[ARTICLE] Effects of a virtual reality-based mirror therapy system on upper extremity rehabilitation after stroke: a systematic review and meta-analysis of randomized controlled trials – Full Text

Introduction: Virtual reality-based mirror therapy (VRMT) has recently attracted attention as a novel and promising approach for treating upper extremity dysfunction in patients with stroke. However, the clinical efficacy of VRMT has not been investigated.

Methods: This study aimed to conduct a meta-analysis to evaluate the effects of VRMT on upper extremity dysfunction in patients with stroke. We screened articles published between January 2010 and July 2022 in PubMed, Scopus, MEDLINE, and Cochrane Central Register of Controlled Trials. Our inclusion criteria focused on randomized controlled trials (RCTs) comparing VRMT groups with control groups (e.g., conventional mirror therapy, occupational therapy, physical therapy, or sham therapy). The outcome measures included the Fugl–Meyer assessment upper extremity test (FMA-UE), the box and block test (BBT), and the manual function test (MFT). Risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool 2.0. We calculated the standardized mean differences (SMD) and 95% confidence intervals (95% CI). The experimental protocol was registered in the PROSPERO database (CRD42022345756).

Results: This study included five RCTs with 148 stroke patients. The meta-analysis showed statistical differences in the results of FMA-UE [SMD = 0.81, 95% CI (0.52, 1.10), p < 0.001], BBT [SMD = 0.48, 95% CI (0.16, 0.80), p = 0.003], and MFT [SMD = 0.72, 95% CI (0.05, 1.40), p = 0.04] between the VRMT and the control groups.

Discussion: VRMT may play a beneficial role in improving upper extremity dysfunction after stroke, especially when combined with conventional rehabilitation. However, there were differences in the type of VRMT, stage of disease, and severity of upper extremity dysfunction. Multiple reports of high-quality RCTs are needed to clarify the effects of VRMT.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022345756.

1 Introduction

Mirror therapy (MT) is a treatment modality that induces cortical reorganization and promotes plastic changes in the brain without requiring movement of the affected limb (1). MT was initially reported by Ramachandran et al. (2), as a promising intervention for reducing phantom pain in amputees. Since then, it has been used as a therapeutic approach to address upper extremity dysfunction in patients with stroke (3). In a systematic review and meta-analysis conducted by Thieme et al. (4), MT was shown to be effective in improving upper extremity motor function, motor disability, activities of daily living, and pain and is considered to be a complementary treatment to conventional therapy for stroke patients, aiding in their recovery.

The development of innovative technologies has led to a considerable focus on new stroke rehabilitation approaches that utilize virtual reality (VR). VR systems can be categorized into three types: non-immersive, semi-immersive, and immersive (5, 6). Recently, a growing number of intervention studies have used immersive VR with head-mounted displays (HMDs) in patients with stroke (6). These VR systems have been suggested to induce neural plasticity and contribute to functional recovery after stroke (7, 8). Additionally, the VR-based mirror therapy system (VRMT), which applies the concept of MT, is expected to be an effective and innovative treatment method compared with conventional MT (cMT) (9, 10). Several previous studies have reported similarities in brain activity between VRMT and cMT (11–14). These findings indicate that VRMT induces neural plasticity, providing sufficient neurophysiological basis for its clinical application. However, the clinical effects of VRMT have not been investigated.

This review investigated the effects of VRMT on the upper extremities after stroke. We defined VRMT as “synchronized visual feedback of the affected side’s movement with that of the unaffected side.” […]

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[ARTICLE] Perspectives of Motor Functional Upper Extremity Recovery with the Use of Immersive Virtual Reality in Stroke Patients – Full Text

Abstract

Stroke is one of the leading causes of disability, including loss of hand manipulative skills. It constitutes a major limitation in independence and the ability to perform everyday tasks. Among the numerous accessible physiotherapeutic methods, it is becoming more common to apply Virtual Reality “VR”. The aim of this study was to establish whether immersive VR was worth considering as a form of physical therapy and the advisability of applying it in restoring post-stroke hand function impairment. A proprietary application Virtual Mirror Hand 1.0 was used in the research and its effectiveness in therapy was compared to classical mirror therapy. A total of 20 survivors after ischaemic stroke with comparable functional status were divided into a study group (n = 10) and control group (n = 10). Diagnostic tools included 36-Item Short Form Survey “SF-36” and the Fugl-Meyer Assessment Upper Extremity “FMA-UE”. Collected metrics showed a normal distribution and the differences in mean values were tested by the student’s t-test. In both, the study and control groups’ changes were recorded. A statistically significant outcome for FMA-UE and SF-36 measured by the student’s t-test for dependent or independent samples (p > 0.05) were obtained in both groups. Importantly, proven by conducted studies, an advantage of VR proprietary application was subjective sensations amelioration in pain and sensory impressions. Applying Virtual Mirror Hand 1.0 treatment to patients after a stroke appears to be a good solution and definitely provides the opportunity to consider VR applications as an integral part of the neurorehabilitation process. These results give a basis to plan further larger-scale observation attempts. Moreover, the development of the Virtual Mirror Hand 1.0 as an innovative application in physiotherapy may become equivalent to classical mirror therapy in improving the quality and effectiveness of the treatment used for post-stroke patients.

Keywords: 

stroke; virtual reality; upper limb; motor function; mirror therapy

1. Introduction

Nowadays, it is inevitable to apply digital solutions in clinical health care. The intensification of this process is provided by the worldwide tendency to develop technological solutions. This transfers into the possibility of gathering data, validating the performance of a patient’s tasks and accurate reflexion of the demanded movement. Based on the clinical experience, the continuation of the rehabilitation process is often practiced at home, which could be successfully resolved by Virtual Reality “VR” appliances and the possibility to remotely monitor the patient’s condition [1,2,3,4]. A significant part of numerous functional stroke symptomatology is manipulative skills dysfunction [5]. This impairment appears as a stroke consequence in almost 60% of cases and can last for more than 12 months [6]. Many years of clinical observations allow for the establishment of a thesis that the restoration of manipulative function is a complex and demanding task [7]. Therefore, various descriptions dedicated to this issue can be found in the literature which provide methods that specify their effectiveness. In the last decade, the use of a botulinum toxin followed by exercises [8], vibration training [9,10], kinesiotaping [11], electrostimulation [12], use of dynamic splint [13] and constraint-induced movement therapy were postulated in rehabilitation [14,15]. The results of research dedicated to mirror therapy being used in order to deal with manipulative skills impairments appear promising [16,17,18,19]. Recently, due to computer technology development, successful use of VR in improving fine motor skills in stroke patients is observed [20,21,22,23]. The mentioned scientific reports are describing the effects of a particular method in relation to the control group, in which it is excluded from the rehabilitation program. However, we have not found any research that would compare the above-mentioned methods giving evidence of the advantage of one over the other in the literature. We assumed that in order to improve the manipulative hand functions, it is beneficial to combine a traditional approach with innovative computer technology, known as virtual rehabilitation or VR [24]. The treatment basis of classic mirror and VR application therapies focuses on the same principle: the patient sees his impaired hand moving and an exact imitation of the not-plegic side motion is presented either in the mirror reflection or in the head-mounted display. VR is an image of “artificial reality” created by multiple devices interconnected by a computer system. Therefore, as a classic approach was already a theme of multiple research projects, we decided to compare the effects of mirror therapy and VR application. A VR system uses the role of visual feedback to make stimuli reaching the patients as realistic as possible. Mei-Hong Zhu et al. devoted their attention to this issue [25]. In the traditional approach to the subject, VR application in the rehabilitation field not only needs dedicated computer software, but also devices that display and collect information about the patients’ movement. The display equipment includes traditional computer monitors, LCD screens and projectors [26]. The most modern systems, Cave Automatic Virtual Environment “CAVE”, represent a high-tech solution, in which projectors present a stereoscopic image on the walls and floor of the room. Patients using this system need to wear stereoscopic glasses to be able to view 3D images [27]. With a second kind of display device being glasses or Head-Mounted Display “HMD”. In order to conduct therapy more effectively, equipment that detects a patient’s movement and provides biofeedback in the form of an image is required. This is possible due to a motion detector or 3D cameras giving the patient the possibility to react and to fulfil a task appearing on the screen or a console [28]. Depending on the display equipment used, there exist VR types: VR with immersion (immersive VR), augmented VR and Mixed Reality “MR”.

In the first one, the activation of proprioceptive sensations let the patient feel that he is being transferred to another multisensory environment, that helps patient keep his attention on a given task. This effect can be obtained due to a HMD-type display placed in a helmet or glasses that isolate the person from their surroundings. When a sound or an avatar character that reflects the patient’s movement is added, an even greater immersion effect can be achieved [29]. We decided to choose that VR type according to the above-mentioned reasons.

In the second type of VR, augmented VR, the user sees both the natural environment and virtual characters or objects placed. This technology integrates application content into real-world settings [30].

In the third type of environment, MR, the latest sensory solutions and imaging technologies are used. The patients register both images displayed by LCD screens or projectors and other objects and people present in the room; thus, receiving stimuli from the virtual world and natural environment [4].

As a conclusion, most beneficial solution for the post-stroke patient might be immersive VR. That VR type provides isolation from the real environment as an essential feature in focusing attention and the correct interpretation of the movement. What is more for the patient, there are no distractive factors, but only a pure image regardless of external stimuli. Adherence to neurotherapy and optimising therapeutic aims can be effectively achieved [4]. Due to dedicated software, the therapy scheme as well as recorded results are saved in the memory of VR device. This allows for the observation of the progress of treatment, to capture weak the point of therapy and to plan the next stages of rehabilitation. VR application use is a modern technology solution simplifying the therapeutic process and collecting a great database in order to conduct diagnostics and to be used in further research [29].

The aim of this study was to establish whether immersive VR was worth considering as a form of physical therapy and the advisability of applying it in restoring post-stroke hand function impairment. Our clinical concept is derived from widely known in the neurorehabilitation mirror therapy.

2. Materials and Methods

2.1. Participants

Randomized studies on 20 patients of Neurological Rehabilitation Department “STROKE” in Wiktor Dega Orthopaedic and Rehabilitation Clinical Hospital in Poznan were conducted from July 2022 to October 2022. The following inclusion criteria were defined and enforced during the qualification assessment:-

diagnosis of first-episode stroke,-

age range 40–64,-

acquired motor impairment of hemiplegic upper limb,-

maximum of 12 months period since diagnosis,-

functional brain damage specified with Rankin scale 1–4 at the last hospital discharge.

Certain exclusion criteria were admitted:-

requirement of constant, intensive medical surveillance,-

active comorbidities significantly influencing rehabilitation process (ex. bone fractures occurred during medical treatment, pressure ulcers, etc.),-

circulatory insufficiency, kidney, liver failure, condition after myocardial infarction with ejection fraction less than 30%,-

vascular disease (active thromboembolism),-

heart aneurysm, aortic aneurysm, malformation of cerebral vessels,-

active inflammation,-

uncompensated endocrine disruption,-

cancer (palliative care or need of urgent treatment),-

severe arterial or pulmonary hypertension,-

uncontrolled diabetes,-

epilepsy.

The above-mentioned criteria were made in order not to disturb or to be a risk during the neurorehabilitation process.

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Poznan University of Medical Sciences (protocol code 587/22, date of approval 23 June 2022). Informed written consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.

In this research, we selected patients from the “STROKE” Department and then randomly divided into two, equal in terms of number study and control group.

Twenty patients with hemiplegia dexter according to computer tomography scan and 3.1 ± 0.57 points in the study (min-max, 2–4) and 3.3 ± 0.67 points in the control group in Rankin Scale (min-max, 2–4) were included in the trial. Mean time after right-sided stroke diagnose (and occurrence) caused by right medial cerebral artery ischaemia resulting in plegic left upper limb was 3.4 ± 1.43 months in the study and 3.3 ± 0.67 points in the control group. All participants of this study were after the first stroke and took part in the first rehabilitation program. The mean age of patients in the experimental group was 54.9 ± 3.98 years, in the control group it was 59.2 ± 4.34 years, and in both groups, it was 57.05 ± 4.62 years. Duration of the research for each group, consistent with the “STROKE” project establishments, was 18 days and occurred in three consecutive weeks, form Monday to Saturday. Each participant of the research was assessed with quality-of-life scale 36-Item Short Form Survey “SF-36” and related to sensorimotor function of upper limb Fugl-Meyer Assessment Upper Extremity “FMA-UE” before the therapy starts.

2.2. VR Application

Patients in the study group followed a physical therapy treatment of upper limb with the use of SciMed system which includes the immersive VR application Virtual Mirror Hand 1.0, implemented on the Oculus Quest 2 VR glasses module (Figure 1).

Figure 1. Oculus Quest 2 module.

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[Conference paper] Robotic System for Hand Rehabilitation Based on Mirror Therapy – Abstract

Abstract

The paper presents the study of a system composed by a sensorized glove that could interface with GLOREHA Lite hand exoskeleton. The movement of each GLOREHA’s motor acts on the flexion or extension of the corresponding finger through a cable transmission, allowing the user to carry out robot-assisted rehabilitation therapy for the hand. The combined use of GLOREHA and of the sensing glove allows performing a bimanual therapy using the Mirror Therapy technique, with the effect of increasing the effectiveness of the treatment. A test bench was used for the characterization of the bending sensors inserted into the sensing glove to detect flexion and extension of the fingers. Two sensor gloves were developed; one made of tissue, where the sensors are inserted into appropriate seams, and one made of Silicon, where the sensors were incorporated between two layers of material. Both solutions proved to be adequate. The characterised sensors have shown performances suitable for this type of application, while the tests on the responsiveness of GLOREHA to the command signal are good for both serial and Bluetooth communication. The presented system favors the achievement of the objectives of pillar three of the sustainable development goals (SDG): good health and well-being. An effective rehabilitation activity at home can allow a greater number of people, compared to the current one, to more quickly recover the motor functions of the hand.

References

1. Prange, G.B., Jannik M.J.A., Groothuis-Oudshoorn, C.G.M., Hermens HJ, Ijzerman, M.J.: Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke. J. Rehabil. Res. Dev. 43(2), 171–184 (2006)Google Scholar 
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8. Tiboni, M., Legnani, G., Lancini, M., Serpelloni, M., Gobbo, M., Fausti, D.: ERRSE: elbow robotic rehabilitation system with an EMG-based force control. In: Ferraresi, C., Quaglia, G. (eds.) RAAD 2017. MMS, vol. 49, pp. 892–900. Springer, Cham (2018). ISBN: 9783319612751, https://doi.org/10.1007/978-3-319-61276-8_95
9. Serpelloni, M., Tiboni, M., Lancini, M., Pasinetti, S., Vertuan, A., Gobbo, M.: Preliminary study of a robotic rehabilitation system driven by EMG for hand mirroring. In: 2016 IE EE International Symposium on Medical Measurements and Applications, MeMeA 2016 – Proceedings, pp. 1–6, Institute of Electrical and Electronics Engineers Inc., University of Sannio, Italy (2016). ISBN: 9781467391726, https://doi.org/10.1109/MeMeA.2016.7533730
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[ARTICLE] Conventional Mirror Therapy versus Immersive Virtual Reality Mirror Therapy: The Perceived Usability after Stroke – Full Text

Abstract

Background. Stroke is a widespread and complex health issue, with many survivors requiring long-term rehabilitation due to upper-limb impairment. This study is aimed at comparing the perceived usability of two feedback-based stroke therapies: conventional mirror therapy (MT) and immersive virtual reality mirror therapy (VR). Methods. The study involved 45 participants, divided into three groups: the stroke survivors (), stroke-free older adults (), and young controls (). Participants performed two tasks using both MT and VR in a semirandom sequence. Usability instruments (SUS and NASA-TLX) were applied at the end of the activities, along with two experience-related questions. Results. The results indicated that both MT and VR had similar levels of perceived usability, with MT being more adaptable and causing less overall discomfort. Conversely, VR increased the perception of task difficulty and prevented participants from diverting their attention from the mirror-based feedback. Conclusion. While VR was found to be less comfortable than MT, both systems exhibited similar perceived usability. The comfort levels of the goggles may play a crucial role in determining the usability of VR for upper limb rehabilitation after stroke.

1. Introduction

Stroke is a major global health problem that results in high acute and chronic care-related costs and contributes to the overall burden of disease [1, 2]. Upper-limb impairment is a common consequence of stroke, with up to 60% of survivors requiring long-term rehabilitation [3–5]. Virtual reality (VR) has been increasingly used in neurorehabilitation to provide lifelike environments. Its application has been studied in various neurological conditions such as stroke, Parkinson’s disease, cerebral palsy, and multiple sclerosis [6–8]. Immersive virtual reality mirror therapy (VR), which replaces physical mirrors used in conventional mirror therapy (MT), has been proposed to increase the therapeutic value of mirror therapy [9].

Mirror neurons, located in the premotor cortex of the frontal lobe, are activated both when an individual performs movements and when they observe others moving [10]. However, conventional MT has several disadvantages that limit its use in clinical settings, including: (a) a monotonous and low-dose therapy; (b) the need for dedicated apparatus and often a professional on site; (c) the need for the patient to constantly observe the mirror-generated feedback; and (d) the potential perception of bilateral rather than unilateral movement [11]. VR-based therapy may help overcome these limitations by facilitating the application of mirror therapy principles in a more clinically feasible manner.

VR is believed to be a promising way to achieve higher doses of therapy and improve poststroke arm/hand recovery [12]. The integration of VR technology with MT principles presents an interesting approach for enhancing stroke rehabilitation outcomes, but the literature is scarce. Moreover, a thorough evaluation of the perceived usability of VR-based feedback in comparison to conventional MT using smartphones with VR capabilities has yet to be carried out. Despite the availability of VR-dedicated devices on the market that offer superior image quality and immersive experiences, at the moment, their cost remains a significant barrier to accessibility, particularly for individuals living in developing regions. Therefore, the current study was designed to address the perceived usability of MT and VR (using a smartphone with VR googles) feedback-based stroke therapies.[…]

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Figure 1. Tools used in this study to perform the cube sorting task and gridlock puzzle using conventional mirror therapy (MT) and virtual reality- (VR-) based feedback. (a, c) show the geometric shape-sorting cube (Form Fitter, Playskool, Brazil) used for the cube sorting task. (d–f) show the gridlock puzzle (Cilada, Estrela, Brazil) used for the gridlock puzzle task. (b, e) show the tools used in conventional MT, while (c, f) show the tools used in VR-based feedback.

[Abstract] Home mirror therapy: a randomized controlled pilot study comparing unimanual and bimanual mirror therapy for improved arm and hand function post-stroke

Abstract

Purpose

To compare home-based unimanual mirror therapy (UMT) and bimanual mirror therapy (BMT) for upper limb recovery in subacute/chronic stroke individuals with moderate-to-severe arm impairment.

Method

Twenty-two participants were randomized into 1 of 3 groups: UMT, BMT or traditional occupational therapy (TOT) home-based programs. The intervention was 6-weeks and consisted of OT 2 days a week, weekly sessions with the research OT, and 30-minutes of the home-based program 5 days a week, according to group allocation. The Action Research Arm Test (ARAT), ABILHAND, Fugl-Meyer Assessment (FMA), grip strength, and Stroke Impact Scale (SIS) were used for outcome measures.

Results

All groups significantly improved over time on all outcome measures and adhered to the prescribed dosage regardless of group (p<0.05). While there were no between-group differences, effect size and 95% confidence interval data suggest a clinical significance in favor of UMT as compared to the other groups.

Conclusions

All participants, regardless of home-based program, adhered to the prescribed dosage and significantly improved over time. Despite no between-group differences, effect size and 95% confidence interval data suggest that UMT may be more beneficial for individuals with moderate-to-severe arm impairment as compared to BMT or TOT. ClinicalTrials.gov: #NCT02780440

• Implications for Rehabilitation
• Home-based unimanual mirror therapy (UMT), bimanual mirror therapy (BMT), and traditional occupational therapy (TOT), when administered in conjunction with outpatient OT, are helpful for improving upper limb recovery post-stroke.
• Home-based UMT may be more beneficial than BMT or TOT for improvement in upper limb motor function and activities of daily living of patients with moderate to severe arm impairment post-stroke.

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[Abstract] Three Ways to Improve Arm Function in the Chronic Phase After Stroke by Robotic Priming Combined With Mirror Therapy, Arm Training, and Movement-Oriented Therapy

Abstract

Objective

To examine the effects of bilateral robotic priming combined with mirror therapy (R-mirr) vs bilateral robotic priming combined with bilateral arm training (R-bilat), relative to the control approach of bilateral robotic priming combined with movement-oriented training (R-mov) in patients with stroke.

Design

A single-blind, preliminary, randomized controlled trial.

Setting

Four outpatient rehabilitation settings.

Participants

Outpatients with stroke and mild to moderate motor impairment (N=63).

Interventions

Patients received 6 weeks of clinic-based R-mirr, R-bilat, or R-mov for 90 min/d, 3 d/wk, plus a transfer package at home for 5 d/wk.

Main Outcome Measures

Fugl-Meyer Assessment Upper Extremity subscale (FMA-UE), ABILHAND, and Stroke Impact Scale v3.0 scores before, immediately after, and 3 months after treatment as well as lateral pinch strength and accelerometry before and immediately after treatment.

Results

The posttest results favored R-mirr over R-bilat and R-mov on the FMA-UE score (P<.05). Follow-up analysis revealed that significant improvement in FMA-UE score was retained at the 3-month follow-up in the R-mirr over R-bilat or R-mov (P<.05). Significant improvements were not observed in the R-mirr over R-bilat and R-mov on other outcomes.

Conclusions

Between-group differences were only detected for the primary outcome, FMA-UE. R-mirr was more effective at enhancing upper limb motor improvement, and the effect has the potential to be maintained at 3 months of follow-up.

Section snippets

Procedure

A single-blind, randomized controlled trial with pretest, posttest, and 3-month follow-up assessments was conducted at 4 outpatient rehabilitation settings. The institutional review board at each of the participating sites approved the study. We used pre hoc planned analyses.^18,27,28 A total sample size of 72 with 24 individuals per group was estimated to achieve a sufficient level of power at 0.8 with a 2-sided type I error of .05 and with an estimated dropout rate of 10%-15% at the 3-month

Results

Recruitment was conducted from November 2018 to February 2022, and 70 patients were recruited for the study; of these, 68 participants finished the 6-week intervention and 63 completed the follow-up assessment (figure 2). Our analyses included all available subjects. The number of participants included in the analysis was 21 for all groups (R-mirr, R-bilat, and R-mov). No significant harm, unintended effects, or intolerable adverse effects were reported. The demographic and baseline clinical

Discussion

This study investigated the effects of R-mirr, R-bilat, and R-mov in stroke rehabilitation. We found that R-mirr has the potential to lead to better benefits and retention effects on upper limb motor impairment than R-bilat and R-mov. The estimated minimal clinically important difference score for the FMA-UE among patients with chronic stroke is between 4.25 and 7.25.54, 55, 56 In our study, in both R-mirr and R-bilat, the improvements were above the minimal clinically important difference for

Conclusions

The study confirms existing findings that neuroplasticity can be promoted even in the chronic stage of stroke.^67,68 The study confirms that functional gains can be maintained at least until 3 months after treatment. Our study findings indicate the best candidate for future, well-designed confirmatory randomized controlled trials. In the light of our findings, R-mirr is a better treatment option if improving motor impairment is the goal of treatment. The findings can inform clinicians about

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[Abstract] Mirror Therapy-Based Hand Rehabilitation

Abstract:

Our hands are critical, complex, and crucial human body parts with many functions. The loss of human hand function results in a severe compromise on the ability to feed and care for oneself and limits one’s work, social, and family life. Hands are often prone to injuries since it is a primary means of interacting with the world. Recovery of the normal functioning of the hand after stroke, hand injuries, and hand surgeries is only possible by proper and continuous rehabilitation. Usually, patients undergoing hand rehabilitation have to visit the rehabilitation center to attend their sessions regularly. And thus, transportation becomes a challenge. Also, if home exercises are given, the patients fear doing the exercises due to pain and lack of motivation. Another challenge is that the physiotherapist does not receive feedback on whether the patients’ given home exercises were correctly done. The proposed mirror therapy-based hand rehabilitation of fingers with a feedback mechanism consists of a transmitter and receiver exoskeleton. The designed transmitter hand exoskeleton initiates the hand movements, and these signals are picked up and transmitted to the receiver hand exoskeleton for the corresponding movement. In our proposed design, the focus is given to mobilizing the Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) joints of all fingers. With the help of the proposed system, the patient can perform the prescribed exercises in their comfort at their homes without the help of a bystander. The proposed system is validated by recording Electromyography (EMG) signals and grip force measurements and comparing the values obtained for a normal hand and the hand with an exoskeleton.

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[Abstract + References] Video augmented mirror therapy for upper extremity rehabilitation after stroke: a randomized controlled trial

Abstract

Purpose

To investigate the effects of mirror therapy using a newly developed video augmented wearable reflection device on reach-to-grasp motor control and upper extremity motor function.

Methods

Participants were randomly allocated to one of three groups: mirror therapy using a video augmented wearable reflection device group (MTVADG), n = 12; traditional mirror therapy group (TMTG), n = 12; and control group (CG), n = 12. Participants in the MTVADG and TMTG received conventional rehabilitation in addition to mirror therapy. Motor control during the reach-to-grasp movement was assessed using kinematic analysis. Each participant’s upper extremity motor function was assessed using the Fugl-Meyer Assessment, Manual Function Test, and Box and Block Test.

Results

While both the MTVADG and TMTG showed significantly improved reach-to-grasp movement. The MTVADG showed greater efficiency in kinematic performance than the TMTG. Moreover, while both the MTVADG and TMTG showed improved upper extremity motor function, the MTVADG showed significantly greater improvement in proximal upper limb function compared to the TMTG.

Conclusion

Our results suggested that mirror therapy using a video augmented wearable reflection device is more efficient compared to traditional mirror therapy for patients with stroke.

References

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[ARTICLE] Effectiveness of robot-assisted virtual reality mirror therapy for upper limb motor dysfunction after stroke: study protocol for a single-center randomized controlled clinical trial – Full Text

Abstract

Background

Upper limb motor dysfunction is a common sequela of stroke, and its clinical efficacy needs to be improved. This protocol describes a trial to verify the clinical efficacy of robot-assisted virtual reality mirror therapy (RAVRMT) in improving upper limb motor dysfunction in stroke patients, and to explore the central mechanism by using functional magnetic resonance imaging (fMRI).

Methods

This trial will be a single-center, assessor-blinded, randomized controlled clinical study. Thirty-two eligible patients will be randomly divided into 2 groups according to the ratio of 1:1, namely virtual reality mirror therapy (VRMT) group and robot-assisted virtual reality mirror therapy (RAVRMT) group. The interventions will be performed once a day for 4 weeks. Primary outcome is Fugl–Meyer motor function assessment-Upper Extremity (FMA-UE), secondary outcomes are the Montreal Cognitive Assessment (MoCA), activities of daily living (ADL), quality of life (QOL), the pain visual analogue scale (VAS-pain) and fMRI. Adverse events will be recorded, and severe adverse events will be used as criteria to discontinue the intervention.

Discussion

Combined application of robot-assisted therapy and virtual reality mirror therapy could theoretically activate mirror neuron system and reward circuits to a greater extent, but further high-quality research is needed. The results of this trial will determine whether RAVRMT could better improve upper limb motor dysfunction after stroke and explore its central mechanism using fMRI.

Background

In recent years, stroke has become the second leading cause of death and the third leading cause of disability in the world [1]. Studies have shown that about 80% of acute stroke patients and more than 55% chronic stroke patients have upper limb motor dysfunction [2, 3], which seriously affects the quality of life of patients and their families [4, 5]. At present, the conventional rehabilitation methods for upper limb motor dysfunction after stroke consists of physical therapy [6], occupational therapy [7], but more than 50% of stroke patients still have long-term upper limb motor dysfunction [8]. The clinical efficacy of conventional rehabilitation methods in the treatment of upper limb motor dysfunction after stroke is not satisfactory, and new rehabilitation concepts and techniques are urgently needed.

How can we better promote the recovery of upper limb motor dysfunction after stroke? The disruption of motor-related brain networks is the primary cause of upper limb motor dysfunction after stroke, and another important cause is the upper limb disuse caused by long-term inactivity, so a single treatment for one cause is not adequate [9]. In stroke, the disruption of motor-related brain networks is the damage at the central level [10] and the upper limb disuse caused by long-term inactivity is the damage at the peripheral level [11]. As a clinical central intervention technology, mirror therapy can activate the motor-related brain network through action observation [12]. A recent meta-analysis demonstrates that mirror therapy can significantly improve upper limb motor dysfunction in stroke patients [13]. As a new kind of mirror therapy, virtual reality mirror therapy (VRMT) can provide immersion mirror therapy for stroke patients [14]. However, mirror therapy lacks the participation of proprioception [15], which may not be able to simulate the actual scene well and activate the motor-related brain network to the greatest extent. As a clinical peripheral intervention technology, a large number of studies have proved that robot-assisted therapy (RAT) can have a positive impact on the recovery of upper limb motor dysfunction in stroke patients through programmed task training [16, 17], including motor function and proprioception. At present, more and more studies show that mirror therapy combined with other interventions is superior to a single rehabilitation therapy in the treatment of upper limb motor dysfunction in stroke patients [18–20].

In this study, we designed a device that combined RAT and immersion VRMT to treat upper limb motor dysfunction after stroke. Moreover, the device can dynamically match the motion trajectory of the RAT with the motion images displayed in real time by the VRMT, so as to realize the cycle of “visual information input-visual information output-motion feedback” in the stroke patient. This is different from other combinations of a central intervention and a peripheral intervention for upper limb motor dysfunction after stroke [21, 22], which a central intervention and a peripheral intervention do not dynamically match each other in real time. In summary, the device is an innovative medical rehabilitation machine, which realizes the cycle of “visual information input-visual information output-motion feedback”, and provides patients with a full-body immersive experience that is consistent with vision, touch, and proprioception. We call the treatment robot-assisted virtual reality mirror therapy (RAVRMT) and the device RAVRMT robot. The RAVRMT robot is ultimately expected to activate mirror neuron system (MNS) and reward circuits to the greatest extent possible, thereby promoting the improvement of upper limb motor dysfunction in patients after stroke.

Therefore, we designed a randomized controlled trial to explore the clinical efficacy of RAVRMT in improving upper limb motor dysfunction in patients after stroke. Meanwhile, in this trial, functional magnetic resonance imaging (fMRI) scans will be performed to find significant changes in motor-related brain functional connectivity, and the motor-related brain functional network will be compared before and after the intervention to further reveal the brain neural mechanism of RAVRMT’s effects.[…]

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Fig. 3
Schematic diagram of virtual reality mirror therapy

[ARTICLE] Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery – Full Text

Abstract

Stroke, including hemorrhagic and ischemic stroke, refers to the blood supply disorder in the local brain tissue for various reasons (aneurysm, occlusion, etc.). It leads to regional brain circulation imbalance, neurological complications, limb motor dysfunction, aphasia, and depression. As the second-leading cause of death worldwide, stroke poses a significant threat to human life characterized by high mortality, disability, and recurrence. Therefore, the clinician has to care about the symptoms of stroke patients in the acute stage and formulate an effective postoperative rehabilitation plan to facilitate the recovery in patients. We summarize a novel application and update of the rehabilitation therapy in limb motor rehabilitation of stroke patients to provide a potential future stroke rehabilitation strategy.

Introduction

Stroke is an acute cerebrovascular disease with high morbidity, mortality, and disability. It is the second leading cause of death worldwide, accounting for 11.6% of deaths. According to the Global Burden of Disease report, an estimated 12.2 million strokes are there worldwide, resulting in 143 million disability-adjusted life years (DALYs) and 6.55 million deaths (GBD 2019 Stroke Collaborators, 2021). China has the highest number of stroke cases globally. The number of patients belonging to the low-income and youth groups is rapidly increasing, with significant gender and regional differences. According to the WHO, in 2019, stroke was the leading cause of death and DALYs in China (World Health Organization [WHO], 2020). Stroke results in lasting sensory, cognitive and visual impairment, impaired limb motor function, and eventually reduce various bodily functions (Katzan et al., 2018a,b). Motor dysfunction is the most common complication of stroke, followed by hemiplegia in about 80% of patients. Half of these symptoms will accompany patients for life and seriously affect their day-to-day activities (Kim et al., 2020). Studies have shown that hemiplegia is the leading cause of long-term disability in stroke patients from the United States, Japan, and France [(Leys et al., 2008; Ovbiagele and Nguyen-Huynh, 2011; Iso, 2021)]. The fatality rate is significantly lower than before with the progress and development of stroke treatment. However, 80% of the survivors have severe sequelae, and the disability rate is about 75% (Langhorne et al., 2018). Effective rehabilitation training can alleviate functional disability, restore the motor function in hemiplegic limbs, and accelerate the rehabilitation process in post-stroke patients (Laver et al., 2020). At present, patient rehabilitation with limb movement disorders after stroke primarily emphasizes early intervention, somehow ignoring the intervention received during the recovery and the sequelae period. There is a decline in the quality-of-life of patients and aggravation of disease conditions. Therefore, improving limb motor function of stroke patients through rehabilitation is essential. Traditional rehabilitation therapy, including massage, acupuncture, physiotherapy, and electrical stimulation, has been widely employed in the clinical practice (McCrimmon et al., 2015; Yang et al., 2016; Cabanas-Valdés et al., 2021). With the progress of science and technology, several potential neurological rehabilitations are being developed using new technologies to restore movement in the stroke patients. In this review, we summarize the novel methods and applications to restore limb motor dysfunction in stroke rehabilitation, which could provide a potential therapeutic strategy against stroke in the future.[…]

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