Posts Tagged motor learning

[ARTICLE] What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review – Full Text

Abstract

Purpose

The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.

Methods

A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.

Results

One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.

Conclusions

Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.

Introduction

An increasing evidence base supports the use of virtual reality (VR) and active video gaming (AVG) systems to promote motor learning in stroke rehabilitation [1234]. However, practical and logistical barriers to VR/AVG implementation in clinical sites have been well described [567]. To support their use, researchers and developers often emphasize the potential advantages of VR/AVG systems over conventional interventions, including that these technologies may enhance a patient’s affective experience in therapy for the purpose of facilitating recovery [891011]. Examining the role of affective factors for motor learning is an emerging area of emphasis in rehabilitation [212131415].

VR/AVG use may enhance patients’ motivation to participate in rehabilitation as well as their engagement in therapeutic tasks. Motivation encourages action toward a goal by eliciting and/or sustaining goal-directed behavior [16]. Motivation can be intrinsic (derived from personal curiosity, importance or relevance of the goal) or extrinsic (elicited via external reward) [17]. Engagement is a cognitive and affective quality or experience of a user during an activity [16]. Many characteristics of VR/AVG play can contribute to user motivation and engagement, such as novelty, salient audiovisual graphics, interactivity, feedback, socialization, optimal challenge [14], extrinsic rewards, intrinsic curiosity or desire to improve in the game, goal-oriented tasks, and meaningful play [18].

Motivation and engagement are hypothesized to support motor learning either indirectly, through increased practice dosage leading to increased repetitive practice, or directly, via enhanced dopaminergic mechanisms influencing motor learning processes [1516]. Yet evidence is required to support these claims. A logical first step is to understand how these constructs are being measured within VR/AVG intervention studies. Several studies have used practice dosage or intensity as an indicator of motivation or engagement [192021]. To the authors’ knowledge, few have specifically evaluated the indirect mechanistic pathway by correlating measurement of patient motivation or engagement in VR/AVGs with practice dosage or intensity. While participants in VR/AVG studies report higher motivation as compared to conventional interventions [222324], conclusions regarding the relationship between motivation and intervention outcomes are limited by lack of consistency and rigour in measurement, including the use of instruments with poor psychometric properties [2223].

The body of research exploring the direct effects of engagement or motivation on motor learning is still in its infancy. Lohse et al. [16] were the first to evaluate whether a more audiovisually enriched as compared to more sterile version of a novel AVG task contributed to skill acquisition and retention in typically developing young adults, finding that participants who played under the enriching condition had greater generalized learning and complex skill retention. Self-reported engagement (User Engagement Scale; UES) was higher in the enriched group, but the only difference in self-reported motivation was in the Effort subscale of the Intrinsic Motivation Inventory (IMI), where the enriched group reported less effort as compared to the sterile group. The authors did not find a significant correlation between engagement, motivation and retention scores. A follow-up study using electroencephalography did not replicate the finding that the more enriched practice condition enhanced learning, it did show that more engaged learners had increased information processing, as measured by reduced attentional reserve [25].

Enjoyment, defined as ‘the state or process of taking pleasure in something’ [26], has less frequently been the subject of study in motor learning research, but has become popular as a way of describing patient interaction with VR/AVGs. Enjoyment may be hypothesized to be a precursor to both motivation and engagement. Given that the prevailing marketing of VR/AVGs is that they are ‘fun’ and ‘enjoyable’ [131427], it is important to evaluate its measurement in the context of other constructs.

Motivation, engagement and enjoyment in VR/AVGs may be influenced by the additional constructs of immersion and presence. Immersion is defined as “the extent to which the VR system succeeds in delivering an environment which refocuses a user’s sensations from the real world to a virtual world” [1328]. Immersion is considered as an objective construct referring to how the computational properties of the technology can deliver an illusion of reality through hardware, software, viewing displays and tracking capabilities [2930]. A recent systematic review [13] could not conclusively state effect of immersion on user performance. Immersion is distinct from presence, defined as the “psychological product of technological immersion” [31]. Presence is influenced by many factors, including the characteristics of the user, the VR/AVG task, and the VR/AVG system [28]. While presence is thought to be related to enhanced motivation and performance [32], relationships between this and other constructs of interest require exploration. Table 1 outlines definitions of constructs of interest to this scoping review.

Table 1

Construct definitions

Construct

Definition

Reference

Motivation

Motivation encourages action toward a goal by eliciting and/or sustaining goal-directed behavior.

[16]

Engagement

Engagement is a cognitive and affective quality or experience of a user during an activity.

[16]

Enjoyment

The state or process of taking pleasure in something.

[26]

Immersion

The extent to which the VR system succeeds in delivering an environment which refocuses a user’s sensations from the real world to a virtual world.

[1328]

Presence

The psychological product of technological immersion.

[31]

The purpose of this scoping review is to explore the impact of these affective constructs on motor learning after stroke. This greater understanding will enhance the clinical rationale for VR/AVG use and inform directions for subsequent research. Specifically, our objectives were to:

  1. 1.

    Describe how VR/AVG studies measure or report client enjoyment, motivation, engagement, immersion and presence.

  2. 2.

    Evaluate the extent to which motivation, enjoyment, engagement, immersion, and presence impact motor learning.

  3. 3.

    Propose directional relationships between enjoyment, motivation, engagement, immersion, presence and motor learning.

[…]

 

Continue —> What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 2Proposed relationships between the five constructs and motor learning

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[SlideShare] Theories of motor learning

Published on Apr 11, 2018

Motor learning is the understanding of acquisition and/or modification of movement. 
As applied to patients, motor learning involves the reacquisition of previously learned movement skills that are lost due to pathology or sensory, motor, or cognitive impairments. This process is often referred to as recovery of function. 

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[ARTICLE] The effect of virtual reality-based balance training on motor learning and postural control in healthy adults: a randomized preliminary study – Full Text

Abstract

Background

Adults with sedentary lifestyles seem to face a higher risk of falling in their later years. Several causes, such as impairment of strength, coordination, and cognitive function, influence worsening health conditions, including balancing ability. Many modalities can be applied to improve the balance function and prevent falling. Several studies have also recorded the effects of balance training in elderly adults for fall prevention. Accordingly, the aim of this study is to define the effect of virtual reality-based balance training on motor learning and postural control abilities in healthy adults.

Methods

For this study, ten subjects were randomly allocated into either the conventional exercise (CON) or the virtual reality (VR) group. The CON group underwent physical balance training, while the VR group used the virtual reality system 4 weeks. In the VR group, the scores from three game modes were utilized to describe the effect of motor learning and define the learning curves that were derived with the power law function. Wilcoxon Signed Ranks Test was performed to analyze the postural control in five standing tasks, and data were collected with the help of a force plate.

Results

The average score was used to describe the effect of motor learning by deriving the mathematical models for determining the learning curve. Additionally, the models were classified into two exponential functions that relied on the aim and requirement skills. A negative exponential function was observed in the game mode, which requires the cognitive-motor function. In contrast, a positive exponential function was found in the game with use of only the motor skill. Moreover, this curve and its model were also used to describe the effect of learning in the long term and the ratio of difficulty in each game. In the balance performance, there was a significant decrease in the center of pressure parameters in the VR group, while in the CON group, there was a significant increase in the parameters during some foot placements, especially in the medio-lateral direction.

Conclusion

The proposed VR-based training relies on the effect of motor learning in long-term training though different kinds of task training. In postural analysis, both exercise programs are emphasized to improve the balance ability in healthy adults. However, the virtual reality system can promote better outcomes to improve postural control post exercising.

Trial registration Retrospectively registered on 25 April 2018. Trial number TCTR20180430005

Electronic supplementary material

The online version of this article (10.1186/s12938-018-0550-0) contains supplementary material, which is available to authorized users.

Background

The incidence of falls can occur in people of all ages and is not exclusively restricted to the elderly population []. Although the causes of falls are different for each age group, the decline in balance ability is a major factor for the high risk of falls. In older people, the decline in balance ability may occur due to physiological deterioration, pathological factors, problems of ambulation, and endurance reduction []. In addition, the physical activity level of children and middle-aged adults has decreased due to the development of technology, which has resulted in restriction of movement. This has led to the worsening of health conditions due to the deterioration of the neurotransmitter system [] and muscle mass and strength [], giving rise to chronic diseases [] as well as cognitive decline [], which may induce a higher risk of falls in the future. People who suffer from these tend to get injured easily, which results in worsening of self-efficacy and functional dysfunction, even though they are disturbed by a small disturbance []. Increasing physical activity, such as exercise, has a positive effect on several aspects, including postural stability and falling prevention [].

Exercising is important, as it improves humans’ individual or systematic system, which is related to balance performance []. Exercises employ help prevent physiological deterioration by increasing strength and endurance of the body. For example, challenging the sensory system during postural tasks can enhance balance ability by reweighting the functional sensory inputs []. However, significant differences have been observed among various exercise programs, and some exercises have little effect on the balance function []. Balance exercise programs may be made ineffective because of several reasons. First, various physiological systems are used to achieve the postural task []. Second, the activities, which require balancing ability, can be achieved by coordinating between motor skills and cognitive activities []. Moreover, the training program with clinical guidelines is more effective than the program without any instruction []. Therefore, a combination of the exercise approach and the feedback during training process is used to improve the body’s functional ability, including balance performance [].

Using the gaming with the biofeedback system, such as the virtual reality (VR) system, is widely used for rehabilitation []. It is due to the fact that the VR system can make the treatment more interesting, reduce the difficulty of rehabilitation, and increase safety []. One advantage of VR-based training is that this technology allows altering the neural organization, encouraging neuroplastic changes in neurological patients [], reducing the fear of falling, and transferring into the real-world task through motor learning []. However, some VR-based balance training requires a specific balance platform, including Wii Fit balance board, to supply the sensory feedback information that may be restricted during the training process due to the requirement of a specific movement []. For this reason, popular sensors, e.g., the Microsoft Kinect sensor, have been used to show improvement in balance ability in several studies. This is due to the fact that Kinect sensor provides three-dimensional positions without using markers. These positions are used as input for the VR-system to improve balance function and reduce the fear of falling in older adults [].

In several studies, there were significant differences in clinical balance measures among participants who had trained with the help of conventional balance exercises, including the VR system []. Additionally, most studies focused on their applications in improving balance for patients with neurological disorders [] or elderly people []. Therefore, the aim of this study is to investigate the effects of VR-based balance training in healthy adults through motor learning and postural control. The questions included in the proposed study are (a) how does the VR-based balance exercise rely on the effect of motor learning? (b) how do the different exercise modalities influence the impairment of balance ability through comparison of balance performance before and after exercise? We hypothesize that the VR system affects postural control through motor learning. In addition, both balance exercise programs influence the postural control, but the balance performance in the VR-based balance exercise is better than the outcome of the conventional exercise.

Methods

Participants

The experiment in this study was designed as the pilot study. Community-dwelling healthy adults around the area of Mahidol University were recruited for the study. The inclusion criteria were (a) 40–60 years of age, (b) no history of injuries or diseases that influence balance function, (c) no intake of medications that affect postural control system, at least 12 h prior to the experiment, (d) no alcohol consumption 12 h prior to the experiment. The exclusion criteria were (a) individuals with dependent ambulation, (b) individuals who cannot communicate in the Thai language, and (c) individuals who have any disease that affects balance function.

Prior to data collection, all participants signed informed consent, which was approved by the Mahidol University Central Institutional Review Board (MU-IRB: 2014/112.1508). Demographic data and health information of the participants were obtained, following which they were randomly categorized into two groups, the virtual reality exercise (VR) group and the conventional balance exercise (CON) group, by blindly drawing a sealed piece of paper. The VR group (n = 5) received the dual-task virtual-reality balance training system (DTVRBT), while the CON group (n = 5) was assigned the conventional balance exercise.

Protocol

The experimental protocol comprised three steps: the pre-test of balance performance, the balance training session, and the post-test for the evaluation of the balance ability after training. In the study, five standing tasks, including standing unsupported with eyes open (EO) and close (EC) conditions, standing with both feet together, tandem, and one-leg stance were evaluated. Results of balance evaluation in each task were collected for 10 s/trial, with three trials, and the testing focused on the dominant leg in tandem and the one-leg stance. The total of time duration for data analysis was 30 s. In this study, the MatScan® model 3150 (Massachusetts, USA) was used to assess the center-of-pressure (CoP) in the anterior–posterior (AP) and medio-lateral (ML) directions with the sampling rate was 64 Hz. The data of each subject was exported with the Sway Analysis Module (SAM™). The training session started after 1 week of completion of the pre-test, and the post-test was performed within 1 week of finishing the training session. All participants received twelve 45-min sessions of training in the DTVRBT or the conventional balance exercise program. Moreover, three sessions were held per week for a period of 4 weeks. The same physical therapist conducted the training for both groups.

Dual-task virtual reality balance training system

The DTVRBT consists of a laptop and the Kinect sensor (Washington, USA) as shown in Fig. Fig.1.1. This sensor can construct 3D images from the functional integration of two components, an RGB camera and an infrared sensor []. The 3D information from this sensor allows users to interact with the object in the virtual environment. In this study, the virtual environment was created with the Unity3D® version 5.3.2. (San Francisco, USA).

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Fig. 1
The process of interaction in the virtual environment by the Kinect sensor

 […]

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[WEB SITE] The Newest Technology Impacting Physical Therapy – Virtual Reality

Digital technologies are increasingly becoming more important in the medical sphere every single day. Already, technologies like telemedicine have proven to be an effective method of treatment and has quickly gained in popularity over the years proving that technology can swiftly replace old systems with new, more efficient methods of treatment. Now, a new technology called Virtual Reality is coming into the therapy world and is changing it forever.
 
HOW IS VR IMPACTING PHYSICAL THERAPY?
Virtual Reality (VR) is now being used by physical therapists for the successful treatment of stroke victims, walking disorders and back pain. The technology has been shown to improve the patients motor learning and coordination skills by using gamified, immersive environments that have been created to help patients suffering from pain and injury relearn the use of their limbs in a way that is motivating and fun.
 
WHY IT MATTERS
Lets be honest, most times physical therapy can be a painful and overwhelming experience. With VR, the patient is able to experience a three-dimensional world surrounding their vision that is quite convincing to the sense’s. Many people report that they actually feel present in another environment, separate from reality. This is the element that aids in eliminating pain during exercises and encourages more repeat workouts. For example, if the patient was exercising their lower limbs, they would be able to appear as if they are walking on a beach or in a forest instead of on a boring treadmill. In another scenario, if the patient was exercising their upper extremities, then they could experience the thrill of being rewarded for successfully climbing up a mountain. Games like this provide motivation at home for the patient to continue exercising, enabling them with visual data on how they are improving their range of motion. These type of “experiences” help to keep the patient on the right path outside of the treatment room, which is a huge bonus because studies have shown that only 30% of exercises get accomplished after leaving rehabilitation.
 
 
What this will do to the therapy industry is still unknown but it is obvious that there is enormous potential for this technology to impact it in a large way.

 

via The Newest Technology Impacting Physical Therapy – Virtual Reality

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[Abstract] Robotic and Sensor Technology for Upper Limb Rehabilitation

Abstract

Robotic and sensor-based neurologic rehabilitation for the upper limb is an established concept for motor learning and is recommended in many national guidelines. The complexity of the human hands and arms and the different activities of daily living are leading to an approach in which robotic and sensor-based devices are used in combination to fulfill the multiple requirements of this intervention.

A multidisciplinary team of the Fondazione Don Carlo Gnocchi (FDG), an Italian nonprofit foundation, which spans across the entire Italian territory with 28 rehabilitation centers, developed a strategy for the implementation of robotic rehabilitation within the FDG centers. Using an ad hoc form developed by the team, 4 robotic and sensor-based devices were identified among the robotic therapy devices commercially available to treat the upper limb in a more comprehensive way (from the shoulder to the hand). Encouraging results from a pilot study, which compared this robotic approach with a conventional treatment, led to the deployment of the same set of robotic devices in 8 other FDG centers to start a multicenter randomized controlled trial. Efficiency and economic factors are just as important as clinical outcome.

The comparison showed that robotic group therapy costs less than half per session in Germany than standard individual arm therapy with equivalent outcomes. To ensure access to high-quality therapy to the largest possible patient group and lower health care costs, robot-assisted group training is a likely option.

 

via Robotic and Sensor Technology for Upper Limb Rehabilitation – ScienceDirect

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[TEDx Talks] A critical window for recovery after stroke – John Krakauer – Johns Hopkins University – YouTube

Δημοσιεύτηκε στις 8 Απρ 2015

Dr. John Krakauer, a Professor of Neurology and Neuroscience at Johns Hopkins University, co-founded the KATA project that combines concepts of neurology and neuroscience with interactive entertainment and motion capture technology to learn how lesions affect motor learning and to aid patients in recovering from brain injury.
Dr. John Krakauer is a Professor of Neurology and Neuroscience, the Director of the Center for the Study of Motor Learning and Brain Repair, and the Director of Brain, Learning, Animation, and Movement Lab (BLAM) at Johns Hopkins. He received his undergraduate and master’s degree from Cambridge University and earned his medical degree from Columbia University College of Physicians and Surgeons, where he was elected to Alpha Omega Alpha Medical Honor Society. His clinical and research expertise is in stroke, ischemic cerebrovascular disease, cerebral aneurysms, arteriovenous malformations, and venous and sinus thrombosis.
He co-founded the KATA project that combines concepts of neurology and neuroscience with interactive entertainment and motion capture technology to learn how lesions affect motor learning and to aid patients in recovering from brain injury.
This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at http://ted.com/tedx

 

via A critical window for recovery after stroke | John Krakauer | TEDxJohnsHopkinsUniversity – YouTube

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[Abstract] A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke

Background. Gait impairments after stroke arise from dysfunction of one or several features of the walking pattern. Traditional rehabilitation practice focuses on improving one component at a time, which may leave certain features unaddressed or prolong rehabilitation time. Recent work shows that neurologically intact adults can learn multiple movement components simultaneously.

Objective. To determine whether a dual-learning paradigm, incorporating 2 distinct motor tasks, can simultaneously improve 2 impaired components of the gait pattern in people posttroke.

Methods. Twelve individuals with stroke participated. Participants completed 2 sessions during which they received visual feedback reflecting paretic knee flexion during walking. During the learning phase of the experiment, an unseen offset was applied to this feedback, promoting increased paretic knee flexion. During the first session, this task was performed while walking on a split-belt treadmill intended to improve step length asymmetry. During the second session, it was performed during tied-belt walking.

Results. The dual-learning task simultaneously increased paretic knee flexion and decreased step length asymmetry in the majority of people post-stroke. Split-belt treadmill walking did not significantly interfere with joint-angle learning: participants had similar rates and magnitudes of joint-angle learning during both single and dual-learning conditions. Participants also had significant changes in the amount of paretic hip flexion in both single and dual-learning conditions.

Conclusions. People with stroke can perform a dual-learning paradigm and change 2 clinically relevant gait impairments in a single session. Long-term studies are needed to determine if this strategy can be used to efficiently and permanently alter multiple gait impairments.

via A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke – Kendra M. Cherry-Allen, Matthew A. Statton, Pablo A. Celnik, Amy J. Bastian, 2018

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[Abstract] A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke

Background. Gait impairments after stroke arise from dysfunction of one or several features of the walking pattern. Traditional rehabilitation practice focuses on improving one component at a time, which may leave certain features unaddressed or prolong rehabilitation time. Recent work shows that neurologically intact adults can learn multiple movement components simultaneously.

Objective. To determine whether a dual-learning paradigm, incorporating 2 distinct motor tasks, can simultaneously improve 2 impaired components of the gait pattern in people posttroke.

Methods. Twelve individuals with stroke participated. Participants completed 2 sessions during which they received visual feedback reflecting paretic knee flexion during walking. During the learning phase of the experiment, an unseen offset was applied to this feedback, promoting increased paretic knee flexion. During the first session, this task was performed while walking on a split-belt treadmill intended to improve step length asymmetry. During the second session, it was performed during tied-belt walking.

Results. The dual-learning task simultaneously increased paretic knee flexion and decreased step length asymmetry in the majority of people post-stroke. Split-belt treadmill walking did not significantly interfere with joint-angle learning: participants had similar rates and magnitudes of joint-angle learning during both single and dual-learning conditions. Participants also had significant changes in the amount of paretic hip flexion in both single and dual-learning conditions.

Conclusions. People with stroke can perform a dual-learning paradigm and change 2 clinically relevant gait impairments in a single session. Long-term studies are needed to determine if this strategy can be used to efficiently and permanently alter multiple gait impairments.

via A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke – Kendra M. Cherry-Allen, Matthew A. Statton, Pablo A. Celnik, Amy J. Bastian, 2018

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[Abstract] Combining functional electrical stimulation and mirror therapy for upper limb motor recovery following stroke: a randomised trial

Introduction: There is a growing need to develop effective rehabilitation interventions for people presenting with stroke as healthcare services experience ever-increasing pressures on staff and resources. The primary objective of this research is to examine the effect that mirror therapy combined with functional electrical stimulation has on upper limb motor recovery and functional outcome for a sample of people admitted to an inpatient stroke unit.

Methods: A total of 50 participants were randomised to one of three treatment arms; Functional Electrical Stimulation, Mirror therapy or a combined intervention of Functional Electrical Stimulation with Mirror therapy. Socio-demographic and health information was collected at recruitment together with admission dates, medical diagnoses and baseline measures. Blinded assessments were undertaken at baseline and at discharge post-stroke by a registered physiotherapist and a clinical nurse specialist.

Results: The Action Research Arm Test and the Fugl–Meyer Upper Extremity assessment revealed statistically superior results for Functional Electrical Stimulation compared with Mirror therapy alone (p = 0.03). There were no other significant differences between the three groups.

Conclusion: The theory of combining interventions requires further investigation and warrants further research. Combining current interventions may have the potential to enhance stroke rehabilitation, improve functional outcomes and help reduce the overall burden of stroke.

 

via Combining functional electrical stimulation and mirror therapy for upper limb motor recovery following stroke: a randomised trial: European Journal of Physiotherapy: Vol 0, No 0

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[ARTICLE] Combining Upper Limb Robotic Rehabilitation with Other Therapeutic Approaches after Stroke: Current Status, Rationale, and Challenges – Full Text

Abstract

A better understanding of the neural substrates that underlie motor recovery after stroke has led to the development of innovative rehabilitation strategies and tools that incorporate key elements of motor skill relearning, that is, intensive motor training involving goal-oriented repeated movements. Robotic devices for the upper limb are increasingly used in rehabilitation. Studies have demonstrated the effectiveness of these devices in reducing motor impairments, but less so for the improvement of upper limb function. Other studies have begun to investigate the benefits of combined approaches that target muscle function (functional electrical stimulation and botulinum toxin injections), modulate neural activity (noninvasive brain stimulation), and enhance motivation (virtual reality) in an attempt to potentialize the benefits of robot-mediated training. The aim of this paper is to overview the current status of such combined treatments and to analyze the rationale behind them.

1. Introduction

Significant advances have been made in the management of stroke (including prevention, acute management, and rehabilitation); however cerebrovascular diseases remain the third most common cause of death and the first cause of disability worldwide [16]. Stroke causes brain damage, leading to loss of motor function. Upper limb (UL) function is particularly reduced, resulting in disability. Many rehabilitation techniques have been developed over the last decades to facilitate motor recovery of the UL in order to improve functional ability and quality of life [710]. They are commonly based on principles of motor skill learning to promote plasticity of motor neural networks. These principles include intensive, repetitive, task-oriented movement-based training [1119]. A better understanding of the neural substrates of motor relearning has led to the development of innovative strategies and tools to deliver exercise that meets these requirements. Treatments mostly target the neurological impairment (paresis, spasticity, etc.) through the activation of neural circuits or by acting on peripheral effectors. Robotic devices provide exercises that incorporate key elements of motor learning. Advanced robotic systems can offer highly repetitive, reproducible, interactive forms of training for the paretic limb, which are quantifiable. Robotic devices also enable easy and objective assessment of motor performance in standardized conditions by the recording of biomechanical data (i.e., speed, forces) [2022]. This data can be used to analyze and assess motor recovery in stroke patients [2326]. Since the 1990s, many other technology-based approaches and innovative pharmaceutical treatments have also been developed for rehabilitation, including virtual reality- (VR-) based systems, botulinum neurotoxin (BoNT) injections, and noninvasive brain stimulation (NIBS) (Direct Current Stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS)). There is currently no high-quality evidence to support any of these innovative interventions, despite the fact that some are used in routine practice [27]. By their respective mechanisms of action, each of these treatments could potentiate the effects of robotic therapy, leading to greater improvements in motor capacity. The aim of this paper is to review studies of combined treatments based on robotic rehabilitation and to analyze the rationale behind such approaches.[…]

 

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