Posts Tagged Hemiparetic
The main goal of this project is to refine and optimize elements of the virtual reality-based training paradigms to enhance neuroplasticity and maximize recovery of function in the hemiplegic hand of patients who had a stroke.
PIs, Sergei Adamovich, Alma Merians, Eugene Tunik, A.M. Barrett
This application seeks funding to continue our on-going investigation into the effects of intensive, high dosage task and impairment based training of the hemiparetic hand, using haptic robots integrated with complex gaming and virtual reality simulations. A growing body of work suggests that there is a time-limited period of post-ischemic heightened neuronal plasticity during which intensive training may optimally affect the recovery of gross motor skills, indicating that the timing of rehabilitation is as important as the dosing. However, recent literature indicates a controversy regarding both the value of intensive, high dosage as well as the optimal timing for therapy in the first two months after stroke. Our study is designed to empirically investigate this controversy. Furthermore, current service delivery models in the United States limit treatment time and length of hospital stay during this period. In order to facilitate timely discharge from the acute care hospital or the acute rehabilitation setting, the initial priority for rehabilitation is independence in transfers and ambulation. This has negatively impacted the provision of intensive hand and upper extremity therapy during this period of heightened neuroplasticity. It is evident that providing additional, intensive therapy during the acute rehabilitation stay is more complicated to implement and difficult for patients to tolerate, than initiating it in the outpatient setting, immediately after discharge. Our pilot data show that we are able to integrate intensive, targeted hand therapy into the routine of an acute rehabilitation setting. Our system has been specifically designed to deliver hand training when motion and strength are limited. The system uses adaptive algorithms to drive individual finger movement, gain adaptation and workspace modification to increase finger range of motion, and haptic and visual feedback from mirrored movements to reinforce motor networks in the lesioned hemisphere. We will translate the extensive experience gained in our previous studies on patients in the chronic phase, to investigate the effects of this type of intervention on recovery and function of the hand, when the training is initiated within early period of heightened plasticity. We will integrate the behavioral, the kinematic/kinetic and neurophysiological aspects of recovery to determine: 1) whether early intensive training focusing on the hand will result in a more functional hemiparetic arm; (2) whether it is necessary to initiate intensive hand therapy during the very early inpatient rehabilitation phase or will comparable outcomes be achieved if the therapy is initiated right after discharge, in the outpatient period; and 3) whether the effect of the early intervention observed at 6 months post stroke can be predicted by the cortical reorganization evaluated immediately after the therapy. This proposal will fill a critical gap in the literature and make a significant advancement in the investigation of putative interventions for recovery of hand function in patients post-stroke. Currently relatively little is known about the effect of very intensive, progressive VR/robotics training in the acute early period (5-30 days) post-stroke. This proposal can move us past a critical barrier to the development of more effective approaches in stroke rehabilitation targeted at the hand and arm.
[WEB SITE] Transcranial Magnetic Stimulation for the Recovery of Gait and Balance in Stroke Patients – BrainPost
Post by Thomas Brown
What’s the science?
The permanent brain damage which occurs following ischemic stroke makes functional recovery difficult. While physiotherapy can result in improved voluntary motor recovery, the improvement of balance and gait can be harder. Issues with balance pose a safety risk for stroke patients, who may be more likely to fall. Ultimately, problems with balance can mean reduced independence for patients. The cerebellum, a structure located at the back of the brain, is known to regulate movement, gait and balance. Deficits to the cerebellum often result in ataxia and widened gaits, making this area a prime target for functional recovery analysis. This week in JAMA Neurology Koch and colleagues demonstrate in a phase IIa clinical trial, an increase in gait and balance in hemiparetic stroke patients, up to three weeks after physiotherapy supplemented with transcranial magnetic stimulation of the cerebellum.
How did they do it?
A group of 36 hemiparetic (one side affected) stroke patients were randomly assigned to one of two age-matched groups; control or experimental. The experimental group was treated with intermittent theta-burst magnetic stimulation (TBS) of the cerebellar region ipsilateral (same side) to their motor issues. Intermittent TBS is a process by which bursts of magnetic energy are applied to the scalp over an area of interest. TBS was administered in conjunction with physiotherapy to the experimental group for three weeks. The control group still received physiotherapy, but received sham (fake) TBS. Patients were assessed using a wide range of balance and gait analysis tests to determine the degree of recovery. The authors relied primarily on the Berg Balance Scale, which is a series of 14 tests that determine the ability of an individual to balance without aid. Gait analysis was also performed, in which patients were asked to walk while a machine measured their gait (the space between each foot while walking). Neural activity was measured with electroencephalography while transcranial magnetic stimulation was applied simultaneously (EEG-TMS). This technique was used to measure neural activity changes in motor regions of the brain following activation of the motor cortex using a different TMS paradigm than the one used for treatment.
What did they find?
The authors found that after three weeks of the last treatment with either sham or cerebellar TBS, there was an average increase in the Berg Balance Scale score in those treated with TBS compared to controls. They also showed a reduction in gait width; a wide gait is often associated with the body’s attempt to compensate for problems with balance. This finding was supported by correlational analysis which found that a reduction is step width was associated with an improvement in Berg Balance Scale score. Interestingly, three weeks after treatment there was also an increase in neural activity in the motor (M1) region of the brain in the hemispheres affected by the stoke, in treated patients compared to controls. This area of the cortex is associated with the movement execution. Altogether these findings suggest that there were significant balance, gait and motor cortex activity improvements following treatment with TBS. Critically, no adverse effects were observed following treatment with TBS during the clinical trial.
What’s the impact?
These findings suggest that theta-burst stimulation may be an effective way of supplementing physiotherapy in those suffering with balance and gait deficits following stroke. Theta-burst stimulation in conjunction with physiotherapy, was able to improve both balance and gait in stroke patients. Treatment with theta-burst stimulation could reduce the chance of falling and improve independence in stroke patients.
Koch et al. Effect of Cerebellar Stimulation on Gait and Balance Recovery
in Patients With Hemiparetic Stroke. JAMA Neurology (2018).Access the original scientific publication here
[Abstract] Motor Impairment–Related Alterations in Biceps and Triceps Brachii Fascicle Lengths in Chronic Hemiparetic Stroke
Poststroke deficits in upper extremity function occur during activities of daily living due to motor impairments of the paretic arm, including weakness and abnormal synergies, both of which result in altered use of the paretic arm. Over time, chronic disuse and a resultant flexed elbow posture may result in secondary changes in the musculoskeletal system that may limit use of the arm and impact functional mobility. This study utilized extended field-of-view ultrasound to measure fascicle lengths of the biceps (long head) and triceps (distal portion of the lateral head) brachii in order to investigate secondary alterations in muscles of the paretic elbow. Data were collected from both arms in 11 individuals with chronic hemiparetic stroke, with moderate to severe impairment as classified by the Fugl-Meyer assessment score. Across all participants, significantly shorter fascicles were observed in both biceps and triceps brachii (P < .0005) in the paretic limb under passive conditions. The shortening in paretic fascicle length relative to the nonparetic arm measured under passive conditions remained observable during active muscle contraction for the biceps but not for the triceps brachii. Finally, average fascicle length differences between arms were significantly correlated to impairment level, with more severely impaired participants showing greater shortening of paretic biceps fascicle length relative to changes seen in the triceps across all elbow positions (r = −0.82, P = .002). Characterization of this secondary adaptation is necessary to facilitate development of interventions designed to reduce or prevent the shortening from occurring in the acute stages of recovery poststroke.
[Abstract] Effectiveness of a single session of dual-transcranial direct current stimulation in combination with upper limb robotic-assisted rehabilitation in chronic stroke patients: a randomized, double-blind, cross-over study
The impact of transcranial direct current stimulation (tDCS) is controversial in the neurorehabilitation literature. It has been suggested that tDCS should be combined with other therapy to improve their efficacy.
To assess the effectiveness of a single session of upper limb robotic-assisted therapy (RAT) combined with real or sham-tDCS in chronic stroke patients. Twenty-one hemiparetic chronic stroke patients were included in a randomized, controlled, cross-over double-blind study.
Each patient underwent two sessions 7 days apart in a randomized order: (a) 20 min of real dual-tDCS associated with RAT (REAL+RAT) and (b) 20 min of sham dual-tDCS associated with RAT (SHAM+RAT). Patient dexterity (Box and Block and Purdue Pegboard tests) and upper limb kinematics were evaluated before and just after each intervention. The assistance provided by the robot during the intervention was also recorded. Gross manual dexterity (1.8±0.7 blocks, P=0.008) and straightness of movement (0.01±0.03, P<0.05) improved slightly after REAL+RAT compared with before the intervention. There was no improvement after SHAM+RAT. The post-hoc analyses did not indicate any difference between interventions: REAL+RAT and SHAM+RAT (P>0.05). The assistance provided by the robot was similar during both interventions (P>0.05).
The results showed a slight improvement in hand dexterity and arm movement after the REAL+RAT tDCS intervention. The observed effect after a single session was small and not clinically relevant. Repetitive sessions could increase the benefits of this combined approach.
[ARTICLE] Wearable robotic exoskeleton for overground gait training in sub-acute and chronic hemiparetic stroke patients: preliminary results – Full Text PDF
BACKGROUND: Recovery of therapeutic or functional ambulatory capacity in post-stroke patients is a primary goal of rehabilitation. Wearable powered exoskeletons allow patients with gait dysfunctions to perform over-ground gait training, even immediately after the acute event.
AIM: To investigate the feasibility and the clinical effects of an over-ground walking training with a wearable powered exoskeleton in sub-acute and chronic stroke patients.
DESIGN: Prospective, pilot pre-post, open label, non-randomized experimental study.
SETTING: A single neurological rehabilitation center for inpatients and outpatients.
POPULATION: Twenty-three post-stroke patients were enrolled: 12 sub-acute (mean age: 43.8±13.3 years, 5 male and 7 female, 7 right hemiparesis and 5 left hemiparesis) and 11 chronic (mean age: 55.5±15.9 years, 7 male and 4 female, 4 right hemiparesis and 7 left hemiparesis) patients.
METHODS: Patients underwent 12 sessions (60 min/session, 3 times/week) of walking rehabilitation training using Ekso™, a wearable bionic suit that enables individuals with lower extremity disabilities and minimal forearm strength to stand up, sit down and walk over a flat hard surface with a full weight-bearing reciprocal gait. Clinical evaluations were performed at the beginning of the training period (t0), after 6 sessions (t1) and after 12 sessions (t2) and were based on the Ashworth scale, Motricity Index, Trunk Control Test, Functional Ambulation Scale, 10-Meter Walking Test, 6-Minute Walking Test, and Walking Handicap Scale. Wilcoxon’s test (P<0.05) was used to detect significant changes.
RESULTS: Statistically significant improvements were observed at the three assessment periods for both groups in Motricity Index, Functional Ambulation Scale, 10-meter walking test, and 6-minute walking test. Sub-acute patients achieved statistically significant improvement in Trunk Control Test and Walking Handicap Scale at t0-t2. Sub-acute and chronic patient did not achieve significant improvement in Ashworth scale at t0-t2.
CONCLUSIONS: Twelve sessions of over-ground gait training using a powered wearable robotic exoskeleton improved ambulatory functions in sub-acute and chronic post-stroke patients. Large, randomized multicenter studies are needed to confirm these preliminary data.
CLINICAL REHABILITATION IMPACT: To plan a completely new individual tailored robotic rehabilitation strategy after stroke, including task-oriented over-ground gait training.
Full Text PDF
via Wearable robotic exoskeleton for overground gait training in sub-acute and chronic hemiparetic stroke patients: preliminary results – European Journal of Physical and Rehabilitation Medicine 2017 October;53(5):676-84 – Minerva Medica – Journals
[Abstract] Effectiveness of the conductive educational approach added to conventional physiotherapy in the improvement of gait parameters of poststroke patients: randomized-controlled pilot study.
Our objective was to assess the benefits of the conductive education (CE) approach added to conventional physiotherapy in gait functions of poststroke, hemiparetic patients. A randomized-controlled trial was designed in a rehabilitation clinic. Late and chronic poststroke patients with gait disturbances (n=17, median age: 55 years, range: 41-72 years) were enrolled in the study. All patients received conventional physiotherapy. However, patients of only one group took part in therapy on the basis of the CE approach. The gait parameters, semiobjective outcome measures, functional independence measure, and International Classification of Functioning, Disability and Health domains were collected. The effectiveness of the CE approach was underlined by those outcome measures that were only significant (P≤0.05) in the conductive group: functional independence measure motor subscale; maintaining body position and walking long distances; and muscle strength in some muscle groups. The results suggest that CE could have an additive effect on gait improvement of stroke patients.
Background. Although rehabilitation therapy is commonly provided after stroke, many patients do not derive maximal benefit because of access, cost, and compliance. A telerehabilitation-based program may overcome these barriers. We designed, then evaluated a home-based telerehabilitation system in patients with chronic hemiparetic stroke. Methods. Patients were 3 to 24 months poststroke with stable arm motor deficits. Each received 28 days of telerehabilitation using a system delivered to their home. Each day consisted of 1 structured hour focused on individualized exercises and games, stroke education, and an hour of free play. Results. Enrollees (n = 12) had baseline Fugl-Meyer (FM) scores of 39 ± 12 (mean ± SD). Compliance was excellent: participants engaged in therapy on 329/336 (97.9%) assigned days. Arm repetitions across the 28 days averaged 24,607 ± 9934 per participant. Arm motor status showed significant gains (FM change 4.8 ± 3.8 points, P = .0015), with half of the participants exceeding the minimal clinically important difference. Although scores on tests of computer literacy declined with age (r = −0.92; P < .0001), neither the motor gains nor the amount of system use varied with computer literacy. Daily stroke education via the telerehabilitation system was associated with a 39% increase in stroke prevention knowledge (P = .0007). Depression scores obtained in person correlated with scores obtained via the telerehabilitation system 16 days later (r = 0.88; P = .0001). In-person blood pressure values closely matched those obtained via this system (r = 0.99; P < .0001). Conclusions. This home-based system was effective in providing telerehabilitation, education, and secondary stroke prevention to participants. Use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.
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Source: A Home-Based Telerehabilitation Program for Patients With StrokeNeurorehabilitation and Neural Repair – Lucy Dodakian, Alison L. McKenzie, Vu Le, Jill See, Kristin Pearson-Fuhrhop, Erin Burke Quinlan, Robert J. Zhou, Renee Augsberger, Xuan A. Tran, Nizan Friedman, David J. Reinkensmeyer, Steven C. Cramer, 2017
[ARTICLE] A novel generation of wearable supernumerary robotic ﬁngers to compensate the missing grasping abilities in hemiparetic upper limb – Full Text PDF
This contribution will focus on the design, analysis, fabrication, experimental characterization and evaluation of a family of prototypes of robotic extra ﬁngers that can be used as grasp compensatory devices for hemiparetic upper limb.
The devices are the results of experimental sessions with chronic stroke patients and consultations with clinical experts. All the devices share a common principle of work which consists in opposing to the paretic hand/wrist so to restrain the motion of an object.
Robotic supernumerary ﬁngers can be used by chronic stroke patients to compensate for grasping in several Activities of Daily Living (ADL) with a particular focus on bimanual tasks.
The devices are designed to be extremely portable and wearable. They can be wrapped as bracelets when not being used, to further reduce the encumbrance. The motion of the robotic devices can be controlled using an Electromyography (EMG) based interface embedded in a cap. The interface allows the user to control the device motion by contracting the frontalis muscle. The performance characteristics of the devices have been measured through experimental set up and the shape adaptability has been conﬁrmed by grasping various objects with different shapes. We tested the devices through qualitative experiments based on ADL involving a group of chronic stroke patients in collaboration with by the Rehabilitation Center of the Azienda Ospedaliera Universitaria Senese.
The prototypes successfully enabled the patients to complete various bi-manual tasks. Results show that the proposed robotic devices improve the autonomy of patients in ADL and allow them to complete tasks which were previously impossible to perform.
[Abstract] Design and Test of a Closed-Loop FES System for Supporting Function of the Hemiparetic Hand Based on Automatic Detection Using the Microsoft Kinect Sensor