principles related to robotic therapy applied to upper limb paresis. We demonstrate how this innovation is an evidence-based approach in that it meets both the improved clinical and more fundamental knowledge-base about regaining effective motor function after stroke and the need of more objective, flexible and controlled therapeutic paradigms.

Introduction

Robot-mediated rehabilitation is an innovative exercise-based therapy using robotic devices that enable the implementation of highly repetitive, intensive, adaptive, and quantifiable physical training. Since the first clinical studies with the MIT-Manus robot (1), robotic applications have been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis but also in cerebral palsy (2), multiple sclerosis (3), spinal cord injury (4), and other disease types. Thus, multiple studies suggested that robot-assisted training, integrated into a multidisciplinary program, resulted in an additional reduction of motor impairments in comparison to usual care alone in different stages of stroke recovery: namely, acute (57), subacute (18), and chronic phases after the stroke onset (911). Typically, patients engaged in the robotic therapy showed an impairment reduction of 5 points or more in the Fugl-Meyer assessment as compared to usual care. Of notice, rehabilitation studies conducted during the chronic stroke phase suggest that a 5-point differential represents the minimum clinically important difference (MCID), i.e., the magnitude of change that is necessary to produce real-world benefits for patients (12). These results were collated in multiple review articles and meta-analyses (1317). In contrast, the advantage of robotic training over usual care in terms of functional benefit is less clear, but there are recent results that suggest how best to organize training to achieve superior results in terms of both impairment and function (18). Indeed, the use of the robotic tool has allowed us the parse and study the ingredients that should form an efficacious and efficient rehabilitation program. The aim of this paper is to provide a general overview of the current state of robotic training in upper limb rehabilitation after stroke, to analyze the rationale behind its use, and to discuss our working model on how to more effectively employ robotics to promote motor recovery after stroke.

Upper Extremity Robotic Therapy: Current Status

Robotic systems used in the field of neurorehabilitation can be organized under two basic categories: exoskeleton and end-effector type robots. Exoskeleton robotic systems allow us to accurately determine the kinematic configuration of human joints, while end-effector type robots exert forces only in the most distal part of the affected limb. A growing number of commercial robotic devices have been developed employing either configuration. Examples of exoskeleton type include the Armeo®Spring, Armeo®Power, and Myomo® and of end-effector type include the InMotion™, Burt®, Kinarm™ and REAplan®. Both categories enable the implementation of intensive training and there are many other devices in different stages of development or commercialization (1920).

The last decade has seen an exponential growth in both the number of devices as well as clinical trials. The results coalesced in a set of systematic reviews, meta-analyses (1317) and guidelines such as those published by the American Heart Association and the Veterans Administration (AHA and VA) (21). There is a clear consensus that upper limb therapy using robotic devices over 30–60-min sessions, is safe despite the larger number of movement repetitions (14).

This technic is feasible and showed a high rate of eligibility; in the VA ROBOTICS (911) study, nearly two thirds of interviewed stroke survivors were enrolled in the study. As a comparison the EXCITE cohort of constraint-induced movement therapy enrolled only 6% of the screened patients participated (22). On that issue, it is relevant to notice the admission criteria of both chronic stroke studies. ROBOTICS enrolled subjects with Fugl-Meyer assessment (FMA) of 38 or lower (out of 66) while EXCITE typically enrolled subjects with an FMA of 42 or higher. Duret and colleagues demonstrated that the target population, based on motor impairments, seems to be broader in the robotic intervention which includes patients with severe motor impairments, a group that typically has not seen much benefit from usual care (23). Indeed, Duret found that more severely impaired patients benefited more from robot-assisted training and that co-factors such as age, aphasia, and neglect had no impact on the amount of repetitive movements performed and were not contraindicated. Furthermore, all patients enrolled in robotic training were satisfied with the intervention. This result is consistent with the literature (24).

The main outcome result is that robotic therapy led to significantly more improvement in impairment as compared to conventional usual care, but only slightly more on motor function of the limb segments targeted by the robotic device (16). For example, Bertani et al. (15) and Zhang et al. (17) found that robotic training was more effective in reducing motor impairment than conventional usual care therapy in patients with chronic stroke, and further meta-analyses suggested that using robotic therapy as an adjunct to conventional usual care treatment is more effective than robotic training alone (1317). Other examples of disproven beliefs: many rehabilitation professionals mistakenly expected significant increase of muscle hyperactivity and shoulder pain due to the intensive training. Most studies showed just the opposite, i.e., that intensive robotic training was associated with tone reduction as compared to the usual care groups (92526). These results are shattering the resistance to the widespread adoption of robotic therapy as a therapeutic modality post-stroke.

That said, not all is rosy. Superior changes in functional outcomes were more controversial until the very last years as most studies and reviews concluded that robotic therapy did not improve activities of daily living beyond traditional care. One first step was reached in 2015 with Mehrholz et al. (14), who found that robotic therapy can provide more functional benefits when compared to other interventions however with a quality of evidence low to very low. 2018 may have seen a decisive step in favor of robotic as the latest meta-analysis conducted by Mehrholz et al. (27) concluded that robot-assisted arm training may improve activities of daily living in the acute phase after stroke with a high quality of evidence However, the results must be interpreted with caution because of the high variability in trial designs as evidenced by the multicenter study (28) in which robotic rehabilitation using the Armeo®Spring, a non-motorized device, was compared to self-management with negative results on motor impairments and potential functional benefits in the robotic group.

The Robot Assisted Training for the Upper Limb after Stroke (RATULS) study (29) might clarify things and put everyone in agreement on the topic. Of notice, RATULS goes beyond the Veterans Administration ROBOTICS with chronic stroke or the French REM_AVC study with subacute stroke. RATULS included 770 stroke patients and covered all stroke phases, from acute to chronic, and it included a positive meaningful control in addition to usual care.[…]

 

Continue —->  Frontiers | Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach | Neurology

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