[Abstract] Effects of motor imagery training on lower limb motor function of patients with chronic stroke: A pilot single‐blind randomized controlled trial

Abstract

Aims

This pilot study aimed to evaluate the effects of motor imagery training on lower limb motor function of stroke patients.

Background

Motor imagery training has played an important role in rehabilitation outcomes of stroke patients.

Methods

In this pilot randomized controlled trial 32 stroke patients were randomly divided into experimental and control groups from January to June 2017. Patients in both groups received conventional neuro‐rehabilitation five times a week in 3‐h segments for 6 weeks. Patients in the experimental group underwent an additional 20 min of motor imagery training. Measures were evaluated by motor function of the lower extremity, activities of daily living and balance ability.

Results

The outcomes significantly improved by motor imagery training were the Fugl‐Meyer Assessment of the lower extremity, the Functional Independence Measure dealing with transfers and locomotion, and the Berg Balance Scale.

Conclusion

Motor imagery training could be used as a complement to physical rehabilitation of stroke patients. Our findings may be helpful to develop nursing strategies aimed at improving functional ability of stroke patients and thus enhancing their quality of life.

Summary statement

What is already known about this topic?

• Lower extremity dyskinesia is among the most common complications that significantly limit the patient’s activities of daily living. Motor imagery training, a safe and cost‐efficient technique, may be used as a complement to physical rehabilitation of stroke patients.
• Evidence suggests that motor imagery training is effective in upper limb recovery after stroke.
• There is limited evidence of the effectiveness of motor imagery training on lower limb motor functions of patients with chronic stroke.

What this paper adds?

• Motor imagery training can be incorporated into conventional therapy among individuals by rehabilitation specialist nurses with sufficient experience of motor imagery training, but substantial resources are needed.
• Six‐week motor imagery training resulted in a significant improvement in the motor performance of lower limbs in patients with stroke.
• Further study is needed to modify and optimize the present programme and should be focused on enabling more stroke patients to benefit from motor imagery training.

The implications of this paper:

• The addition of motor imagery training to the conventional neuro‐rehabilitation can significantly promote the recovery of motor performance of lower limbs in stroke patients, thus reducing long‐term disability and associated socio‐economic burden.
• The findings of this pilot study may be helpful to develop nursing strategies aimed at improving functional ability and consequently the quality of life of stroke patients.
• Nurses can learn the motor imagery training as a technique for practising psychomotor nursing skills.

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[ARTICLE] A Depth Camera–Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study – Full Text

Figure 1. A participant experiencing Stomp Joy

Abstract

Background:The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed.

Objective:We developed a depth camera–based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy.

Methods:We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded.

Results:This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported.

Conclusions:Stomp Joy is an effective depth camera–based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size.

Introduction

There are 800,000 new or recurring incidences of stroke annually in the United States; the number is rising as the population ages. More than half of stroke survivors live with at least one type of motor impairment [1]. In China, there are approximately 2 million incidences of a stroke every year. Among these stroke survivors, 70% to 80% cannot live independently as a result of multiple impairments, such as motor impairments with loss of strength, stereotypic movements, changes in muscle tone, and limitations in activities [2]. For many patients with stroke, balance and weight shift management constitute a risk for secondary injury. Lower extremity (LE) functional deficits in patients after stroke have aroused a great amount of attention because they play a vital role in stroke survivors’ quality of life [1,2]. Although stroke (new and recurring) remains prevalent, the number of available therapists is far from meeting the need, since the development of physical therapy has still not matured [3,4]. Rehabilitation technologies have the potential to increase the intensity and dose of rehabilitation, improve access to rehabilitation, reduce the workload of therapists, measure and provide feedback about performance and recovery, and engage and motivate patients [5–7]. Evidence-based medicine shows that high-intensity, repetitive, task-specific training tends to benefit patients greatly [8]. However, it is difficult to implement high-intensity, repetitive, task-specific training in a real clinical setting for a variety of reasons, including limited necessary resources and difficulty maintaining patients’ interest. Therefore, virtual reality–based gaming systems have become popular in medical rehabilitation and can be used as a novel alternative therapy method for motor recovery after stroke.

Kinect (Microsoft) is the leader in commercially available low-cost virtual reality (VR) hardware. This is because most of the Kinect’s games are aimed at the average person, and there are many more games designed by research teams for people with stroke, especially for upper limb motor function. However, there are few games focused on lower limb motor function [9]. VR, also known as immersive multimedia or computer-simulated reality, is a computer technology that replicates an environment, real or imagined, and simulates the user’s physical presence and environment to allow for user interaction and immersion. Virtual realities artificially create sensory experience, which can include sight, touch, hearing, and smell [10]. VR systems consist of a development platform, display system, interaction system, and integrated control system [11]. To realize the complete information interaction between computers and humans, normally we need some external device or devices to record the user’s movements. Among the kinds of external devices are force or tactile feedback systems, position trackers, data gloves or 6-degrees-of-freedom space mice, joysticks, and the Kinect sensor [11–13]. Kinect allows users to play without holding a game controller, which means they will not be bothered by wearing sensors that can be intrusive. This also saves time. Zhu et al [14] showed that the Kinect motion capture system was reliable and that the correlation coefficient of the dynamic track was quite good. A large number of clinical studies have shown that the accuracy of the Kinect somatosensory technology sensor for posture control and evaluation can fully meet the needs of body motion evaluation [15–17]. Eltoukhy et al [18] indicated that Kinect-based assessment might provide clinicians a simple tool to simultaneously assess reach distances while developing a clearer understanding of lower extremity movement patterns. Park et al [19] showed that the use of additional VR training with the Xbox Kinect gaming system was an effective therapeutic approach for improving motor function during stroke rehabilitation.

However, these systems were not specifically developed for patients after stroke, and those training sessions might produce multiple effects [20]. Those studies did not assess the flow experience of users, and few of them conducted a clinical randomized controlled trial. To address these issues, we developed a depth camera–based game, Stomp Joy, specifically for the lower limbs of patients with stroke. We also applied two principles of game design that are highly relevant to rehabilitation. The aim of this study was twofold: (1) develop a depth camera–based, task-oriented rehabilitation game for patients with stroke and (2) assess its usability and conduct a pilot study for stroke survivors’ LE rehabilitation.[…]

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[WEB PAGE] Gait & Balance Product Showcase – Physical Therapy Products

Posted by Deborah Overman | Mar 24, 2021     

SLIP TRAINER 6.0

MASS Rehab Inc offers a tool built to be simple, affordable and effective for providing reactive perturbation and step training. Supported by the latest research, the Slip Trainer 6.0 is engineered to allow therapists to improve balance and reduce fall rates among their client base. Using Reactive Training instead of the typical anticipatory training, the Slip Trainer 6.0 allows therapists to quickly and dramatically improve reactive stepping responses in as little as one visit.

For more information, contact MASS Rehab Inc, (937) 760-4874; www.massrehabinc.com

AFOS FOR FOOT DROP

ToeOFF 2 ½, ToeOFF Flow 2 ½, and BlueROCKER 2 ½ AFOs from Allard USA, Rockaway, NJ, are designed with a reduced heel height to accommodate shoes with lower heel heights. In addition, the footplate has a lower toe lift for more space in the shoe box. ToeOFF 2 ½ Addition models offer three surface options: Camouflage, Birch, and Black. Both offer a choice of wrap-around or D-Ring straps that are easily applied for right or left hand “pull” and shorter, more gently contoured wings that fit comfortably to the anatomy. Allard now offers 13 different AFO models that aim to improve outcomes for more patients. E-mail info@allardusa.com to receive a free Product Selection Guide.

For more information, contact Allard USA, (888) 678-6548; https://www.allardusa.com/products/foot-drop-afos

PEDIATRIC ROLLATOR/GAIT TRAINER

The Marcy anterior rollator/gait trainer from Clarke Health Care Products, Oakdale, Pa, can be a child’s new best friend for indoor or outdoor play and all the adventures walking offers. Marcy is sized to assist toddlers and children in their first attempts at mobility. Four sizes are available, each with growth adjustability. Color customization options encourage the child’s attention and participation in walking and play. Accessories include braking options for safety and control.

For more information, contact Clarke Health Care Products, (888) 347-4537; www.clarkehealthcare.com

SOLAR-BASED GAIT ANALYSIS

GAITRite from CIR Systems Inc, Franklin, NJ, introduces a new level of portability to the world of gait analysis. GAITRite Safari offers all of the exceptional performance of a standard GAITRite system, but also allows for use in remote locations where on-grid power is not readily available. With GAITRite Safari’s solar-based power system, therapists are free to collect gait data anywhere in the world. GAITRite Safari removes the requirement to bring a subject to the artificial environment of the lab and allows for unlimited opportunities to study gait in the real world. All system components can be stored and transported in a standard GAITRite rolling case.

For more information, contact CIR Systems Inc, (888) 482-2362; www.gaitrite.com

SOLUTIONS THAT TRANSFORM THERAPY

Exclusively distributed by DIH, Norwell, Mass, are the SafeGait 360° Balance and Mobility Trainer and SafeGait ACTIVE Dynamic Mobility Trainer by Gorbel; comprehensive gait and balance solutions for inpatient and outpatient therapy. Designed to follow patients through the continuum of care, these advanced dynamic body-weight support and fall protection systems aim to help facilitate increased challenge and patient confidence, leading to faster recovery.

For more information, contact DIH, (877) 944-2200; www.DIH.com/SafeGait

BALANCE SYSTEM SD

The Biodex Balance System SD from Biodex Medical Systems Inc, headquartered in Shirley, NY, is a versatile balance testing and training device designed to add value with features including turnkey programs to help therapists grow their businesses. Access science-based technology solutions, from fall risk to concussion management. Objective data and reporting help meet requirements for value-based care.

For more information, contact Biodex, (800) 224-6339; www.biodex.com/balance

LEG LENGTH MEASURING PAD

The LIMP—from G&W Heel Lift Inc, Cuba, Mo—is designed to determine leg-length deficiency when using the indirect method of measuring. It consists of eight layers of tinted vinyl measuring 3mm per layer, each one separated at the toe and reattached using static electricity. It is placed under the patient’s short leg with layers added or removed until therapists determine that the pelvis is level. The material does not absorb moisture or support bacterial growth, and each layer can be cleaned with soap and water.

For more information, contact G&W Heel Lift Inc, (800) 235-4387; www.gwheellift.com

INSTRUMENTED TREADMILL

The C-Mill HERO, available from Hocoma Inc, Norwell, Mass, is engineered to address a patient’s functional goals related to improving gait, balance, and motor control and coordination issues. The C-Mill HERO includes an instrumented treadmill with a force plate, which provides objective balance, gait, and running assessments, offering clinically relevant outcome measures for treatment planning and monitoring progression. C-Mill HERO’s intuitive exercise gaming with real-time feedback about performance is made to be fun, motivational, and engaging, offering therapists the right tools to provide targeted functional therapy goals for their patients.

For more information, contact Hocoma, (877) 944-2200; www.hocoma.com

NEUROLOGICAL WALKER

The U-Step Neuro Walker, a family of three advanced versions (Standard, Platform, Press-Down) from In-Step Mobility Products Inc, is designed to increase independence and eliminate falling among those with neurological conditions. The U-Step Neuro Walker’s features are designed to make it a superior walking aid that offers excellent stability, maneuverability and control. The U-Step Neuro Walker can be beneficial for patients with various neurological conditions, including: Parkinson’s Disease, multiple sclerosis, balance disorders, brain injuries, ALS, PSP/MSA, ataxia and stroke. Optional electronic visual/audio cueing module is available for addressing Parkinson’s freezing.

For more information, contact In-Step Mobility Products Inc, (800) 558-7837; www.ustep.com

ZENO ELECTRONIC WALKWAY SYSTEM

Managing and synthesizing accurate gait data is essential to outcomes-driven healthcare. The Zeno Walkway from ProtoKinetics, Havertown, Pa, is a portable solution with a wide, flat surface that allows for the capture of loading patterns of the patients’ footsteps without any impedance to assistive device performance. PKMAS software is engineered to automatically eliminate walker tracks, while expertly identifying overlapping steps, to provide robust temporal-spatial measurements for even the most complicated gait patterns. Recent implementation of the enhanced Gait Variability Index (eGVI), automated Four Square Step Test and Limits of Stability balance test are examples of rehabilitation-related outcome measures that can assist in clinical treatment planning and hospital discharge decisions.

For more information, contact ProtoKinetics, (610) 449-4879; www.protokinetics.com

IN-SHOE, WIRELESS ANALYSIS SYSTEM

The F-Scan64 from Tekscan, South Boston, is engineered to be an easy-to-use, wireless in-shoe pressure measurement system, offering quick set-up and flexibility to collect pressure, force, and temporal gait parameters. Featuring small and lightweight data acquisition electronics, which can connect directly to the patient’s shoe, F-Scan64 is designed to allow for a more natural gait collection environment free from cords and excessive weight or bulk to patients. The combination of a simple set-up process and gait analysis software essentials is meant to help clinicians save time when working with patients, without sacrificing data quality or reporting capabilities.

For more information, contact Tekscan, (800) 248-3669; www.tekscan.com/f-scan64

BALANCE STEPPER

The Stepping Wolf from Stretchwell, Warminster, Pa, is an air stepper designed to be versatile. The product can be used to help improve balance, perform core stability exercises, build ankle and calf muscle strength, and massage the feet.

For more information, contact Stretchwell, (888) 396-2430; www.stretchwell.com

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[Abstract] Ipsilateral motor pathways to the lower limb after stroke: Insights and opportunities – Review

Abstract

Stroke‐related damage to the crossed lateral corticospinal tract causes motor deficits in the contralateral (paretic) limb. To restore functional movement in the paretic limb, the nervous system may increase its reliance on ipsilaterally descending motor pathways, including the uncrossed lateral corticospinal tract, the reticulospinal tract, the rubrospinal tract, and the vestibulospinal tract. Our knowledge about the role of these pathways for upper limb motor recovery is incomplete, and even less is known about the role of these pathways for lower limb motor recovery. Understanding the role of ipsilateral motor pathways to paretic lower limb movement and recovery after stroke may help improve our rehabilitative efforts and provide alternate solutions to address stroke‐related impairments. These advances are important because walking and mobility impairments are major contributors to long‐term disability after stroke, and improving walking is a high priority for individuals with stroke. This perspective highlights evidence regarding the contributions of ipsilateral motor pathways from the contralesional hemisphere and spinal interneuronal pathways for paretic lower limb movement and recovery. This perspective also identifies opportunities for future research to expand our knowledge about ipsilateral motor pathways and provides insights into how this information may be used to guide rehabilitation.

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[ARTICLE] Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy

Abstract

More innovative technologies are used worldwide in patient’s rehabilitation after stroke, as it represents a significant cause of disability. The majority of the studies use a single type of therapy in therapeutic protocols. We aimed to identify if the association of virtual reality (VR) therapy and mirror therapy (MT) exercises have better outcomes in lower extremity rehabilitation in post-stroke patients compared to standard physiotherapy. Fifty-nine inpatients from 76 initially identified were included in the research. One experimental group (n = 31) received VR therapy and MT, while the control group (n = 28) received standard physiotherapy. Each group performed seventy minutes of therapy per day for ten days. Statistical analysis was performed with nonparametric tests. Wilcoxon Signed-Rank test showed that both groups registered significant differences between pre-and post-therapy clinical status for the range of motion and muscle strength (p < 0.001 and Cohen’s d between 0.324 and 0.645). Motor Fugl Meyer Lower Extremity Assessment also suggested significant differences pre-and post-therapy for both groups (p < 0.05 and Cohen’s d 0.254 for the control group and 0.685 for the experimental group). Mann-Whitney results suggested that VR and MT as a therapeutic intervention have better outcomes than standard physiotherapy in range of motion (p < 0.05, Cohen’s d 0.693), muscle strength (p < 0.05, Cohen’s d 0.924), lower extremity functionality (p < 0.05, Cohen’s d 0.984) and postural balance (p < 0.05, Cohen’s d 0.936). Our research suggests that VR therapy associated with MT may successfully substitute classic physiotherapy in lower extremity rehabilitation after stroke.

1. Introduction

Stroke is a significant cause of disability, with millions of stroke patients burdened with permanent neurological deficits, mainly motor and psychological. In most cases, post-stroke recovery requires long-time interventions in a multidisciplinary team, primarily depending on the severity of the stroke, the associated pathologies, the patient’s age, the time since stroke and the beginning of rehabilitation [1,2]. Neurorehabilitation after a stroke engages the recovery of the motor deficit and the recovery of language function, cognitive recovery, sensory and sphincter functions, and the functional reintegration as much as possible, as active as possible, into family and socio-professional life components. Post-stroke rehabilitation in the subacute phase begins when the patients’ are clinically balanced and stable, especially with regards to cardiorespiratory functions, and last but not least, when the tasks can be understood and supported by the patients’ participation and involvement in the rehabilitation program. It starts with the fifth week after stroke and has a relative duration of about three months [3]. Also, significant features in the physical rehabilitation of post-stroke patients are related to behavioral, cognitive and contextual factors that should be taken into account when planning therapy [4,5].Rehabilitation in the chronic phase begins after the patient has passed the subacute stage entering the chronic phase, followed by a constant and consistent rehabilitation program necessary to be continued throughout his life. The maximum level of complexity of the physiotherapy program is reached in the chronic phase when the highest acquisition and velocity of motor improvement are also expected. Regardless of the pathology stage, the basic principle is to stimulate and activate somatic structures through different activities and tasks. The most commonly used post-stroke rehabilitation techniques usually refer to correct posture, avoiding synkinesis, increasing muscle strength, active mobilization, proprioception, balance, and daily activities training. All these techniques and objectives are achieved in rehabilitation programs designed to repeatedly challenge the body during the day and through relaxation and a correct posture during the night [6,7].Mirror therapy (MT) is a type of rehabilitation method which activates the so-called mirror neurons. By visualizing in the mirror, the movement of the opposite healthy limb, the mirror neurons receive the necessary feedback to initiate the process of neuroplasticity. The healthy extremity is placed in front of a mirror and the illusion of the movement of the paretic side is created when the healthy part is activated. MT showed good results on motor deficiencies, as well as on sensations, visual-spatial neglect and pain after stroke [8].Therefore, MT is a method successfully used in the post-stroke patient’s rehabilitation. This method, along with virtual reality (VR), is used to improve the motor function of the lower extremity (LE), helping to regain balance, stability, and coordinated gait by training the muscles responsible for these activities. MT has been shown to improve the voluntary control of the impaired lower limb, especially the ankle joint by amplifying information (visual pathway, motor pathway, proprioceptive pathway), which determine a more complex efficiency of neurological deficit recovery. By applying MT to the lower limbs affected by stroke, it was observed the improvement of the stability of the patients, as the lower limbs play an essential role in performing ambulation and stability during daily activities. This approach exploits the brain’s preferences to prioritize the visual reaction over the somatosensory reaction regarding limb position [9,10,11]. New research is evaluating MT efficiency when combined with other techniques, such as cognitive therapeutic exercise, and other research shows that MT combined with other types of therapies has a better effect on the physical rehabilitation of post-stroke patients [12,13].VR is a new technology involving several scientific fields’ collaboration: biomechanics, internet technology engineering, rehabilitation and cognitive neuroscience. One of the most applicable areas of this modern technology is the medical field. VR has emerged as a new treatment approached in stroke rehabilitation, assuming the use of exercise programs designed to simulate real-life objects and activities using a computer [14]. This new approach is very advantageous as recovery programs design provided by the new environment and seems to be more exciting and enjoyable than traditional physiotherapy tasks, thus encouraging more repetition and involving the patient in the therapeutic program through “gamification” [15,16]. Patients become more motivated as they achieve increasingly performances and complexity.VR is a technology that allows the user to interact with a computer-simulated environment, whether that environment is a simulation of the real or merely an imaginary world, which influence the patient’s visual and proprioception feedback mechanism, therefore, facilitating the therapy outcomes. The VR therapy involves a computer generation of a virtual environment capable to interact with the patients through the sensory-motor functions. Real-time interaction with a multidimensional and multisensory environment is the critical element of VR therapy. The patient interacts not only with the virtual environment but also with various objects that are part of that environment [17,18].VR began to be successfully used in post-stroke patient’s rehabilitation due to the many advantages it entails:(a)the access in a safe environment to real-life situations, otherwise inaccessible to patients due to cognitive, motor and psychological limitations(b)the possibility to alter the exercises, to emphasize specific movements during patient execution, thus becoming more comfortable to perform,(c)the unique and personalized character of the exercises from one patient to another [19].VR technology is currently being explored for its potential benefits as a therapeutic intervention for training coordinated movement patterns, as well as for its entrepreneurial outcomes [20]. This technology offers the ability to create an environment in which the intensity of feedback and training can be systematically manipulated and improved to create the most appropriate paradigm of individualized motor learning. Most literature reviews have shown that VR has good results in post-stroke patients’ therapy, especially as an adjunct to classical physiotherapy [21,22,23].Researches address the burden of the individuals and families of the society and the health care systems concerning post-stroke patients who have disabilities and often can no longer reintegrate into socio-professional activities. Therefore, more and more emphasis is placed on developing facilities to speed patients’ physical rehabilitation after stroke [24,25,26]. Therefore, this study aims to determine the effectiveness and particularities of the use of VR associated with MT in the recovery of the LE of patients with post-stroke sequelae, compared to a standard physiotherapy program, as a novel approach in LE post-stroke rehabilitation, to contribute to the amendment of the efficient techniques and methods used in post-stroke rehabilitation. […]

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[WEB PAGE] Rise&Walk InClinic Robotic Technology Completes Shepherd Center Pilot Program

Posted by Debbie Overman

Healing Innovations Inc announces the successful completion of the first pilot for the new Rise&Walk InClinic technology at Shepherd Center in Atlanta. The pilot included the technology’s different use cases, and gathered session data including clinician and patient feedback. 

“The Rise&Walk has helped our team facilitate upright lower-extremity motor training with fewer staff than is typically required of some other locomotor-related training activities, while also allowing us to objectively track user progress. We are excited to continue to partner with Healing Innovations to further support advances in rehabilitation technology.”

— Rebecca Washburn, MS, manager of Beyond Therapy

Beyond Therapy is an intensive outpatient neurological rehabilitation program that integrates the disciplines of physical therapy and exercise physiology at Shepherd Center.

“The Rise&Walk enables our team to create intensive and engaging training sessions that are in keeping with the aims and objectives of our program. Individuals have enjoyed using the Rise&Walk, and we see unique opportunities for integrating the technology into the existing repertoire of motor training and conditioning devices we have to offer.”

— Nicholas Evans, MHS, ACSM CEP, lead exercise physiologist in Beyond Therapy

The Rise&Walk InClinic is a robotic neurorehabilitation technology that targets muscle groups important for walking and facilitates locomotor-related movements to help a wide range of patients recovering from neurological injuries. The sit-and-stand device is designed to replicate up to three different therapy modalities, giving clinicians more flexibility in a therapy session, a media release from Healing Innovations Inc explains.

“This pilot was an important first step in the introduction of this technology to the rehabilitation community. The Beyond Therapy team has an incredibly innovative spirit that made them the perfect partner in this initiative.”

— Luke Benda, Chief Executive Officer of Healing Innovations, based in Nashville, Tenn

Healing Innovations will release the Rise&Walk InClinic technology with additional rehabilitation providers in 2021, per the release.

[Source(s): Healing Innovations Inc, PR Newswire]

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[ARTICLE] Functional changes in the lower extremity after non-immersive virtual reality and physiotherapy following stroke – Full Text HTML

Abstract

Objective: To analyse the effect of virtual reality (VR) ther-apy combined with conventional physiotherapy on balance, gait and motor functional disturbances, and to determine whether there is an influence on motor recovery in the subacute (< 6 months) or chronic (> 6 months) phases after stroke.

Methods: A total of 59 stroke inpatients (mean age 60.3 years (standard deviation (SD) 14.8); 14.0 months (SD 25.7) post-stroke) were stratified into 2 groups: subacute (n  =  31) and chronic (n  =  28). Clin-ical scales (Fugl-Meyer lower extremity (FM LE); Func-tional Independence Measure (FIM); Berg  Balance Scale (BBS); Functional Ambulation Category  (FAC); modified Ashworth scale (MAS); 10-metre walk test (10MWT); and kinematic parameters during specific motor tasks in sitting and standing position (speed; time; jerk; spatial error; length) were applied before and after treatment. The VR treatment lasted for 15 sessions, 5 days/week, 1 h/day.

Results: The subacute group underwent significant change in all variables, except MAS and length. The chronic group underwent significant improvement in  clinical scales, except MAS and kinematics. Motor impairment improved in the severe ≤ 19 FM LE points, moderate 20–28 FM LE points, mild ≥ 29 FM LE points. Neither time since stroke onset nor affected hemisphere differed significantly between groups. The correlations were investigated between the clinical scales and the kinematic parameters of the whole sample. Moreover, FM LE, BBS, MAS, and speed showed high correlations (R²> 0.70) with independent variables.

Conclusion: VR therapy combined with conventional physiotherapy can contribute to func-tional improvement in the subacute and chronic phases after stroke.

Lay Abstract

Specific treatment, enriched with artificially reinforced feedback, may facilitate physiological activation of the brain areas devoted to motor learning. Based on this rationale it was hypothesized that motor learning could be improved when an enriched environment focused on optimizing the interaction between the human body and the physical environment is used for motor training. The aims of this study were to examine the effect of virtual reality therapy on balance, gait and motor impairment, and to determine whether there is an influence on  motor recovery in the subacute (< 6 months) or chronic (> 6 months) phases after stroke. This study was conducted among stroke inpatients, divided into 2 groups (subacute and chronic). Patients improved fower limb function in both subacute and chronic stroke phase.  Virtual reality therapy could be a useful tool for specific rehabilitation of the lower limb, which may lead to  improved rehabilitation outcomes.

Introduction

Several neurophysiological studies have shown that, after a brain lesion, the central nervous system (CNS) undergoes phases of neuronal reorganization (1). This neurophysiological mechanism, called neuroplasticity, is based on two fundamental process-es; functional reorganization of neuronal circuits and structural restoration of damaged circuits (e.g. axonal sprouting). Neuroplasticity after stroke can be  regarded as a mechanism of spontaneous recovery, or else the biological basis for restorative rehabilitation modalities, thus promoting physiological mechanisms of recovery through adequate stimuli (2). The purpose of rehabilitation in stroke survivors is to address these neurophysiological mechanisms of restoration and reorganization, with the aim of exploiting all the potential of motor learning. Recent findings suggest that therapeutic modalities should be deployed on the basis of motor learning principles to reshape disrupted neural circuitries, allowing voluntary motor activation to emerge (3–5). Thus the recovery process under-pinned by rehabilitation modalities could be intended as a learning process deployed by the CNS (6).

Infarction or haemorrhage of the neural tissue often results in severe neurological disorders. Apart from sensory disorder, muscle weakness, aphasia or apraxia, balance and walking inability are among the most devastating consequences of stroke (7). Moreover, impairment of the lower extremity (LE) muscles has an important correlation with limitations in balance and walking ability. Therefore, gait recovery is a primary aim to be pursued in stroke rehabilitation. On the other hand, LE rehabilitation cannot be regarded only as gait training (i.e. supported or unsupported walking), but should take into consideration all pre-walking rehabil-itation processes, which comprise training in both  sitting and standing positions. Change in compensatory gait patterns is difficult in post-stroke patients, and rehabilitation protocols with training of activation of selective muscles in a sitting or standing position is advantageous for future functional movements (1, 8).

In the last decade, therapeutic modalities based on virtual reality (VR) technologies for rehabilitation have shown positive results in post-stroke gait and balance recovery (3, 9). Innovative technologies have provided the opportunity to enrich the environment in which motor rehabilitation programmes are carried out. This enrichment could potentially facilitate physiological activation of brain areas devoted to motor learning (10, 11). Previous research has demonstrated that training in a virtual environment promotes learning in both healthy subjects and patients after stroke, due to augmented feedback related to motor performance and outcomes provided by VR (12, 13). Moreover, some reviews have reported that VR therapy, when applied to the LE, results in moderate improvement in motor function (14). According to the literature, the use of VR ensures a greater number of repetitions than the same training using traditional therapy, which can have a positive influence, not only on motor recovery, but also on enhancing balance and physical fitness (7, 15, 16). Some studies suggest that VR therapy in patients after stroke can have a positive impact on balance and gait recovery (17). Conversely, Laver et al. states that there is insufficient evidence to claim that VR therapy can increase, for example, speed walking (13). This could be due to the heterogeneity of the VR systems used for post-stroke LE functional recovery, which makes it difficult to draw firm conclusions. How-ever, it seems that postural exercises with enhanced feedback (18), enriched by virtual obstacles (19) in the non-immersive modality can have a positive  effect on walking speed. Increased walking speed has indeed been observed following VR therapy using a treadmill (20) and after execution of functional tasks (21), even in the sitting position (22). Despite these positive results, there is strong evidence to support that walking training at moderate-to-high intensities or VR therapy should be applied in patients with chronic stroke to improve walking speed or distance (3, 17, 23). Conversely, there is weak evidence to support that strength training, combined training or cycling training at moderate-to-high intensities, and VR balance training may improve walking speed and distance in these patient groups (24).

It seems, then, that more intensive therapy results in better outcomes, and that the effect of VR in addition to conventional physiotherapy (CP) could provide an optimal complement in improving the functionality of the LE (25). However, there is some controversy, since parameters such as walking speed are not only improved with intensive VR gait training. Analytical training, even in the sitting or standing position, is also crucial in the chronic stages. For example, to achieve an effective gait, the patient with stroke first needs to undergo analytical training in order to improve joint kinematics, and then integrate and automate this improvement into gait re-education. Thus, the final objective may be focused on functional aspects of gait (not necessarily gait speed alone) with less compen-sation and less energy expenditure, enabling patients to walk greater dis-tances (1, 8).

The present study used a non-immersive VR modality with reinforced visual and auditory feedback. VR therapy was based on analytical work in both  sitting and standing positions, through the application of functional tasks (such as climbing a step (25)) in a population of stroke patients in subacute and chronic phases (21). The aim of the study was to evaluate  possible clinical differences due to the implementation of this approach in these different groups.

The primary objective of this study was to examine the effect of VR LE therapy combined with CP on balance and gait functional disturbances and overall level of motor function (i.e. severe, moderate, mild) in post-stroke patients. Further aims were: to analyse whether time since stroke influences greater motor recovery of the LE in the subacute (<  6 months) or chronic (> 6 months) phase; to explore the correlation between kinematic parameters and clinical scales; and to analyse differences in motor outcomes related to the side of brain lesion (i.e. right or left).[…]

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[ARTICLE] Impact of Somatosensory Training on Neural and Functional Recovery of Lower Extremity in Patients with Chronic Stroke: A Single Blind Controlled Randomized Trial – Full Text

Abstract

Recovery of lower extremity (LE) function in chronic stroke patients is considered a barrier to community reintegration. An adequate training program is required to improve neural and functional performance of the affected LE in chronic stroke patients. The current study aimed to evaluate the effect of somatosensory rehabilitation on neural and functional recovery of LE in stroke patients. Thirty male and female patients were recruited and randomized to equal groups: control group (GI) and intervention group (GII). All patients were matched for age, duration of stroke, and degree of motor impairment of the affected LE. Both groups received standard program of physical therapy in addition to somatosensory rehabilitation for GII. The duration of treatment for both groups was eight consecutive weeks. Outcome measures used were Functional Independent Measure (FIM) and Quantitative Electroencephalography (QEEG), obtained pre- and post-treatment. A significant improvement was found in the FIM scores of the intervention group (GII), as compared to the control group (GI) (p < 0.001). Additionally, QEEG scores improved within the intervention group post-treatment. QEEG scores did not improve within the control group post-treatment, except for “Cz-AR”, compared to pretreatment, with no significant difference between groups. Adding somatosensory training to standard physical therapy program results in better improvement of neuromuscular control of LE function in chronic stroke patients.

1. Introduction

Stroke is a common cause of disability in the world [1]. Almost three-quarters of cases occur in low- to middle-income countries, leading to residual motor disabilities and intensive rehabilitation needs [2,3]. After stroke, many functions are affected, including both basic and instrumental daily living activities [2] and sensorimotor skills [4]. Lower extremity (LE) deficits are present in two-thirds of stroke patients, affecting motor control, gait, and balance, which in turn lead to poor quality of life and various degrees of dependence [5,6], which in turn require effective treatment and are considered a priority in rehabilitation [7].Many approaches of rehabilitation are recommended to enhance motor recovery in stroke patient [8,9,10,11]; among them is the somatosensory stimulation approach, which is a new noninvasive intervention that stimulates the motor cortex through its connections with the sensory cortex, acting on the somatosensory system neuroplasticity [8,12]. It includes sensory stimulation and sensory retraining/re-education [13,14,15,16,17]. Sensory stimulation includes various methods, such as electrical stimulation (e.g., transcutaneous electrical nerve stimulation/TENS) [18], proprioceptors training, constraint-induced movement therapy (CIMT) [8], and thermal stimulation (TS) [19].In normal individuals, TS causes greater brain area activation, compared to tactile and mechanical stimuli [20,21]. TS is a cheap and convenient technique that can be used in rehabilitation and home settings. It depends on stimulating cold and hot receptors alternatively, sending signals to the lateral spinothalamic tract through the spinal cord and up to the thalamus, to the somatosensory cortex [21]. Adding TS to the standard rehabilitation program in stroke patients resulted in significant improvement in outcome measures of both upper and lower extremities, compared to the standard rehabilitation program alone [19,22,23,24,25,26,27].Electroencephalography (EEG) is a neurophysiological technique that measures cortical activity and brain waves. It can determine the effect of a treatment approach used in stroke patients [2]; that is why this safe technique can be of great help in detecting which treatment modality can lead to better improvement in patients’ performance. EEG has four frequency bands: delta, theta, alpha, and beta, with frequency ranges of (1–4 Hz), (4–8 Hz), (8–12 Hz), and (12–30 Hz), respectively. Brain status of the stroke patient can be characterized by Quantitative EEG (QEEG), which is very valuable for decision-making in clinical practice, as reported by many authors [28,29,30].Despite the effectiveness of TS, only two studies were performed on LE function in chronic stroke patients: One of them measured functional outcomes, post-treatment, with no objective evaluation [26], and the other one used a different TS protocol, wherein thermal pain receptors were stimulated [25]. Because stroke recovery is a very complicated process [8,11], and multiple methods of rehabilitation techniques are used, therapists may find it difficult to decide which approach to adopt in patient management in order to achieve the greatest functional improvement with minimal cost of time and money.This study aimed to investigate the influence of adding TS augmented with visual, auditory, and tactile somatosensory rehabilitation to standard rehabilitation on the functional recovery of LE in chronic stroke patients and how that can affect brain activity, using QEEG.[…]

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[WEB PAGE] RevoFlex DorsiFlexion AFO

RevoFlex by Click Medical is an AFO solution for safely progressing a patient through therapy. The dorsiflexion kit can be easily fabricated into plastic-hinged AFOs to give on-demand support while enabling patients to safely dial in when fatigued or in unstable situations. With this orthotic solution, the patient can tune their progressive tension levels to safely and independently dial in optimal support and increase their mobility faster. RevoFlex allows muscle development by reducing device dependence and enabling progression toward full range of motion, thus reducing the risk of re-injury. Using 1 adjustable device to progress patients through therapy eliminates the cost of multiple fabrications and refitting appointments. The powerful dial provides patients with limited strength and/or dexterity to effectively adjust the device. With RevoFlex, practitioners can create AFOs that work for patients, not against them.

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[Abstract + References] Wearable Robotic Approaches to Lower Extremity Gait Systems – eBook

Abstract

The field of wearable robotics has emerged as a leading-edge industry through a surge of development over the last 20 years. The increasing physical and cognitive interaction between robotics and their human creators has set the stage for a host of new robotic applications in medicine, aerospace, military, industry, and personal use. Military and medical applications have driven the development of advanced robotic technology, and their objectives will accelerate applications to neurological, orthopedic, and traumatic injuries that involve lost or degraded motor function of the lower extremities. Key enabling technologies are promoting wearable robotic systems that are effective, practical, affordable, and reliable. The field of wearable robotics is poised to change the way we view human abilities, disabilities, limitations, and potential. This chapter explores the current state of the art in wearable robotics, considering engineering and clinical perspectives. Key aspects of design are addressed and supported by examples to illustrate design features and traits. Finally, results are presented from recent pilot studies of lower extremity systems to support rehabilitation.

References

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