Posts Tagged hemiparesis

[Abstract] Virtual reality and non-invasive brain stimulation in stroke: How effective is their combination for upper limb motor improvement?

Abstract:

Upper limb (UL) hemiparesis is frequently a disabling consequence of stroke. The ability to improve UL functioning is associated with motor relearning and experience dependent neuroplasticity. Interventions such as non-invasive brain stimulation (NIBS) and task-practice in virtual environments (VEs) can influence motor relearning as well as adaptive plasticity. However, the effectiveness of a combination of NIBS and task-practice in VEs on UL motor improvement has not been systematically examined. The objective of this review was to examine the evidence regarding the effectiveness of combining NIBS with task-practice in VEs on UL motor impairment and activity levels. A systematic review of the published literature was conducted using standard methodology. Study quality was assessed using the PEDro scale and Down’s and Black checklist. Four studies examining the effects of a combination of NIBS (involving transcranial direct current stimulation; tDCS and repetitive transcranial magnetic stimulation; rTMS) were retrieved. Of these, three studies were randomized controlled trials (RCTs) and one was a cross-sectional study. There was 1a level evidence that the combination of NIBS and task-practice in a VE was beneficial in the sub-acute stage. A combination of training in a VE with rTMS as well as tDCS was beneficial for motor improvements in the UL in sub-acute stage of stroke (1b level). The combination was not found to be superior compared to task practice in VEs alone in the chronic stage (1b level). The results suggest that people with stroke may be capable of improving levels of motor impairment and activity in the sub-acute stage if their rehabilitation program involves a combination on NIBS and VE training. Emergent questions regarding the use of more sensitive outcomes, different types of stimulation parameters, locations and training environments still need to be addressed.

Source: Virtual reality and non-invasive brain stimulation in stroke: How effective is their combination for upper limb motor improvement? – IEEE Xplore Document

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[ARTICLE] Domiciliary VR-Based Therapy for Functional Recovery and Cortical Reorganization: Randomized Controlled Trial in Participants at the Chronic Stage Post Stroke – Full Text

ABSTRACT

Background: Most stroke survivors continue to experience motor impairments even after hospital discharge. Virtual reality-based techniques have shown potential for rehabilitative training of these motor impairments. Here we assess the impact of at-home VR-based motor training on functional motor recovery, corticospinal excitability and cortical reorganization.

Objective: The aim of this study was to identify the effects of home-based VR-based motor rehabilitation on (1) cortical reorganization, (2) corticospinal tract, and (3) functional recovery after stroke in comparison to home-based occupational therapy.

Methods: We conducted a parallel-group, controlled trial to compare the effectiveness of domiciliary VR-based therapy with occupational therapy in inducing motor recovery of the upper extremities. A total of 35 participants with chronic stroke underwent 3 weeks of home-based treatment. A group of subjects was trained using a VR-based system for motor rehabilitation, while the control group followed a conventional therapy. Motor function was evaluated at baseline, after the intervention, and at 12-weeks follow-up. In a subgroup of subjects, we used Navigated Brain Stimulation (NBS) procedures to measure the effect of the interventions on corticospinal excitability and cortical reorganization.

Results: Results from the system’s recordings and clinical evaluation showed significantly greater functional recovery for the experimental group when compared with the control group (1.53, SD 2.4 in Chedoke Arm and Hand Activity Inventory). However, functional improvements did not reach clinical significance. After the therapy, physiological measures obtained from a subgroup of subjects revealed an increased corticospinal excitability for distal muscles driven by the pathological hemisphere, that is, abductor pollicis brevis. We also observed a displacement of the centroid of the cortical map for each tested muscle in the damaged hemisphere, which strongly correlated with improvements in clinical scales.

Conclusions: These findings suggest that, in chronic stages, remote delivery of customized VR-based motor training promotes functional gains that are accompanied by neuroplastic changes.

Introduction

After initial hospitalization, many stroke patients return home relatively soon despite still suffering from impairments that require continuous rehabilitation [1]. Therefore, ¼ to ¾ of patients display persistent functional limitations for a period of 3 to 6 months after stroke [2]. Although clinicians may prescribe a home exercise regimen, reports indicate that only one-third of patients actually accomplish it [3]. Consequently, substantial gains in health-related quality of life during inpatient stroke rehabilitation may be followed by equally substantial declines in the 6 months after discharge [4]. Multiple studies have shown, however, that supported discharge combined with at home rehabilitation services does not compromise clinical inpatient outcomes [57] and may enhance recovery in subacute stroke patients [8]. Hence, it is essential that new approaches are deployed that help to manage chronic conditions associated with stroke, including domiciliary interventions [9] and the augmentation of current rehabilitation approaches in order to enhance their efficiency. There should be increased provision of home-based rehabilitation services for community-based adults following stroke, taking cost-effectiveness, and a quick family and social reintegration into account [10].

One of the latest approaches in rehabilitation science is based on the use of robotics and virtual reality (VR), which allow remote delivery of customized treatment by combining dedicated interface devices with automatized training scenarios [1012]. Several studies have tested the acceptability of VR-based setups as an intervention and evaluation tool for rehabilitation [1315]. One example of this technology is the, so called, Rehabilitation Gaming System (RGS) [16], which has been shown to be effective in the rehabilitation of the upper extremities in the acute and the chronic phases of stroke [13]. However, so far little work exists on the quantitative assessment of the clinical impact of VR based approaches and their effects on neural reorganization that can directly inform the design of these systems and their application in the domiciliary context. The main objective of this paper is to further explore the potential and limitations of VR technologies in domiciliary settings. Specifically, we examine the efficacy of a VR-based therapy when used at home for (1) assessing functional improvement, (2) facilitating functional recovery of the upper-limbs, and (3) inducing cortical reorganization. This is the first study testing the effects of VR-based therapy on cortical reorganization and corticospinal integrity using NBS.

Methods

Design

We conducted a parallel-group, controlled trial in order to compare the effectiveness of domiciliary VR-based therapy versus domiciliary occupational therapy (OT) in inducing functional recovery and cortical reorganization in chronic stroke patients.

Participants

Participants were first approached by an occupational therapist from the rehabilitation units of Hospital Esperanza and Hospital Vall d’Hebron from Barcelona to determine their interest in participating in a research project. Recruited participants met the following inclusion criteria: (1) mild-to-moderate upper-limbs hemiparesis (Proximal MRC>2) secondary to a first-ever stroke (>12 months post-stroke), (2) age between 45 and 85 years old, (3) absence of any major cognitive impairment (Mini-Mental State Evaluation, MMSE>22), and (4) previous experience with RGS in the clinic. The ethics committee of clinical research of the Parc de Salut Mar and Vall d’Hebron Research Institute approved the experimental guidelines. Thirty-nine participants at the chronic stage post-stroke were recruited for the study by two occupational therapists, between October 2011 and January 2012, and were assigned to a RGS (n=20) or a control group (n=19) using stratified permuted block randomization methods for balancing the participants’ demographics and clinical scores at baseline (Table 1). One participant in the RGS group refused to participate. Prior to the experiment, participants signed informed consent forms. This trial was not registered at or before the onset of participants’ enrollment because it is a pilot study that evaluates the feasibility of a prototype device. However, this study was registered retrospectively in ClinicalTrials.gov and has the identifier NCT02699398.

Instrumentation

Description of the Rehabilitation Gaming System

The RGS integrates a paradigm of goal-directed action execution and motor imagery [17], allowing the user to control a virtual body (avatar) through an image capture device (Figure 1). For this study, we developed training and evaluation scenarios within the RGS framework. In the Spheroids training scenario (Figure 1), the user has to perform bilateral reaching movements to intercept and grasp a maximum number of spheres moving towards him [16]. RGS captures only joint flexion and extension and filters out the participant’s trunk movements, therefore preventing the execution of compensatory body movements [18]. This task was defined by three difficulty parameters, each of them associated with a specific performance descriptor: (1) different trajectories of the spheres require different ranges of joint motion for elbow and shoulder, (2) the size of the spheres require different hand and grasp precision and perceptual abilities, and (3) the velocity of the spheres require different movement speeds and timing. All these parameters, also including the range of finger flexion and extension required to grasp and release spheroids, were dynamically modulated by the RGS Adaptive Difficulty Controller [19] to maintain the performance ratio (ie, successful trials over the total trials) above 0.6 and below 0.8, optimizing effort and reinforcement during training [20]. […]

Figure 1. Experimental setup and protocol: (A) Movements of the user’s upper limbs are captured and mapped onto an avatar displayed on a screen in first person perspective so that the user sees the movements of the virtual upper extremities. A pair of data gloves equipped with bend sensors captures finger flexion. (B) The Spheroids is divided into three subtasks: hit, grasp, and place. A white separator line divides the workspace in a paretic and non-paretic zone only allowing for ipsilateral movements.(C) The experimental protocol. Evaluation periods (Eval.) indicate clinical evaluations using standard clinical scales and Navigated Brain Stimulation procedures (NBS). These evaluations took place before the first session (W0), after the last session of the treatment (day 15, W3), and at follow-up (week 12, W12).

Continue —>  JSG-Domiciliary VR-Based Therapy for Functional Recovery and Cortical Reorganization: Randomized Controlled Trial in Participants at the Chronic Stage Post Stroke | Ballester | JMIR Serious Games

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[Abstract+References] Wearable Rehabilitation Training System for Upper Limbs Based on Virtual Reality – Conference paper

Abstract

In this paper, wearable rehabilitation training system for the upper limb based on virtual reality is designed for patients with upper extremity hemiparesis. The six-axis IMU sensor is used to collect the joint training angles of the shoulder and elbow. In view of the patient’s shoulder and elbow joint active rehabilitation training, the virtual rehabilitation training games based on the Unity3D engine are designed to complete different tasks. Its purpose is to increase the interest of rehabilitation training. The data obtained from the experiment showed that the movement ranges of the shoulder and elbow joint reached the required ranges in the rehabilitation training game. The basic function of the system is verified by the experiments, which can provide effective rehabilitation training for patients with upper extremity hemiparesis.

References

 

 

1.
Liang, M., Dou, Z.L., Wang, Q.H.: Application of virtual reality technique in rehabilitation of hemiplegic upper extremities function of stroke patients. Chin. J. Rehabil. Med. 02, 114–118 (2013)Google Scholar

 

2.
Valencia, N., Cardoso, V., Frizera, A.: Serious Game for Post-stroke Upper Limb Rehabilitation. Converging Clinical and Engineering Research on Neurorehabilitation II. Springer, Berlin (2017)Google Scholar

 

3.
Lei, Y., Yu, H.L., Wang, L.L., Wang, Z.P.: Research on virtual reality-based interactive upper-limb rehabilitation training system. Prog. Biomed. Eng. 36(1), 21–24 (2015)Google Scholar

 

4.
Xu, B.G., Peng, S., Song, A.G.: Upper-limb rehabilitation robot based on motor imagery EEG. Robot 33(3), 307–313 (2011)CrossRefGoogle Scholar

 

5.
Wang, H.T.: Status of Application of Virtual Reality Technique in Motor Rehabilitation in Stroke. Chin. J. Rehabil. Theory Pract. 10, 911–915 (2014)Google Scholar

 

6.
Zhang, J.L.: Research of Finger Rehabilitation System Based on Virtual Reality Technology. Huazhong University of Science and Technology (2012)Google Scholar

 

7.
Mei, Z., He, L.W., Wu, L., Jian, Z.: Design and test of a portable exoskeleton elbow rehabilitation training device. Chin. J. Rehabil. Med. 11, 1155–1157 (2015)Google Scholar

 

8.
Mazzone, B., Haubert, L.L., Mulroy, S.: Intensity of shoulder muscle activation during resistive exercises performed with and without virtual reality games. In: International Conference on Virtual Rehabilitation, pp. 127–133. IEEE (2013)Google Scholar

 

9.
Fischer, H.C., Stubblefield, K., Kline, T.: Hand rehabilitation following stroke: a pilot study of assisted finger extension training in a virtual environment. Topics Stroke Rehabil. 14(1), 1–12 (2014)CrossRefGoogle Scholar

 

10.
Kapandji, A.I.: The Physiology of the Joints, 6th edn. People’s Military Medical Press, Beijing (2011)Google Scholar

 

11.
Gu, Y., Tian, L.H., Chen, H.: Application of virtual reality training system and rehabilitation therapy in the treatment in hemiplegic patients with upper limb dysfunction. Chin. J. Rehabil. Med. 26(6), 579–581 (2011)Google Scholar

Source: Wearable Rehabilitation Training System for Upper Limbs Based on Virtual Reality | SpringerLink

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[Conference paper] Hand Robotic Rehabilitation: From Hospital to Home – Abstract+References

Abstract

Stroke patients are often affected by hemiparesis. In the rehabilitation of these patients the function of the hand is often neglected. Thus in this work we propose a robotic approach to the rehabilitation of the hand of a stroke patient in hospital and also at home. Some experimental results can be presented here especially for inpatients. Further experimental results on home-patients must be acquired through a telemedicine platform, designed for this application. 

References

  1. 1.
    Song D, Lan N, Loeb GE, Gordon J (2008) Model-based sensorimotor integration for multi-joint control: development of a virtual arm model. Ann Biomed Eng 36(6):1033–1048. doi:10.1007/s10439-008-9461-8 CrossRefGoogle Scholar
  2. 2.
    Prange GB, Jannink MJA, Groothuis-Oudshoorn CGM, Hermens HJ, Ijzerman MJ (2006) Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke. J Rehabil Res Dev 43(2):171–183. doi:10.1682/Jrrd.2005.04.0076 CrossRefGoogle Scholar
  3. 3.
    Fulesdi B, Limburg M, Bereczki D, Kaplar M, Molnar C, Kappelmayer J, Neuwirth G, Csiba L (1999) Cerebrovascular reactivity and reserve capacity in type II diabetes mellitus. J Diabetes Complicat 13(4):191–199. doi:10.1016/S1056-8727(99)00044-6 CrossRefGoogle Scholar
  4. 4.
    Mukherjee M, Koutakis P, Siu KC, Fayad PB, Stergiou N (2013) Stroke survivors control the temporal structure of variability during reaching in dynamic environments. Ann Biomed Eng 41(2):366–376. doi:10.1007/s10439-012-0670-9 CrossRefGoogle Scholar
  5. 5.
    Nowak DA (2008) The impact of stroke on the performance of grasping: usefulness of kinetic and kinematic motion analysis. Neurosci Biobehav R 32(8):1439–1450. doi:10.1016/j.neubiorev.2008.05.021 CrossRefGoogle Scholar
  6. 6.
    Salter RB (2004) Continuous passive motion: from origination to research to clinical applications. J Rheumatol 31(11):2104–2105Google Scholar
  7. 7.
    Fu MJ, Knutson JS, Chae J (2015) Stroke rehabilitation using virtual environments. Phys Med Rehabil Clin N Am 26(4):747–757. doi:10.1016/j.pmr.2015.06.001 CrossRefGoogle Scholar
  8. 8.
    Jarrassé N, Proietti T, Crocher V, Robertson O, Sahbani A, Morel G, Roby-Brami A (2014) Robotic exoskeletons: a perspective for the rehabilitation of arm coordination in stroke patients. Front Hum Neurosc 8. doi:10.3389/fnhum.2014.00947
  9. 9.
    Pisotta I, Perruchoud D, Ionta S (2015) Hand-in-hand advances in biomedical engineering and sensorimotor restoration. J Neurosci Methods 246:22–29. doi:10.1016/j.jneumeth.2015.03.003 CrossRefGoogle Scholar
  10. 10.
    Saudabayev A, Varol HA (2015) Sensors for robotic hands: a survey of state of the art. IEEE Access 3:1765–1782. doi:10.1109/ACCESS.2015.2482543 CrossRefGoogle Scholar
  11. 11.
    Schott J, Rossor M (2003) The grasp and other primitive reflexes. J Neurol Neurosurg Psychiatry 74(5):558–560. doi:10.1136/jnnp.74.5.558 CrossRefGoogle Scholar
  12. 12.
    Cruz EG, Kamper DG (2010) Use of a novel robotic interface to study finger motor control. Ann Biomed Eng 38(2):259–268. doi:10.1007/s10439-009-9845-4 CrossRefGoogle Scholar
  13. 13.
    Legnani G, Casolo F, Righettini P, Zappa B (1996) A homogeneous matrix approach to 3D kinematics and dynamics – I. Theory. Mech Mach Theory 31(5):573–587. doi:10.1016/0094-114X(95)00100-D CrossRefGoogle Scholar
  14. 14.
    Borboni A, Mor M, Faglia R (2016) Gloreha-hand robotic rehabilitation: design, mechanical model, and experiments. J Dyn Syst Meas Control Trans ASME 138(11). doi:10.1115/1.4033831
  15. 15.
    Borboni A, Villafañe JH, Mullè C, Valdes K, Faglia R, Taveggia G, Negrini S (2017) Robot-assisted rehabilitation of hand paralysis after stroke reduces wrist edema and pain: a prospective clinical trial. J Manipulative Physiol Ther 40(1):21–30. doi:10.1016/j.jmpt.2016.10.003 CrossRefGoogle Scholar
  16. 16.
    Dobkin BH (2005) Rehabilitation after stroke. N Engl J Med 352(16):1677–1684. doi:10.1056/NEJMcp043511 CrossRefGoogle Scholar
  17. 17.
    Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS (1999) Stroke: neurologic and functional recovery the Copenhagen Stroke Study. Phys Med Rehabil Clin N Am 10(4):887–906Google Scholar
  18. 18.
    Kuptniratsaikul V, Kovindha A, Suethanapornkul S, Massakulpan P, Permsirivanich W, Kuptniratsaikul PSA (2017) Motor recovery of stroke patients after rehabilitation: one-year follow-up study. Int J Neurosci 127(1):37–43. doi:10.3109/00207454.2016.1138474 CrossRefGoogle Scholar
  19. 19.
    Ferrucci L, Bandinelli S, Guralnik JM, Lamponi M, Bertini C, Falchini M, Baroni A (1993) Recovery of functional status after stroke a postrehabilitation follow-up study. Stroke 24(2):200–205CrossRefGoogle Scholar
  20. 20.
    Kelly-Hayes M, Wolf PA, Kase CS, Gresham GE, Kannel WB, D’Agostino RB (1989) Time course of functional recovery after stroke: the Framingham study. Neurorehabilitation Neural Repair 3(2):65–70. doi:10.1177/136140968900300202 CrossRefGoogle Scholar
  21. 21.
    Borghetti M, Sardini E, Serpelloni M (2013) Sensorized glove for measuring hand finger flexion for rehabilitation purposes. IEEE Trans Instrum Meas 62(12):3308–3314. doi:10.1109/TIM.2013.2272848 CrossRefGoogle Scholar

Source: Hand Robotic Rehabilitation: From Hospital to Home | SpringerLink

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[ARTICLE] Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial – Full Text

 

Continue —> Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trialClinical Rehabilitation – Alexander J Street, Wendy L Magee, Andrew Bateman, Michael Parker, Helen Odell-Miller, Jorg Fachner, 2017

figure

Figure 1. Study flow diagram. Data collection occurred at weeks 1, 6, 9, 15 and 18. Cross-over analysis required data from weeks 1, 6, 9 and 15.

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[ARTICLE] Robotic-assisted serious game for motor and cognitive post-stroke rehabilitation – Full Text PDF

 

Abstract

Stroke is a major cause of long-term disability that can cause motor and cognitive impairments. New technologies such as robotic devices and serious games are increasingly being developed to improve post-stroke rehabilitation. The aim of the present project was to develop a ROBiGAME serious game to simultaneously improve motor and cognitive deficits (in particular hemiparesis and hemineglect). In this context, the difficulty level of the game was adapted to each patient’s performance, and this individualized adaptation was addressed as the main challenge of the game development. The game was implemented on the REAplan end-effector rehabilitation robot, which was used in continuous interaction with the game. A preliminary feasibility study of a target pointing game was run in order to validate the game features and parameters. Results showed that the game was perceived as enjoyable, and that patients reported a desire to play the game again. Most of the targets included in the game design were realistic, and they were well perceived by the patients. Results also suggested that the cognitive help strategy could include one visual prompting cue, possibly combined with an auditory cue. It was observed that the motor assistance provided by the robot was well adapted for each patient’s impairments, but the study results led to a suggestion that the triggering conditions should be reviewed. Patients and therapists reported the desire to receive more feedback on the patient’s performances. Nevertheless, more patients and therapists are needed to play the game in order to give further and more comprehensive feedback that will allow for improvements of the serious game. Future steps also include the validation of the motivation assessment module that is currently under development.

Full Text PDF

 

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[Abstract] A Randomized Trial on the Effects of Attentional Focus on Motor Training of the Upper Extremity Using Robotics with Individuals after Chronic Stroke 

 

Highlights

  • Individuals with moderate-to-severe arm impairment after stroke improved motor control after engaging in high-repetition training
  • There were no differences between external focus or internal focus of attention on retention of motor skills after four weeks of arm training for individuals with stroke
  • Individuals with moderate-to-severe arm impairment may not experience the advantages of an external focus during motor training found in healthy individuals
  • Attentional focus is most likely not an active ingredient for retention of trained motor skills for individuals with moderate-to-severe arm impairment

Abstract

Objective

To compare the long-term effects of external focus (EF) versus internal focus (IF) of attention after 4-weeks of arm training. Design: Randomized, repeated measure, mixed ANOVA.

Setting

Outpatient clinic.

Participants

33 individuals with stroke and moderate-to-severe arm impairment living in the community (3 withdrawals).

Interventions

4-week arm training protocol on the InMotion ARM robot (12 sessions).

Main Outcome Measures

Joint independence, Fugl-Meyer Assessment, and Wolf Motor Function Test measured at baseline, discharge, and 4-week follow-up.

Results

There were no between-group effects for attentional focus. Participants in both groups improved significantly on all outcome measures from baseline to discharge and maintained those changes at 4-week follow-up regardless of group assignment [Jt indep-EF, F(1.6, 45.4) = 17.74, p<.0005, partial η2=.39; Jt indep-IF, F(2, 56)= 18.66, p<.0005, partial η2=.40; FMA, F(2, 56) = 27.83, p<.0005, partial η2=.50 ; WMFT, F(2, 56) =14.05, p<.0005, partial η2=.35].

Conclusion

There were no differences in retention of motor skills between EF and IF participants four weeks after arm training, suggesting that individuals with moderate-to-severe arm impairment may not experience the advantages of an EF found in healthy individuals. Attentional focus is most likely not an active ingredient for retention of trained motor skills for individuals with moderate-to-severe arm impairment, whereas dosage and intensity of practice appear to be pivotal. Future studies should investigate the long-term effects of attentional focus for individuals with mild arm impairment.

Source: A Randomized Trial on the Effects of Attentional Focus on Motor Training of the Upper Extremity Using Robotics with Individuals after Chronic Stroke – Archives of Physical Medicine and Rehabilitation

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[BOOK] Chapter 7: After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation – Full Text

 

 “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s)

Chapter 7: After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation

Abstract

This chapter presents a review of the rehabilitation technologies for people who have suffered a stroke, comparing and analyzing the impact that these technologies have on their recovery in the short and long term. The problematic is presented, and motor impairments for upper and lower limbs are characterized. The goal of this chapter is to show novel trends and research for the assistance and treatment of motor impairment caused by strokes.

1. Introduction

Stroke is the most common acquired neurological disease in the adult population worldwide (15 million every year [1]). Based on recently published studies, incidence of stroke in Europe at the beginning of the twenty-first century ranged from 95 to 290/100,000 per year [37]. Between 2000 and 2010, the relative rate of stroke deaths dropped by 35.8% in the United States and other countries. However, each year stroke affects nearly 800,000 individuals, becoming the first cause of chronic disability and the third cause of death. It is a global public health problem worldwide that generates a significant burden of illness for healthy life years lost due to disability and premature death.

One-third of stroke survivors achieve only a poor functional outcome 5 years after the onset of stroke. Although there is great progress in the management of acute stroke, most of the care to reduce dependence on post-stroke patients depends on rehabilitation. Optimal functional recovery is the ultimate goal of neurorehabilitation after acute brain injury, mainly by optimizing sensorimotor performance in functional actions. New brain imaging techniques are making it clear that the neurological system is continually remodeling throughout life and after damage through experience and learning in response to activity and behavior.

Rehabilitation in stroke patients seeks to minimize the neurological deficit and its complications, encourage family, and facilitate social reintegration of the individual to ultimately improve their quality of life. Stroke rehabilitation is divided into three phases. The acute phase usually extends for the 1st weeks, where patients get treated and stabilized in a hospital and get stabilized. Subacute phase (1–6 months) is the phase where the rehabilitation process is more effective for recovering functions. In chronic phase (after 6 months), rehabilitation is meant to treat and decrease motor sequels.

The potential ability of the brain to readapt after injury is known as neuroplasticity, which is the basic mechanism underlying improvement in functional outcome after stroke. Therefore, one important goal of rehabilitation of stroke patients is the effective use of neuroplasticity for functional recovery [38].

As mentioned before, neural plasticity is the ability of nervous system to reorganize its structure, function, and connections in response to training. The type and extent of neural plasticity is task—specific, highly time-sensitive and strongly influenced by environmental factors as well as motivation and attention.

Current understanding of mechanisms underlying neural plasticity changes after stroke stems from experimental models as well as clinical studies and provides the foundation for evidence-based neurorehabilitation. Evidence accumulated during the past 2 decades together with recent advances in the field of stroke recovery clearly shows that the effects of neurorehabilitation can be enhanced by behavioral manipulations in combination with adjuvant therapies that stimulate the endogenous neural plasticity.

Nowadays, a large toolbox of training-oriented rehabilitation techniques has been developed, which allows the increase of independence and quality of life of the patients and their families [39]. The recovery of function has been shown to depend on the intensity of therapy, repetition of specified-skilled movements directed toward the motor deficits and rewarded with performance-dependent feedback.

The use of technological devices not only helps to increase these aspects but also facilitates the work of therapists in order to enhance the abilities of patients and a higher level of functional recovery. They create environments with a greater amount of sensorimotor stimuli that enhance the neuroplasticity of patients, translating into a successful functional recovery. The use of technological devices can transfer the effects of rehabilitation to the different environments where patients spend their daily life allowing a favorable social reintegration. In this chapter, a review of technologies for rehabilitation of mobility in upper and lower extremity is presented.[…]

Continue —>  After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation | InTechOpen

Figure 1. Mechanical treatment devices. (a) Armeo Spring and (b) Saebo ReJoyce.

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[ARTICLE] Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation – Full Text

 

Abstract

Background

Arm-hand rehabilitation programs applied in stroke rehabilitation frequently target specific populations and thus are less applicable in heterogeneous patient populations. Besides, changes in arm-hand function (AHF) and arm-hand skill performance (AHSP) during and after a specific and well-described rehabilitation treatment are often not well evaluated.

Method

This single-armed prospective cohort study featured three subgroups of stroke patients with either a severely, moderately or mildly impaired AHF. Rehabilitation treatment consisted of a Concise_Arm_and_hand_ Rehabilitation_Approach_in_Stroke (CARAS). Measurements at function and activity level were performed at admission, clinical discharge, 3, 6, 9 and 12 months after clinical discharge.

Results

Eighty-nine stroke patients (M/F:63/23; mean age:57.6yr (+/-10.6); post-stroke time:29.8 days (+/-20.1)) participated. All patients improved on AHF and arm-hand capacity during and after rehabilitation, except on grip strength in the severely affected subgroup. Largest gains occurred in patients with a moderately affected AHF. As to self-perceived AHSP, on average, all subgroups improved over time. A small percentage of patients declined regarding self-perceived AHSP post-rehabilitation.

Conclusions

A majority of stroke patients across the whole arm-hand impairment severity spectrum significantly improved on AHF, arm-hand capacity and self-perceived AHSP. These were maintained up to one year post-rehabilitation. Results may serve as a control condition in future studies.

Introduction

One of the most common deficits following stroke is a persistent impairment of the arm and hand due to a hemiparesis, which has a significant impact on performance in daily life activities [1]. Recovery of arm-hand function and skills is a major rehabilitation and health care challenge. Motor rehabilitation approaches for arm-hand performance after stroke has been changing substantially over the last decades. However, an integral arm-hand skill training approach, accommodating both the heterogeneity of the patient population and its associated patterns and levels of recovery directly post-stroke seems to be absent. A large number of well-explored and well-investigated examples of training approaches in specific (sub) populations have been identified [2] like, for instance, task-oriented training [3], mental practice [4] and constraint-induced movement therapy (CIMT) [5]. In task-oriented approaches specific functional, skill-related tasks are trained. This is done preferably by using real-life objects [6], thereby teaching patients to solve specific problems related to, e.g., anticipatory motor adjustments or cognitive processing by using efficient goal-oriented movement strategies [7, 8].

Existing task-oriented arm-hand programs (e.g. [916]) are valuable contributions to rehabilitation practice and may offer a stable point of departure for clinicians to select the most appropriate therapy for a particular patient.

However, several aspects make it difficult for clinicians to choose the most appropriate arm-hand therapy intervention(s) for a particular patient: 1) Most studies or programs target specific populations (in particular those with some preservation of wrist and/or finger extension) and thus are less applicable for patients with a more severely affected arm-hand as seen in the heterogeneous populations of many rehabilitation centres [17]. 2) Programs are focused on either the arm or the hand alone. 3) Most of the current studies in research projects feature strictly protocolled interventions, which cannot be easily adopted in the clinicians’ daily practice. 4) The lack of information about the proportional improvement or deterioration to be expected in stroke survivors in the sub-acute phase after stroke may lead to difficulties for clinicians to make decisions about arm-hand treatment objectives and concomitant prognostics regarding arm-hand skill performance.

In order to overcome these four drawbacks a Concise Arm and hand Rehabilitation Approach in Stroke (acronym: CARAS) [18] was developed in order to guide clinicians, during their daily practice, in systematically designing a patient’s optimal arm-hand rehabilitation program. CARAS is based on four constructs: a) stratification of the patient population is based on the severity of arm–hand impairment for which the Utrechtse Arm-hand Test (UAT) is used [19], b) clear focus on the individual’s rehabilitation goals and concomitant potential rehabilitation treatment outcomes, c) principles of self-efficacy, and d) possibility to systematically incorporate (new) technology and new evidence-based training elements swiftly. CARAS has proven to be feasible in a number of stroke units of rehabilitation centres throughout the Netherlands.

In the present study, the term ‘arm–hand function’ (AHF) refers to the ICF ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF activity level, covering both capacity and performance [20].

The present paper focusses on two aspects.

Firstly, during rehabilitation AHF and AHSP may improve to a certain level. However, once a stroke patient has left the rehabilitation program, his arm-hand capacity and performance may deteriorate [21]. Whereas stroke patients with mild to moderate initial impairments show an almost fixed amount of recovery after stroke, ranging up to 70% [22, 23], stroke patients with a more severely affected arm-hand, i.e. absence of finger extension combined with large motor impairments, strongly lag behind this recovery percentage. Four years after stroke, 67% of stroke survivors still experience non-use or disuse of the moderately or severely affected arm–hand [24].

However, it is neither well understood at what rate such deterioration (or improvement) occurs, nor in which patient categories, i.e. patients with a certain level of arm-hand severity, this is most prominent. Answers to these questions are essential for the development of more adequate, personalised and cost-effective interventions that may augment and/or maintain arm-hand skill performance (AHSP) levels in stroke patients living in their home environment.

Secondly, the risk of losing the opportunity to clearly define ‘therapy-as-usual’ (TAU) is becoming a problem in AHSP research in stroke patients. In the myriad of studies evaluating newly developed training protocols aimed at improving AHF and/or AHSP, each of these new training approaches is contrasted to some kind of TAU, the latter of which may vary widely between clinics and institutes. Even worse, often TAU is not clearly defined at all.

As the implementation of many of the tested experimental treatments progresses, the concept of ‘therapy-as-usual’ inevitably will be lost.

The aim of the present study was to evaluate the course AHF and AHSP take in a broad range of sub-acute stroke patients during and after rehabilitation involving a therapy-as-usual (i.e. CARAS) [18].

Three subgroups, i.e. a subgroup of patients with a severely affected arm-hand, a subgroup of patients with a moderately affected arm-hand and a subgroup of patients with a mildly affected arm-hand, were formed.

The research questions were:

  1. To what extent do arm-hand function and arm-hand skill performance in stroke patients change during and after their rehabilitation involving therapy-as-usual?
  2. To what extent does the rate of improvement or deterioration (over time) of arm-hand function and arm-hand skill performance differ between three subgroups of stroke patients, i.e. patients with either a severely, moderately or mildly affected functional arm-hand, during and after their rehabilitation involving CARAS?[…]

Continue —> Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation

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[ARTICLE] Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis – Full Text

 

Abstract

Background

Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined.

Methods

This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL).

Discussion

This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation.

Background

Clinical practice guidelines recommend outpatient rehabilitation for stroke survivors who remain disabled after discharge from inpatient rehabilitation [1]. Although these guidelines recommend that the majority of stroke survivors receive at least some outpatient rehabilitation [2], many cannot access long-term care [3]. Among those individuals who do undergo outpatient rehabilitation, the standard of care for upper extremity rehabilitation is suboptimal.

In an observational study of 312 rehabilitation sessions (83 occupational and physical therapists at 7 rehabilitation sites), Lang and colleagues [4] found that functional rehabilitation (i.e., movement that accomplishes a functional task, such as eating, as opposed to strength training or passive movement) was provided in only 51% of the sessions of upper extremity rehabilitation, with only 45 repetitions per session on average. This is concerning given that empirically-validated interventions incorporate higher doses of active motor practice [5, 6, 7]. Additionally, functional upper extremity movements are most likely to generalize to everyday tasks [8], an aspect of recovery that is critically important to patients and their families [9, 10, 11]. Yet, passive movement and non-goal-directed exercise are more frequently administered [4].

There appear to be at least two critical elements required for successful upper extremity motor rehabilitation: 1) motor practice that is sufficiently intense and 2) techniques to carryover motor improvements to functional activities. Carry-over techniques to increase a person’s use of the more affected upper extremity for daily activities are extremely important for rehabilitation and appear necessary for structural brain change [12, 13, 14, 15]. When rehabilitation incorporates these techniques, there is substantially improved improvement in self-perceived quality of arm use for daily activities [12, 16]. Carry-over techniques enable the patient to overcome the conditioned suppression of movement (learned nonuse) characteristic of chronic hemiparesis [17]. Techniques include structured self-monitoring, a treatment contract, daily home practice of specific functional motor skills, and guided problem-solving to overcome perceived barriers to using the extremity [18].

Constraint-Induced Movement therapy (CI therapy) has strong empirical backing [5, 19] and combines high-repetition functional practice of the more affected arm with behavioral techniques to enhance carry-over [13, 18]. CI therapy produces consistently superior motor performance and retention of gains versus standard upper extremity rehabilitation [20, 21], particularly when it includes the critically important carry-over (transfer package) techniques [12]. When compared to other equally intensive interventions (i.e., equal hours of training on functional tasks), CI therapy with carry-over (transfer package) techniques has also shown enhanced carry-over of clinical gains to daily activities [12, 13, 22, 23, 24] that are retained for at least 2 years [19, 25, 26, 27, 28].

Despite its inclusion in best practice recommendations [29, 30], CI therapy is available to only a very small minority of those who could benefit from it in the US. CI therapy is not typically covered by insurance and the 30+ hours of assessment and physical training cost upwards of $6000. Access barriers for the patient include limited transportation and insurance coverage, whereas therapists may have difficulty accommodating the CI therapy schedule [31, 32]. Access barriers aside, CI therapy has also been plagued by a variety of misconceptions regarding use of restraint and the transfer package. Most iterations of CI therapy employ use of a restraint mitt to promote use of the affected arm, which is viewed by many patients and clinicians as excessively prohibitive [32]. Yet, literature demonstrates that restraint is not specifically required to achieve positive outcomes [33, 34]. Moreover, the transfer package, a component found to be critical [13, 14], is omitted from the majority of research studies on CI therapy [35].

To address transportation barriers, a telerehabilitation model of CI therapy delivery (AutoCITE) has been tested. AutoCITE is a large specialized motor apparatus (not commercially available, cost not established) that was installed in patients’ homes to enable therapeutic manipulation of actual objects with continuous video monitoring via Internet. This telerehabilitation approach demonstrated efficacy approximately equivalent to that of in-clinic CI therapy [36, 37, 38], thus establishing the feasibility of utilizing technology to deliver CI therapy remotely. However, this system involved specialized equipment at a high cost and did not become available outside a research setting.

To more fully address the barriers to accessing CI therapy and to counter the misconceptions surrounding CI therapy, a patient-centered treatment approach was developed that incorporated the high-repetition practice and carry-over strategies from CI therapy, while reforming non-patient-centric elements of the protocol that lack strong empirical support (i.e., the restraint). To deliver engaging high-repetition practice, a Kinect-based video game was created that can accommodate a wide range of motor disability, can be customized to each user, and automatically progresses in difficulty as the individual’s performance improves (termed “shaping” in the CI therapy literature). A player’s body movements drive game play (there is no external controller), which makes the game easy to use for those who may be unfamiliar with technology. To date, such high-repetition practice through motor gaming [39] has shown initial promise compared to traditional clinic-based approaches [40]. To promote increased use of the weaker arm, a smart watch biofeedback application is utilized in lieu of the restraint mitt. This application counts movements made with the weaker arm and provides alerts when a period of inactivity is detected. Previous approaches for providing CI therapy in the home and reducing the amount of therapist effort have been carried out [36, 37, 38, 41]. These approaches automated the delivery of training and permitted remote supervision of the training via an Internet-based audio-visual link, but did not embed the training within the context of a video game, rely on manipulation of virtual objects, or incorporate a patient-centric substitute for the mitt.

Initial evidence from a pilot trial of this system (Borstad A, Crawfis R, Phillips K, Pax Lowes L, Worthen-Chaudhari L, Maung D, et al.: In-home delivery of constraint induced movement therapy via virtual reality gaming is safe and feasible: a pilot study, submitted) suggests that improvements in motor speed, as measured by Wolf Motor Function Test (WMFT) performance time [42], an outcome of prime importance to stroke survivors, are approximately equivalent to those reported in the traditional CI therapy literature [5, 13, 19, 25]. Qualitative data reveal that the technology is accepted irrespective of age, technological expertise, ethnicity, or cultural background. Thus, this technology has the potential to address the main barriers to adoption of CI therapy, while reducing the cost of care. A randomized clinical trial is now required to provide Level 1 evidence of the comparative effectiveness of this novel model of CI therapy delivery. Data from this trial will enable individuals with motor disability to evaluate whether a home-based video game therapy has the potential to help them meet their rehabilitation goals compared to in-clinic CI therapy and traditional approaches. By combining novel gaming elements with the transfer package from CI therapy, this trial will also address a major limitation of rehabilitation gaming interventions that have been tried to date: extremely limited emphasis on carry-over of training to daily activities.

The primary objective of this trial is to compare the effectiveness of two video game-based models of CI therapy versus traditional clinic-based CI therapy versus standard upper extremity rehabilitation for improving upper extremity motor function. One video gaming group will match the number of total hours spent on the CI therapy transfer package, but will involve fewer days of therapist-client interaction (4 versus 10); the other will match the number of interactions with a therapist to that of clinic-based CI therapy using video consultation between in-person sessions and, as such, will involve more therapist contact hours spent focusing on the transfer package. The secondary objective of this project is to promote personalized medicine by examining individual factors that may differentially influence response to one treatment versus another.

Continue —>  Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis | BMC Neurology | Full Text

Fig. 1 Screen capture of the Recovery Rapids gaming environment

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