Posts Tagged Motor function
[Abstract] Effectiveness of virtual reality-based rehabilitation versus conventional therapy on upper limb motor function of chronic stroke patients: a systematic review and meta-analysis of randomized controlled trials
Objective: To systematically review the available randomized controlled trials in the literature concerning the application of virtual reality (VR) rehabilitation interventions compared to conventional physical therapy, in regaining the upper limb motor function among patients with chronic stroke.
Methods: A systematic electronic database search was conducted for related studies published from inauguration and until June 25, 2020 in nine databases. Another new search was done on February 1, 2021 and no new studies were identified.
Results: Six studies were included in the analysis. Significant improvement was seen following the VR therapy in patients with chronic stroke, compared to their scores prior to it (SMD = 0.28; 95% CI = 0.03–0.53; p = .03). There was neither heterogeneity (I2 = 0% and P = .5) nor a risk of bias (P = .8) among the included studies. VR interventions produced a comparable effectiveness to that of the conventional rehabilitation, with no statistically significant difference (SMD = 0.15; 95% CI = −0.14–0.44; P = .3). There was neither heterogeneity (I2 = 40% and P = .1) nor a risk of bias (P = .5) among the included studies.
Conclusions: The upper limb motor function of patients with chronic stroke who underwent VR-based rehabilitative intervention showed significant improvement as compared to the pre-treatment state. Our analysis also revealed no superiority of VR interventions over conservative therapies; however, the difference observed did not accomplish statistical significance.
[Abstract] Computer Game Assisted Task Specific Exercises in the Treatment of Motor and Cognitive Function and Quality of Life in Stroke: A Randomized Control Study
• Computer game assisted task specific exercises (CGATSE) is a contemporary approach to stroke rehabilitation.
• CGATSE may be used in hospital and home environments in stroke rehabilitation.
• CGATE improved arm motor function and quality of life in stroke rehabilitation.
Computer game assisted task specific exercises (CGATSE) are rehabilitation gaming systems (RGS) used in stroke rehabilitation to facilitate patient performance of high intensity, task based, repetitive exercises aiming to enhance neuroplasticity. CGATSE maybe an appealing option in home based rehabilitation of stroke patients, especially during the COVID-19 pandemic. This study aimed to determine the effects of CGATSE on hemiplegic arm-hand function, cognitive function and quality of life in stroke.
Materials and methods
Thirty stroke patients were randomized into two groups. All participants received twenty sessions of physical therapy. In addition, the therapy group undertook thirty minutes of CGATSE using the Rejoyce gaming system; while the control group undertook thirty minutes of occupational therapy (OT). Motor function was evaluated before and after treatment using the Fugl Meyer upper extremity (FMUE), Brunnstrom stages of stroke recovery (BSSR) arm and hand. The CGATSE group also completed the Rejoyce arm hand function test (RAHFT). Cognitive function was evaluated using the mini mental state examination, Montreal Cognitive Assessment (MoCA) and Stroke Specific Quality of Life (SS-QOL) scale.
The FMUE, BSSR arm and SSQOL improved in both groups (p < 0.05). BSSR of the hand improved only in the CGATSE group (p = 0.024). RAHFT scores improved in the CGATSE group (p = 0.008). MoCA scores significantly improved in the control group (p = 0.008).
CGATSE may be beneficial in providing continuation of care after stroke, especially during the Covid-19 pandemic when home based rehabilitation options are becoming increasingly important. Benefits of CGATSE in improving cognitive function is less clear. RGS aimed at improving motor function may be compared to gaming systems designed to target cognitive development and more detailed higher cortical function deficit tests can be used as outcome measures.
[ARTICLE] The effect of mirror therapy on lower extremity motor function and ambulation in post-stroke patients: A prospective, randomized-controlled study – Full Text
Objectives: This study aims to evaluate the effects of mirror therapy (MT) on lower extremity motor function and ambulation in post-stroke patients.
Patients and methods: A total of 42 post-stroke patients (25 males, 17 females; mean age 58 years; range, 32 to 71 years) were included. All patients were randomly divided into two groups as the control group (n=21) receiving a conventional rehabilitation program for four weeks (60 to 120 min/day for five days a week) and as the MT group (n=21) receiving MT for 30 min in each session in addition to the conventional rehabilitation program. The Brunnstrom stages of stroke recovery, Functional Independence Measure (FIM), Berg Balance Scale (BBS) and Motricity Index (MI) scores, six-minute walking test (6MWT), Functional Ambulation Category (FAC), and the degree of ankle plantar flexion spasticity using the Modified Ashworth Scale (MAS) were evaluated at baseline (Day 0), at post-treatment (Week 4), and eight weeks after the end of treatment (Week 12).
Results: There were significant differences in all parameters between the groups, except for the degree of ankle plantar flexion spasticity, and in all time points between Week 0 and 4 and between Week 0 and 12 (p<0.05).
Conclusion: These results suggest that MT in addition to conventional rehabilitation program yields a greater improvement in the lower extremity motor function and ambulation, which sustains for a short period of time after the treatment.
[ARTICLE] Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial – Full Text
Transcranial direct current stimulation (tDCS) and intermittent theta burst stimulation (iTBS) were both demonstrated to have therapeutic potentials to rapidly induce neuroplastic effects in various rehabilitation training regimens. Recently, we developed a novel transcranial electrostimulation device that can flexibly output an electrical current with combined tDCS and iTBS waveforms. However, limited studies have determined the therapeutic effects of this special waveform combination on clinical rehabilitation. Herein, we investigated brain stimulation effects of tDCS-iTBS on upper-limb motor function in chronic stroke patients.
Twenty-four subjects with a chronic stroke were randomly assigned to a real non-invasive brain stimulation (NIBS; who received the real tDCS + iTBS output) group or a sham NIBS (who received sham tDCS + iTBS output) group. All subjects underwent 18 treatment sessions of 1 h of a conventional rehabilitation program (3 days a week for 6 weeks), where a 20-min NIBS intervention was simultaneously applied during conventional rehabilitation. Outcome measures were assessed before and immediately after the intervention period: Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Jebsen-Taylor Hand Function Test (JTT), and Finger-to-Nose Test (FNT).
Both groups showed improvements in FMA-UE, JTT, and FNT scores after the 6-week rehabilitation program. Notably, the real NIBS group had greater improvements in the JTT (p = 0. 016) and FNT (p = 0. 037) scores than the sham NIBS group, as determined by the Mann–Whitney rank-sum test.
Patients who underwent the combined ipsilesional tDCS-iTBS stimulation with conventional rehabilitation exhibited greater impacts than did patients who underwent sham stimulation-conventional rehabilitation in statistically significant clinical responses of the total JTT time and FNT after the stroke. Preliminary results of upper-limb functional recovery suggest that tDCS-iTBS combined with a conventional rehabilitation intervention may be a promising strategy to enhance therapeutic benefits in future clinical settings.
Neuromodulation is an evolving therapy for rehabilitation after a stroke and is also used to improve motor function in the lesioned cortex. Recently, studies indicated that neuromodulation could enhance neuroplasticity, the ability of the brain to reorganize or relearn in response to a new stimulus, resulting in facilitation of motor sensory recovery in stroke patients [1,2,3]. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation (NIBS) technique, is contemporarily important as it can modulate neuroplasticity in advanced rehabilitation medicine, such as pain, depression and, addictive diseases [4,5,6]. tDCS can selectively change the excitability of the regional cortex non-invasively and safely . In addition, tDCS has been explored as a treatment option for stroke, particularly for upper/lower-limb motor function [8,9,10,11]. However, studies reported only 10% ~ 30% improvement in forearm motor function after stroke rehabilitation. Optimal stimulation strategies of tDCS to improve plasticity and enhance motor learning need to be determined.
Recovery as a result of traditional stroke rehabilitation often has poor outcomes and long rehabilitation times. Therefore, developing a more-effective therapeutic device is an important issue for stroke rehabilitation. To develop an optimal tDCS protocol to improve motor function, we designed and implemented a prototype of a novel transcranial electrostimulation device that can flexibly output an electrical current waveform by combining DC and theta burst waveforms . Theta burst stimulation (TBS) was originally a novel waveform of repetitive transcranial magnetic stimulation (rTMS) that is more rapid and efficacious than rTMS . Numerous studies determined that TBS has more advantages than other traditional waveforms of rTMS, such as long-lasting effects on motor-evoked potentials (MEPs) and neuronal excitability after a shorter stimulation duration [14,15,16], and it was associated with fewer adverse events . It is well known that the most widely used TBS patterns are intermittent (i)TBS and continuous (c)TBS. iTBS consists of a 2-s train of TBS repeated every 10 s for a total of 190 s which produces long-term potentiation (LTP)-like effects, whereas cTBS consists of three-pulse bursts at 50 Hz repeated every 200 ms for 40 s, which induces long-term depression (LTD)-like cortical plasticity [14, 18,19,20].
Use of an rTMS protocol with iTBS in chronic stroke patients was shown to significantly increase ipsilesional M1 excitability, enhanced MEP amplitudes, and improve upper-limb motor functions [15, 21,22,23]. One recent meta-analysis showed that the standardized mean difference (SMD) of iTBS was 0.60 (p = 0.018), whereas that for cTBS was 0.35 (p = 0.138) for the recovery of upper-limb motor outcomes in stroke patients, indicating that iTBS was more beneficial than cTBS in motor recovery after a stroke . Therefore, modulation of cortical plasticity induced by iTBS may have therapeutic potential for patients with post-stroke motor disorders.
Both rTMS and tDCS can cause physiological effects and indirectly modulate deep-brain locations via neural circuits [25, 26]. In general, rTMS therapy is usually applied before undertaking occupational therapy for patients with motor function deficits, due to the bulky size of the rTMS device. On the contrary, the lightweight, portable tDCS device can be directly worn on a patient’s head during active rehabilitation exercises, which was associated with augmentation of synaptic plasticity [27,28,29]. However, most traditional transcranial stimulators have only a DC waveform mode at present. Thus, our novel transcranial burst electrostimulator was designed to develop an effective and optimal therapeutic system for patients who need rehabilitation therapy. We previously demonstrated that compared to conventional anodal tDCS, the combined DC-iTBS electrostimulator induced LTP-like plasticity as evident from significantly enhanced MEP amplitudes for at least 30 min in animal experiments .
With the excellent efficacy of previously combined stimulation, we report a pilot randomized controlled study to examine the combined effects of DC-iTBS and conventional rehabilitation (CR) on upper-limb motor function as measured by the Fugl-Meyer Assessment upper extremity (FMA-UE), Finger-to-Nose test (FNT), and Jebsen-Taylor hand function test (JTT) in patients with chronic stroke compared to a sham intervention. To our knowledge, this is the first randomized controlled trial (RCT) to apply tDCS with iTBS to facilitate upper-limb motor function in chronic stroke patients. We also expected that the novel DC-iTBS stimulation combined with rehabilitation of the upper extremities would result in greater improvements and have potential to become a routine treatment strategy for stroke patients at hospitals and residential rehabilitation facilities.[…]
[ARTICLE] Effects of a robot‐aided somatosensory training on proprioception and motor function in stroke survivors – Full Text
Proprioceptive deficits after stroke are associated with poor upper limb function, slower motor recovery, and decreased self-care ability. Improving proprioception should enhance motor control in stroke survivors, but current evidence is inconclusive. Thus, this study examined whether a robot-aided somatosensory-based training requiring increasingly accurate active wrist movements improves proprioceptive acuity as well as motor performance in chronic stroke.
Twelve adults with chronic stroke completed a 2-day training (age range: 42–74 years; median time-after-stroke: 12 months; median Fugl–Meyer UE: 65). Retention was assessed at Day 5. Grasping the handle of a wrist-robotic exoskeleton, participants trained to roll a virtual ball to a target through continuous wrist adduction/abduction movements. During training vision was occluded, but participants received real-time, vibro-tactile feedback on their forearm about ball position and speed. Primary outcome was the just-noticeable-difference (JND) wrist position sense threshold as a measure of proprioceptive acuity. Secondary outcomes were spatial error in an untrained wrist tracing task and somatosensory-evoked potentials (SEP) as a neural correlate of proprioceptive function. Ten neurologically-intact adults were recruited to serve as non-stroke controls for matched age, gender and hand dominance (age range: 44 to 79 years; 6 women, 4 men).
Participants significantly reduced JND thresholds at posttest and retention (Stroke group: pretest: mean: 1.77° [SD: 0.54°] to posttest mean: 1.38° [0.34°]; Control group: 1.50° [0.46°] to posttest mean: 1.45° [SD: 0.54°]; F[2,37] = 4.54, p = 0.017, ηp2 = 0.20) in both groups. A higher pretest JND threshold was associated with a higher threshold reduction at posttest and retention (r = − 0.86, − 0.90, p ≤ 0.001) among the stroke participants. Error in the untrained tracing task was reduced by 22 % at posttest, yielding an effect size of w = 0.13. Stroke participants exhibited significantly reduced P27-N30 peak-to-peak SEP amplitude at pretest (U = 11, p = 0.03) compared to the non-stroke group. SEP measures did not change systematically with training.
This study provides proof-of-concept that non-visual, proprioceptive training can induce fast, measurable improvements in proprioceptive function in chronic stroke survivors. There is encouraging but inconclusive evidence that such somatosensory learning transfers to untrained motor tasks.
Trial registration Clinicaltrials.gov; Registration ID: NCT02565407; Date of registration: 01/10/2015; URL: https://clinicaltrials.gov/ct2/show/NCT02565407.
Nearly two-thirds of stroke survivors exhibit forms of somatosensory or proprioceptive dysfunction [1, 2]. Proprioceptive deficits are related to longer length-of-stay in hospitals , poor quality of movement, poorer activities of daily (ADL) function and reduced participation in physical activity [4,5,6]. Proprioceptive deficits predict treatment responses to robot-assisted motor retraining with augmented proprioceptive feedback  These may be explained by the crucial role of proprioception in motor control and learning [8, 9]. Proprioceptive training is a form of somatosensory intervention that aims to enhance proprioceptive function. Several forms of somatosensory intervention such as passive, repetitive cutaneous stimulation [10, 11], passive limb movement training , repeated somatosensory discrimination practice and active sensorimotor training with augmented somatosensory feedback [7, 13, 14, 15] have been proposed to aid recovery of proprioceptive function and motor function after stroke. Proprioceptive improvements observed after proprioceptive training interventions correlated with improvement of untrained motor performance in healthy young adults [16, 17]. This further supports the rationale to implement proprioceptive-motor training for people with stroke. Among all types of proprioceptive intervention, active sensorimotor training with augmented somatosensory feedback [7, 13,14,15] seem to produce consistent results across studies [1, 18]. These interventions often employ somatosensory signals either to replace visual feedback on motor performance or to augment existing visual and somatosensory feedback for online motor control. One well studied mode of somatosensory feedback is vibro-tactile feedback (VTF) applied to the skin surface. Incorporating VTF with movement training has been shown to improve the learning of simple motor tasks in healthy adults and clinical populations [19,20,21]. There is evidence that it can effectively enhance proprioceptive function .
Somatosensory evoked potentials (SEPs) recorded via electroencephalography (EEG) are an objective neurophysiological marker of somatosensory processing with established procedures and normative values that has been used among clinical populations. Adults after stroke typically present with a lower peak amplitude or longer peak latency of SEPs (e.g. [23, 24]). Moreover, the restoration of typical SEPs has been reported following somatosensory interventions [25, 26]. Thus, we here recorded SEP to verify changes in the neural processing of somatosensory signals in sensorimotor cortex as a function of the somatosensory-motor intervention employed in this project […]
IpsiHand System designed for individuals with upper-extremity disability
by Nicole Lou, Staff Writer, MedPage Today April 23, 2021
FDA has authorized the Neurolutions IpsiHand Upper Extremity Rehabilitation System (IpsiHand System) for stroke survivors trying to regain hand, wrist, or arm function.
The IpsiHand System may be prescribed to stroke patients wishing to improve grasping as part of their rehabilitation therapy. The brain-computer-interface device uses non-invasive electroencephalography electrodes to record a person’s brain activity, and then moves an electronic hand brace according to the intended muscle movement.
“Thousands of stroke survivors require rehabilitation each year,” said Christopher Loftus, MD, acting director of the Office of Neurological and Physical Medicine Devices at the FDA, in a statement. “Today’s authorization offers certain chronic stroke patients undergoing stroke rehabilitation an additional treatment option to help them move their hands and arms again and fills an unmet need for patients who may not have access to home-based stroke rehabilitation technologies.”
Approval was based on a 40-person unblinded study in which all participants showed motor function improvement with the device over 12 weeks. Adverse events reported in the study included minor fatigue, discomfort, and temporary skin redness.
The IpsiHand System had been granted breakthrough device designation by the FDA and was authorized for marketing through the de novo premarket review pathway.
The device should not be used by patients who cannot be properly fitted for the electronic hand brace, nor those with skull defects due to craniotomy or craniectomy, the FDA cautioned.
- Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow
[Abstract] Effectiveness of walking training on balance, motor functions, activity, participation and quality of life in people with chronic stroke: a systematic review with meta-analysis and meta-regression of recent randomized controlled trials
To review and quantify the effects of walking training for the improvement of various aspects of physical function of people with chronic stroke.
We conducted a systematic search and meta-analysis of randomized controlled trials (RCTs) of chronic stroke rehabilitation interventions published from 2008 to 2020 in English or French. Of the 6476-screened articles collated from four databases, 15 RCTs were included and analyzed. We performed a meta-regression with the total training time as dependent variable in order to have a better understanding of how did the training dosage affect the effect sizes.
Treadmill walking training was more effective on balance and motor functions (standardized mean difference (SMD)=0.70[0.02, 1.37], p = 0.04) and 0.56[0.15, 0.96], p = 0.007 respectively). Overground walking training improved significantly walking endurance (SMD = 0.38[0.16, 0.59], p < 0.001), walking speed (MD = 0.12[0.05, 0.18], p < 0.001), participation (SMD = 0.35[0.02, 0.68], p = 0.04) and quality of life (SMD = 0.46[0.12, 0.80], p = 0.008). Aquatic training improved balance (SMD = 2.41[1.20, 3.62], p < 0.001). The Meta-regression analysis did not show significant effect of total training time on the effect sizes.
Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in people with chronic stroke.
- Implications for rehabilitation
- Treadmill walking training is effective for improving balance and motor functions.
- Overground walking training improved significantly walking endurance, walking speed, participation and quality of life.
- Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in patient with chronic stroke.
[Abstract] Effects of motor imagery training on lower limb motor function of patients with chronic stroke: A pilot single‐blind randomized controlled trial
This pilot study aimed to evaluate the effects of motor imagery training on lower limb motor function of stroke patients.
Motor imagery training has played an important role in rehabilitation outcomes of stroke patients.
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.
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.
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.
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.
Posted by Debbie Overman
Treating patients with an injection of bone marrow cells may lead to a reduction in brain injury after a stroke, according to results from a clinical trial published in STEM CELLS Translational Medicine.
“Nearly 90 percent of patients who suffer an ischemic stroke – the most common type of stroke – exhibit weakness or paralysis to one side of the body. Injuries to the corticospinal tract (CST), which is the main white matter connection in the brain responsible for carrying movement-related information to the spinal cord, is the primary cause of this motor function impairment. In stroke animal models, we’ve seen how bone marrow mononuclear cells (BM-MNC) attenuate secondary degeneration and enhance recovery, including white matter tract remodeling. That led us to our current study.”
— Muhammad E. Haque, PhD
Hague, along with Sean I. Savitz, MD, and colleagues from the Institute for Stroke and Cerebrovascular Disease at The University of Texas Health Science Center in Houston, conducted the study.
Previously, the team led by Dr. Savitz had conducted a phase I clinical trial on the safety and feasibility of intravenous administration of autologous (a patient’s own) bone marrow-derived mononuclear cells (BM-MNCs) in patients with ischemic stroke. In that study, they reported preliminary CST recovery in the part of the brain stem called the rostral pons.
In their current work, they delved deeper into this intriguing finding by using 3D anatomical and DTI images obtained from MRI scans to compare extensive longitudinal microstructural changes in the white matter of BM-MNC-treated stroke patients to a group who did not receive the cells. (DTI – or diffusion tensor imaging – is an MRI technique that is most commonly used to examine the brain and estimate its white matter organization.)
CST Improvement from Injections
The 37 patients in the study ranged in age from 18 to 80. While all received the standard stroke treatment and rehabilitation follow-up, 17 patients whose strokes were the most severe received the additional BM-MNC injections. Three months later, MRI scans of each patient showed, as the researchers expected, a decrease in the integrity of their CST. However, scans taken 12 months after the stroke occurred showed an improvement in the CST of the 17 patients who received injections. Conversely, the CST of the non-injected group exhibited ongoing and continuing microstructural injury and axonal degeneration.
“These results suggest the possibility of microstructural stabilization in the cell-injected group as compared with the non-treated patients. We envision that future clinical trials might be directed toward identifying white matter protection or repair as an important mechanistic target of efficacy studies and potency assays for bone marrow cell therapies.”
— Muhammad E. Haque, PhD
[Source(s): Alphamed Press, EurekAlert]