Posts Tagged home
Rutgers virtual reality tools show promise for at-home stroke recovery
A small propeller plane operated by Allen DeNiear climbs into the sky. With a stark desert valley, seemingly inhabited by nothing more than cacti, visible on the red earth below, DeNiear makes a small motion with his hand. The plane pitches downward and dives.
DeNiear is not a pilot.
Nevertheless, his eyes focus on his targets, a series of orbs floating in the sky at various altitudes. His goal is simple enough: collect the orbs without crashing.
His reality, for the moment, is virtual.
Ready, player one.
Sitting in a lab at the Rutgers School of Health Professions in Newark, DeNiear moves his hand again. In his lap, a small infrared camera linked to the computer running the virtual reality (VR) flight simulator registers his hand movement. The plane ascends, and he collects another orb.
Both the motion and the game seem deceptively easy, but for DeNiear, who is recovering from a stroke and has limited mobility in his right hand, arm, and shoulder, the move is more than meets the eye, and the game, which can be played from anywhere you can fit a laptop, could wind up revolutionizing physical therapy treatments for stroke victims.
Today, DeNiear is with his Rutgers recovery team. But tomorrow, when he needs to do therapeutic work on his hand and arm, he’ll do it from home. No appointment is needed, the trek to a rehab center is eliminated, and—because the games are a lot more fun than monotonous rehab programs—he is more likely to actually do his exercises, thanks to the at-home approach to rehabilitation being tested and refined by Rutgers researchers.
Improving at-home therapy’s low score.
Standard at-home physical therapy regimens for stroke recovery are both boring and frustrating for patients. “The adherence to home exercise programs is incredibly low,” said Gerry Fluet, an associate professor in the rehabilitation and movement sciences department. A physical therapist by trade, Fluet’s research is focused on using VR games to increase patient participation in at-home therapy programs.
“We’re trying to create something that’s more pleasurable and interesting than opening your hand 50 times while you watch it and wish it would move more,” he said. “We set out to develop simulations that people would stop in the middle of their day to play, and tomorrow, pick them up and play them again, and then again the day after that.”
By building the physical rehabilitation regimen into a game, Fluet and his team are able to turn the monotony of stroke rehabilitation into something that is a lot more fun than it used to be. This is important, he said, because after a stroke, a person must put in a lot of work to regain control of the hand.
Without gaming therapy, people are exercising at home two or three times a week, for about five to 10 minutes, if they even bother doing it at all, Fluet said. Meanwhile, people in the lab’s study using the VR games at home are averaging anywhere from 60 to 90 minutes of exercise therapy in a week, with no additional reminders or encouragement. In the real world, this could translate into a much more cost effective and impactful form of stroke rehabilitation.
“We’re seeing tangible, measurable results,” he said.
The game library developed so far has a dozen titles. In addition to piloting a plane, players can drive a car, run through a maze, hit the keys of a piano, and more—all from a Windows-based application developed by Fluet’s long-time collaborator Qinyin Qiu, an assistant professor in the Department of Rehabilitation and Movement Sciences at Rutgers, and Amanda Cronce, a digital designer in the Department of Biomedical Engineering at New Jersey Institute of Technology (NJIT), as part of a collaboration between Rutgers Biomedical and Health Sciences and the Motor Control and Rehabilitation Lab led by Sergei Adamovich at NJIT.
The study has patients play the VR games at home for at least 15 minutes a day, every day for three months. The gaming application collects the patient data and transfers it to a remote data server so Qiu and Fluet can monitor the at-home progress. They can even use the application real-time chat with the patient.
“We’re really trying to turn this into tele-rehab,” said Qiu, adding that the team is exploring go-to-market strategies and commercialization opportunities for their project through an I-Corps grant.
DeNiear is, self-admittedly, “not a video game person,” but he embraces gaming as a method for recovering from his stroke. “As you’re playing the game, it breaks the monotony of what you’re supposed to be doing. If I didn’t have the games, it would be a lot slower,” he said of his recovery. “It helped speed the process up, I think.”
Today, DeNiear has regained enough mobility to be able to drive again, and write with his right hand. He is still not 100 percent recovered, and he acknowledges that he may never be totally back to his old self. But he is committed to making the most of his situation by taking advantage of opportunities to participate in studies like Fluet and Qiu’s at-home VR physical therapy program.
“You gotta work at it,” he said. “You gotta do it.”
What is Mollii?
Mollii is a suit consisting of a pair of trousers, a jacket and a detachable control unit. The Mollii garments includes 58 imbedded electrodes, positioned to stimulate 40 key muscles in the body. Through a low frequency electro-stimulation therapy, Mollii relaxes spastic, tense and aching muscles safely and simply. Programmed after each person’s needs, Mollii prevents and counteracts different forms of muscle shortening and rigidity, helps the user regain control over muscular tension, and reduces pain related to spasticity. In addition, through electro-stimulation settings, Mollii may facilitate the activation of muscles, and thereby may facilitate muscle contractions, which in turn enable movements.
Who uses Mollii?
Mollii is used by people who suffer from spasticity and spasticity-related pain, which is typically found in people with cerebral palsy, stroke, multiple sclerosis, spinal cord injury, acquired brain damages and other neurological injuries that result from or create motor disabilities, and generally induce pain. Mollii is used both by adults and children; and is available in men and women sizes starting from 104 cm. up to XXXL.
Mollii can be used in both a home and clinic environment; and is simple to use for all ages. Users dress-up with a Mollii the same way they would with an ordinary garment. There is a button for on/off and a button for play/ pause. A single push of the button starts the muscle stimulation, which proceeds automatically for 60 minutes, and has a lasting positive effect for up to 48 hours.”
How does it work?
Mollii stimulates the antagonist to the spastic muscle. If the bicep is spastic, the tricep is stimulated, which in turn makes the bicep relaxed. Relaxing the muscle enables active movements and a gradual improvement in function, while the body keeps this positive effect for up to 48 hours. The physiological mechanism is called reciprocal inhibition.
Mollii also reduces pain related to spasticity, both through the reciprocal inhibition, and via the gate control theory of pain, which asserts that non-painful input such as the electric stimulation of skin-nerves closes the nerve-gates to painful input, which prevents pain sensation from traveling to the central nervous system.
Moreover, Mollii may facilitate the sub-threshold stimulation of a muscle by preparing the muscle for contraction before generating a shortening of the muscle, thereby reducing the nerve signal-strength required by the patient to actually generate a muscle contraction.
It is a safe and simple assistive device that can increase quality of life and help recover faster motor functions. The device is used for one hour every second day. For optimum effect, Mollii should be used together with physiotherapy, training, activity and movement. The positive effect is individual and remains for up to 48 hours.
Frequently asked questions
[ARTICLE] Development of a Novel Home Based Multiscene Upper Limb Rehabilitation Training and Evaluation System for Post-stroke Patients – Full Text PDF
Upper limb rehabilitation requires long-term, repetitive rehabilitation training and assessment, and many patients cannot pay for expensive medical fees in the hospital for so long time. It is necessary to design an effective, low cost, and reasonable home rehabilitation and evaluation system. In this paper, we developed a novel home based multi-scene upper limb rehabilitation training and evaluation system (HomeRehabMaster) for post-stroke patients. Based on the Kinect sensor and posture sensor, multi-sensors fusion method was used to track the motion of the patients. Multiple virtual scenes were designed to encourage rehabilitation training of upper limbs and trunk. A rehabilitation evaluation method integrating Fugl-meyer assessment (FMA) scale and upper limb reachable workspace relative surface area (RSA) was
proposed, and a FMA-RSA assessment model was established to assess upper limb motor function.
Correlation based dynamic time warping (CBDTW) was used to solve the problem of inconsistent upper limb movement path in different patients. Two clinical trials were conducted. The experimental results show that the system is very friendly to the subjects, the rehabilitation assessment results by this system are highly correlated with the therapist’s (the highest forecast accuracy was 92.7% in the 13th item), and longterm rehabilitation training can improve the upper limb motor function of the patients statistically significant (p=0.02<0.05). The system has the potential to become an effective home rehabilitation training and evaluation system.[…]
Full Text PDF —> IEEE Xplore Full-Text PDF:
U of A researcher developing personalized program that brings the appeal of electronic gaming to physical therapy for older adults.
By BEV BETKOWSKI
A high-tech University of Alberta research project is letting seniors hit a computerized gym especially designed for their needs.
VirtualGym, an electronic game that combines the entertainment of gaming with prescribed exercises, is being put through its paces in a Calgary seniors’ residence to test its user-friendliness and appeal.
Once perfected, it will deliver at-home therapeutic exercises for seniors with chronic health issues, mobility problems or dementia, at the click of a button.
“It’s a concept of bringing rehabilitation home,” said PhD candidate Noelannah Neubauer, who helped design the program. “We already have telehealth being used by doctors, why not rehabilitation too?”
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The joint research project is teaming computing scientist Eleni Stroulia and other researchers from the faculties of science and rehabilitation medicine, with support from AGE-WELL, Canada’s Technology and Aging Network.
Designed to work through Kinect, a motion sensor system originally designed for Xbox video game consoles, VirtualGym works by giving users personalized feedback as they exercise along with an onscreen avatar using a “Simon Says” theme.
“It’s designed so the exercises are completely customizable from a personal trainer or physical therapist and their progress can be monitored,” Neubauer said. By recording users’ movements through VirtualGym, therapists can remotely watch for progressions and adjust exercises accordingly.
Stroulia and her team thought their original version of VirtualGym, developed in 2015, would be a good fit for seniors, but it was a flop with their test group, who found the game too busy.
“They didn’t like it at all,” said Victor Fernandez-Cervantes, a post-doctoral researcher in computing science, who took it back to the drawing board.
Using feedback from Edmonton senior Stuart Embleton and other volunteers from the Cardiac Athletic Society of Edmonton who tried the system, Fernandez-Cervantes made VirtualGym more user-friendly.
“We wanted to design it from their point of view.”
He dialled down the noise with a less distracting and cartoonish version of the game. The screen scenery evolved from its original version—an instructional avatar exercising on snowy ground in front of a brick building—to a soothing blank-walled room with a potted plant at either side. The avatar’s build was also adjusted to reflect a more typical body shape for older adults. As well, he programmed its movements with simple but specific instructions on how to do an exercise properly, complete with correctional tools like arrows and colours that pop up if needed.
Fernandez-Cervantes is continuing to tweak VirtualGym to create a 3-D version. Right now the exercises are only partially viewable, which is a problem for seniors, Embleton believes. “If the program wants you to lift your leg and kick your foot up, you should be able to see that action from a suitable perspective,” he explained.
Other planned improvements include adding simple games to measure cognitive awareness for users. “Over time, perhaps changes in scores could reflect varying levels of cognitive impairment,” Neubauer said.
The eventual plan is to market VirtualGym widely through a spinoff company, Stroulia said.
Embleton, 77, believes seniors would use VirtualGym if it were available to them.
“Most seniors nowadays have computers and TV sets, and that, plus an optical input, is all you need to use the system. It’s going to be more and more useful as it’s further developed. It’s called a game, but it’s really a useful therapeutic process. If I had a broken hip or was frail or couldn’t drive, and needed some physical therapy, I could use a virtual gym at home,” he said.
That’s especially valuable for rural or shut-in seniors who can’t go to real-life gym classes or make regular visits to physiotherapy clinics, said Neubauer.
“We want seniors to be able to exercise more, and this provides another option for them.”
Their work on VirtualGym also offers insight and a set of guidelines for other game designers wanting to develop exercise technology for seniors, said Fernandez-Cervantes.
“When designing products, seniors need to be involved. Soon enough, everyone will be a senior.”
[ARTICLE] Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke (RHOMBUS): protocol of an intervention feasibility trial – Full Text
Introduction Effective interventions to promote upper-limb recovery poststroke are characterised by intensive and repetitive movements. However, the repetitive nature of practice may adversely impact on adherence. Therefore, the development of rehabilitation devices that can be used safely and easily at home, and are motivating, enjoyable and affordable is essential to the health and well-being of stroke survivors.
The Neurofenix platform is a non-immersive virtual reality device for poststroke upper-limb rehabilitation. The platform uses a hand controller (a NeuroBall) or arm bands (NeuroBands) that facilitate upper-limb exercise via games displayed on a tablet. The Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke trial aims to determine the safety, feasibility and acceptability of the Neurofenix platform for home-based rehabilitation of the upper-limb poststroke.
Methods and analysis Thirty people poststroke will be provided with a Neurofenix platform, consisting of a NeuroBall or NeuroBands (dependent on impairment level), seven specially designed games, a tablet and handbook to independently exercise their upper limb for 7 weeks. Training commences with a home visit from a research therapist to teach the participant how to safely use the device. Outcomes assessed at baseline and 8 weeks and 12 weeks are gross level of disability, pain, objectively measured arm function and impairment, self-reported arm function, passive range of movement, spasticity, fatigue, participation, quality of life (QOL) and health service use. A parallel process evaluation will assess feasibility, acceptability and safety of the intervention through assessment of fidelity to the intervention measured objectively through the Neurofenix platform, a postintervention questionnaire and semistructured interviews exploring participants’ experiences of the intervention. The feasibility of conducting an economic evaluation will be determined by collecting data on QOL and resource use.
Strengths and limitations of this study
The Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke trial will investigate the feasibility, acceptability and safety of a novel gaming platform (the Neurofenix platform) at home for upper-limb exercise after stroke.
Upper-limb activity data will be objectively measured by the device. Assessment outcome measures include objective (assessed blind to timepoint) and self-reported measures.
To be maximally inclusive, stroke survivors with moderate to severe arm impairment will be included in the study.
The feasibility of conducting an economic evaluation will be determined by collected data on quality of life and resource use.
This is a home-based intervention study; thus, participants and researchers collecting the data will not be blinded.
Stroke is the leading cause of severe disability worldwide with approximately 17 million new strokes each year.1 2 The UK has 1.2 million stroke survivors with 110 000 first-time strokes occurring each year resulting in an estimated societal cost of £26 billion per year.1 2 Following stroke, 85% of people initially experience upper-limb weakness, and of those with minimal movement on hospital admission, only 11%–14% regain full function of their arm.2–4 This loss in upper-limb function results in increased dependence and decreased quality of life (QOL).5 Reduced upper-limb function has been identified as a strong predictor of lowered psychological well-being poststroke.5 6 Innovation and investigation of effective treatments for arm recovery has been identified as a priority for stroke research.7
Evidence indicates the most effective interventions to improve upper-limb function are characterised by high intensity and repetitive practice.8 A higher intensity and frequency of upper-limb stroke rehabilitation is associated with improved QOL,9 motor function and ability to perform activities of daily life10 and is cost-effective.11 The UK quality standard for stroke advises 45 min of each relevant therapy for a minimum of 5 days a week.11 However, a 2015 UK national stroke audit showed on average most hospitals are unable to meet this quality standard.12 Specifically, time spent retraining the upper limb is very low, with an average of 32 repetitions per rehabilitation session.13 14 As such, there is a growing emphasis on the stroke survivor exercising independently without the presence of a therapist. However, adherence to home exercise is known to be poor.15 16 A perceived lack of support and feedback along with boredom with exercises are the most frequently cited factors associated with poor compliance.17 18
Virtual reality (VR)-based activities have been suggested as an intervention to improve upper-limb recovery by providing motivating environments or gameplay to facilitate rehabilitation.19 This digital health solution helps address boredom and compliance problems, can facilitate increased time in therapy and may not be reliant on therapist contact time.19 20 In addition, the ability of VR activities to provide feedback may enhance motor learning.21 22 Visual feedback via an on-screen character (avatar) can activate mirror neurones, which may aid recovery from stroke.23 24
VR can be considered in terms of the level of immersion provided, that is, the degree the user feels present in the virtual world due to the technical aspects of the VR environment. Immersive systems can generate life-scaled, three-dimensional images, with surround sound auditory and sensory feedback such as vibration, and pressure,25 whereas non-immersive systems involve two-dimensional images typically viewed on a screen with interaction being via controller-based systems (such as computer keyboards, joysticks, balance boards and handheld devices) or via camera-based tracking systems.26 Non-immersive systems are more commonly used for rehabilitation as they have smaller space requirements, cost less and have fewer side effects (eg, motion sickness).27
The Neurofenix platform is a non-immersive device designed to enable and encourage stroke survivors to independently exercise their upper limb with minimal therapist input. The platform was developed by Neurofenix, a bioengineering enterprise (www.neurofenix.com), along with stroke survivors and neurological physiotherapists. The platform consists of a hand controller or armbands, seven specially designed games, a tablet and an instruction handbook.[…]
[Abstract + References] Evaluation of an Upper-Limb Rehabilitation Robotic Device for Home Use from Patient Perspective
This paper presents a user study to evaluate the system’s performance by measuring objective indicators and subjective perception between the two versions of a planar rehabilitation robotic device: (i) PupArm system, called RoboTherapist 2D system for commercial purpose, designed and developed for clinical settings; and (ii) Homerehab system, developed for home use. Homerehab system is a home rehabilitation robotic platform developed inside the EU HOMEREHAB-Echord++ project framework. Nine patients with different neurological disorders participate in the study. Based on the analysis of subjective assessments of usability and the data acquired objectively by the robotic devices, we can conclude that the performance and user experience with both systems are very similar. This finding will be the base of more extensively studies to demonstrate that home-therapy with HomeRehab could be as efficient as therapy in clinical settings assisted by PupArm robot.
This work has been supported by the European Commission through the project HOMEREHAB: “Development of Robotic Technology for Post-Stroke Home Tele-Rehabilitation – Echord++” (Grant agreement: 601116); by the AURORA project (DPI2015-70415-C2-2-R), which is funded by the Spanish Ministry of Economy and Competitiveness and by the European Union through the European Regional Development Fund (ERDF), “A way to build Europe” and by Conselleria d’Educació, Cultura i Esport of Generalitat Valenciana through the grant APOTIP/2017/001.
Go, A.S., Mozaffarian, D., Roger, V.L.: Heart disease and stroke statistics–2014 update: a report from the American Heart Association. Circulation 129, e28–e292 (2014)
Langhorne, P., Coupar, F., Pollock, A.: Motor recovery after stroke: a systematic review. Lancet Neurol. 8(8), 741–754 (2009)
Richards, L., Hanson, C., Wellborn, M., Sethi, A.: Driving motor recovery after stroke. Top. Stroke Rehabil. 15(5), 397–411 (2008)
Linder, S.M., Rosenfeldt, A.B., Reiss, A., Buchanan, S., Sahu, K., Bay, C.R., Wolf, S.L., Alberts, J.L.: The home stroke rehabilitation and monitoring system trial: a randomized con-trolled trial. Int. J. Stroke 8(1), 1747–4949 (2013)
Diaz, I., Catalan, J.M., Badesa, F.J., Justo, X., Lledo, L.D., Ugartemendia, A., Gil, J.J., Díez, J., Garca-Aracil, N.: Development of a robotic device for post-stroke home tele-rehabilitation. Adv. Mech. Eng
Badesa, F.J., Llinares, A., Morales, R., Garcia-Aracil, N., Sabater, J.M., Perez-Vidal, C.: Pneumatic planar rehabilitation robot for post-stroke patients. Biomed. Eng. Appl. Basis Commun. 26(2), 1450025 (2014)
Brooke, J.: SUS: a quick and dirty usability scale. In: Jordan, P.W., Thomas, B., Weerdmeester, B.A., McClealland, I.L. (eds.) Usability Evaluation in Industry, pp. 189–194. Taylor and Francis, London (1996)
LLinares, A., Badesa, F.J., Morales, R., Garcia-Aracil, N., Sabater, J., Fernandez, E.: Robotic assessment of the influence of age on upper-limb sensorimotor function. Clin. Interv. Aging 8, 879 (2013). https://doi.org/10.2147/CIA.S45900
[ARTICLE] Automatic Control of Wrist Rehabilitation Therapy (WRist-T) device for Post-Ischemic Stroke Patient – Full Text PDF
Full Text: PDF
N. Bayona,“The role of task-specific training in rehabilitation therapies,”Topics in Stroke Rehabilitation, vol. 12, 2005,pp. 58–65.
R. Bonita, R. Beaglehole, “Recovery of motor function after stroke,”Stroke, 1988,pp. 19.
S. Cramer, J. Riley, “Neuroplasticity and brain repair after stroke,”Current Opinion in Neurology,vol. 21, 2008,pp. 76–82.
D.J. Reinkensmeyer, J. Emken, S. Cramer, “Robotics, motor learning, and neurologic recovery,”Annual Review of Biomedical Engineering, vol. 6, 2004, pp. 497-525.
M. Takaiwa, “Wrist rehabilitation training simulator for P.T. using pneumatic parallel manipulator,”IEEE International Conference on Advanced Intelligent Mechatronics (AIM), 2016, pp. 276-281.
H. Al-Fahaam, S. Davis, S. Nefti-Meziani, “Wrist Rehabilitation exoskeleton robot based on pneumatic soft actuators,”International Conference for Students of Applied Engineering (ICSAE), 2016, pp. 491-496.
D. Dauria, F. Persia, B. Siciliano,“Human-Computer Interaction in Healthcare: How to Support Patients during their Wrist Rehabilitation,”IEEE Tenth International Conference on Semantic Computing (ICSC), 2016, pp. 325-328.
W.M. Hsieh, Y.S. Hwang, S.C. Chen, S.Y. Tan,C.C. Chen, and Y.L. Chen, “Application of the Blobo Bluetooth ball in wrist rehabilitation training,”Journal of Physical Therapy Science, vol. 28, 2016, pp. 27- 32.
A. Hacıoğlu, O.F. Özdemir, A,K, Şahin, Y.S. Akgül, “Augmented reality based wrist rehabilitation system,”Signal Processing and Communication Application Conference (SIU), 2016. pp. 1869-1872.
Z.J. Lu, L.C.B. Wang, L.H. Duan, Q.Q. Lui, H.Q. Sun, Z.I. Chen, “Development of a robot MKW-II for hand and Wrist Rehabilitation Training,”The Annual IEEE International Conference on Cyber Technology in Automation, Control and Intelligent Systems, 2016, pp. 302-307.
There’s no place like home for engaging in the levels of physical activity (PA) that can aid in recovery poststroke—at least compared with the current hospital setting—according to a small study from Australia.
For the study, researchers used accelerometers and self-reports to track the PA and sitting time of 32 participants (mean age of 68, 53% male) who had experienced a stroke, comparing data gathered during their last week in the hospital with data gathered during their first week home. Participants were also assessed in a number of areas during their final week in the hospital, including physical function, functional independence, pain, anxiety, and depression.
The researchers were interested in finding out if an individual’s environment plays a role in PA poststroke—something they describe as “pivotal” to recovery—and whether other factors, such as depression, have an effect on any changes in PA levels. Results were e-published ahead of print in theArchives of Physical Medicine and Rehabilitation (abstract only available for free).
They found that environment does seem to make a difference—and a fairly big one at that. While the amount of time spent awake didn’t change much from hospital to home (13.1 hours a day in the hospital vs 13.5 hours per day at home), the amount of PA achieved—and time spent in sedentary behaviors—varied significantly. Participants sat for an average of 45 fewer minutes a day at home than they did in their last week in the hospital, were upright for 45 more minutes a day, spent 12 more minutes a day walking, and completed an average of 724 additional daily steps.
The results were similar when adjusted for demographic variables and didn’t seem to be significantly affected by any of the secondary factors assessed in the hospital, save one—depression, which when present was associated with no gains in PA at home.
The researchers don’t pin the improvement to any single factor but speculate that “the home environment may provide greater opportunity for activities of daily living such as cooking, cleaning, social and community activities, and there may be fewer external restrictions such as hospital routines and safety concerns around mobilization.”
Authors of the study also believe the gap between home and hospital PA poststroke could be closed if hospitals were to take more cues from the home environment.
“Physically, cognitively, and socially enriched stroke rehabilitation environments appear to increase activity by 20%,” they write. “Wards [that] include communal areas to promote more time spent upright, and the need to transport patients further for personal care may create opportunities for activity. The low activity levels in [the] hospital and at home found in our study, and in prior reports…indicate that there is clearly more work to be done in promoting activity after stroke.”
[ARTICLE] A customized home-based computerized cognitive rehabilitation platform for patients with chronic-stage stroke: study protocol for a randomized controlled trial – Full Text
Stroke patients usually suffer primary cognitive impairment related to attention, memory, and executive functions. This impairment causes a negative impact on the quality of life of patients and their families, and may be long term. Cognitive rehabilitation has been shown to be an effective way to treat cognitive impairment and should be continued after hospital discharge. Computerized cognitive rehabilitation can be performed at home using exercise programs that advance with predetermined course content, interval, and pace. We hypothesize that computerized rehabilitation might be improved if a program could customize course content and pace in response to patient-specific progress. The present pilot study is a randomized controlled double-blind crossover clinical trial aiming to study if chronic stroke patients with cognitive impairment could benefit from cognitive training through a customized tele-rehabilitation platform (“Guttmann, NeuroPersonalTrainer”®, GNPT®).
Individuals with chronic-stage stroke will be recruited. Participants will be randomized to receive experimental intervention (customized tele-rehabilitation platform, GNPT®) or sham intervention (ictus.online), both with the same frequency and duration (five sessions per week over 6 weeks). After a washout period of 3 months, crossover will occur and participants from the GNPT® condition will receive sham intervention, while participants originally from the sham intervention will receive GNPT®. Patients will be assessed before and after receiving each treatment regimen with an exhaustive neuropsychological battery. Primary outcomes will include rating measures that assess attention difficulties, memory failures, and executive dysfunction for daily activities, as well as performance-based measures of attention, memory, and executive functions.
Customized cognitive training could lead to better cognitive function in patients with chronic-stage stroke and improve their quality of life.
Stroke, the most common cerebrovascular disease, is a focal neurological disorder of abrupt development due to a pathological process in blood vessels . There are three main types of stroke, namely transient ischemic attack, characterized by a loss of blood flow in the brain and which reverts in less than 24 h without associated acute infarction ; ischemic stroke, characterized by a lack of blood reaching part of the brain due to the obstruction of blood vessels and causing tissue damage (infarction), wherein cells die in the immediate area and those surrounding the infarction area are at risk; and a hemorrhagic stroke, where either a brain aneurysm bursts or a weakened blood vessel leaks, resulting in blood spillage into or around the brain, creating swelling and pressure, and damaging cells and tissue in the brain .
In 2013, according to the World Health Organization (WHO) and the Global Burden of Disease study, worldwide, there were 11–15 million people affected by stroke and almost 1.5 million deaths from this cerebrovascular disease [4, 5]. Moreover, in 2013, the total Disability-Adjusted Life Years (years of healthy life lost while living with a poor health condition) from all strokes was 51,429,440. In Spain, in 2011, the National Institute of Statistics reported 116,017 cases of stroke, corresponding to an incidence of 252 episodes per 100,000 inhabitants . Although stroke incidence increases with advancing age, adults aged 20–64 years comprise 31% of the total global incidence.
Stroke often results in cognitive dysfunction, and medical treatment may cause great expense on a personal, family, economic, and social level. Depending on the area of the brain affected and the severity of lesions, stroke patients may suffer cognitive impairment, and alteration in emotional and behavioral regulation . Generally, cognitive impairment derived from stroke includes alterations in attention, memory, and executive function .
Recent reports have begun to show positive results from the use of computerized cognitive rehabilitation systems (CCRS) for stroke patients to improve attention, memory, and executive functions. Nevertheless, more research is needed to better control variables and improve training designs in order to reduce heterogeneity and increase control of the intensity and level of performance during treatments [9, 10, 11, 12].
CCRS allow adjustment of the type of exercises administered to the specific cognitive impairment profile of each patient, but within a fixed set of possible exercises such that heterogeneity of therapy choice is minimized. This can improve studies by allowing better categorization of patient groups that execute similar training sessions in a similar range of responses . Further, CCRS offers the possibility of applying cognitive rehabilitation at home, while patient adherence and performance can be monitored online, so that patients do not need to live near, lodge near, or travel to a rehabilitation center to receive therapy. Because CCRS therapy is entirely digitized, it generates objective data that can be analyzed to determine the relative effectiveness of these interventions. We hypothesize that by allowing a trained professional to oversee an automated customization program that stratifies the level of difficulty, duration, and stimulus speed of presentation, we will reduce the heterogeneity of traditional cognitive training and improve the efficacy of intervention in chronic stroke patients.
The first objective of this pilot study is to assess if chronic stroke patients with cognitive impairment could benefit from cognitive training through a customized tele-rehabilitation platform (“Guttmann, NeuroPersonalTrainer”®, GNPT ® )  intended to increase the control of experimental variables (cognitive impairment profile, adherence, and performance) traditionally identified as a source of experimental heterogeneity. The study aims to assess if this benefit could translate into an improvement of the trained cognitive domains (attention, memory, and executive functions).
The second objective is focused on generalization, namely the ability to use what has been learned in rehabilitation contexts and apply it in different environments . Transfer of learning is included within the concept of generalization when specifically referring to the ability to apply specific strategies to related tasks . Two types of transfer have been proposed – near transfer and far transfer . By near transfer we mean that, through the training of a task within a given cognitive domain, improved function in other similar, untrained tasks may be observed in the same cognitive domain. For instance, a patient who performs selective attention exercises and improves execution through the training might improve their performance in other selective attention exercises too. By far transfer we mean that training in a given cognitive domain may improve performance of tasks in other cognitive domains. Such improvement will be observable in tasks that are structurally dissimilar from the ones used in the training. For instance, if a patient performs selective attention exercises, they may also improve their performance in memory tasks.
It has been demonstrated that computerized cognitive training can lead to the phenomenon of transfer, as previously studied in stroke patients . Thus, our research aims to note whether the application of patient-customized tele-rehabilitation can give rise to an improvement in other functions that are based on cognitive domains related to those that have been trained (near transfer) as well as in different ones (far transfer).
Finally, the third objective is to assess the variables of demography (age, sex, years of education) and etiology (ischemic stroke or hemorrhage) and their impact on rehabilitation outcome, given the need to understand the patient characteristics that may influence treatment effectiveness .[…]
[Abstract] Application of Commercial Games for Home-Based Rehabilitation for People with Hemiparesis: Challenges and Lessons Learned
Objective: To identify the factors that influence the use of an at-home virtual rehabilitation gaming system from the perspective of therapists, engineers, and adults and adolescents with hemiparesis secondary to stroke, brain injury, and cerebral palsy.
Materials and Methods: This study reports on qualitative findings from a study, involving seven adults (two female; mean age: 65 ± 8 years) and three adolescents (one female; mean age: 15 ± 2 years) with hemiparesis, evaluating the feasibility and clinical effectiveness of a home-based custom-designed virtual rehabilitation system over 2 months. Thematic analysis was used to analyze qualitative data from therapists’ weekly telephone interview notes, research team documentation regarding issues raised during technical support interactions, and the transcript of a poststudy debriefing session involving research team members and collaborators.
Results: Qualitative themes that emerged suggested that system use was associated with three key factors as follows: (1) the technology itself (e.g., characteristics of the games and their clinical implications, system accessibility, and hardware and software design); (2) communication processes (e.g., preferences and effectiveness of methods used during the study); and (3) knowledge and training of participants and therapists on the technology’s use (e.g., familiarity with Facebook, time required to gain competence with the system, and need for clinical observations during remote therapy). Strategies to address these factors are proposed.
Conclusion: Lessons learned from this study can inform future clinical and implementation research using commercial videogames and social media platforms. The capacity to track compensatory movements, clinical considerations in game selection, the provision of kinematic and treatment progress reports to participants, and effective communication and training for therapists and participants may enhance research success, system usability, and adoption.