Posts Tagged Motor training
[ARTICLE] Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke? – Full Text HTML
Motor-training software on tablets or smartphones (Apps) offer a low-cost, widely-available solution to supplement arm physiotherapy after stroke. We assessed the proportions of hemiplegic stroke patients who, with their plegic hand, could meaningfully engage with mobile-gaming devices using a range of standard control-methods, as well as by using a novel wireless grip-controller, adapted for neurodisability. We screened all newly-diagnosed hemiplegic stroke patients presenting to a stroke centre over 6 months. Subjects were compared on their ability to control a tablet or smartphone cursor using: finger-swipe, tap, joystick, screen-tilt, and an adapted handgrip. Cursor control was graded as: no movement (0); less than full-range movement (1); full-range movement (2); directed movement (3). In total, we screened 345 patients, of which 87 satisfied recruitment criteria and completed testing. The commonest reason for exclusion was cognitive impairment. Using conventional controls, the proportion of patients able to direct cursor movement was 38–48%; and to move it full-range was 55–67% (controller comparison: p>0.1). By comparison, handgrip enabled directed control in 75%, and full-range movement in 93% (controller comparison: p<0.001). This difference between controllers was most apparent amongst severely-disabled subjects, with 0% achieving directed or full-range control with conventional controls, compared to 58% and 83% achieving these two levels of movement, respectively, with handgrip. In conclusion, hand, or arm, training Apps played on conventional mobile devices are likely to be accessible only to mildly-disabled stroke patients. Technological adaptations such as grip-control can enable more severely affected subjects to engage with self-training software.
The most important intervention shown to improve physical function after stroke is repetitive, task-directed exercises, supervised by a physiotherapist, with higher intensity leading to faster and greater recovery. In practice, access to physiotherapy is significantly limited by resource availability . For example, 55% of UK stroke in-patients receive less than half the recommended physiotherapy time of 45 minutes per day.
One solution to inadequate physiotherapy is robotic technology, that enables patients to self-practice, with mechanical assistance, via interaction with adapted computer games. While a range of rehabilitation robotics have been marketed over the last decade, and shown to be efficacious, they are not widely used due to factors such as high-cost (typically, $10,000–100,000), cumbersome size, and restriction to patients with high baseline performance, and who have access to specialist rehabilitation centres.
An alternative approach to self-rehabilitation, are medical applications (Apps), or gaming software, run on mobile media devices e.g. tablets or smartphones. Because such devices are low-cost ($200–500), and ubiquitous, they have the potential to democratize computerized-physiotherapy, especially in under-resourced settings, e.g. chronically-disabled in the community. Furthermore, their portability enables home use, while their employment of motivational gaming strategies can potentiate high-intensity motor practice. Accordingly, increasing numbers of motor-training Apps for mobile devices have been commercialised in recent years, and clinical trials are under way. However, since these devices are designed for able-person use, it is questionable as to how well disabled people can access them, and engage meaningfully and repeatedly with rehabilitation software.
This study assesses the degree of motor interaction that can be achieved by hemiplegic stroke patients using four types of conventional hand-control methods (finger swipe, tap, joystick and tilt) for mobile devices. An adapted controller of the same mobile devices, whose materials cost ~$100, was evaluated alongside. Since the latter interface exploits the fact that handgrip is relatively spared in stroke hemiplegia, and is sensitive to subtle forces, we expected that this would increase the range of arm-disability severities able to achieve meaningful computer-game control. In order to assess motor control, with minimal cognitive confounding (given that many softwares also have cognitive demands), we used a simple 1-dimensional motor assessment for all controller types.
[Abstract] Nerve Stimulation Enhances Task-Oriented Training in Chronic, Severe Motor Deficit After Stroke. A Randomized Trial
Background and Purpose— A sensory-based intervention called peripheral nerve stimulation can enhance outcomes of motor training for stroke survivors with mild-to-moderate hemiparesis. Further research is needed to establish whether this paired intervention can have benefit in cases of severe impairment (almost no active movement).
Methods— Subjects with chronic, severe poststroke hemiparesis (n=36) were randomized to receive 10 daily sessions of either active or sham stimulation (2 hours) immediately preceding intensive task-oriented training (4 hours). Upper extremity movement function was assessed using Fugl–Meyer Assessment (primary outcome measure), Wolf Motor Function Test, and Action Research Arm Test at baseline, immediately post intervention and at 1-month follow-up.
Results— Statistically significant difference between groups favored the active stimulation group on Fugl–Meyer at postintervention (95% confidence interval [CI], 1.1–6.9; P =0.008) and 1-month follow-up (95% CI, 0.6–8.3; P =0.025), Wolf Motor Function Test at postintervention (95% CI, −0.21 to −0.02; P =0.020), and Action Research Arm Test at postintervention (95% CI, 0.8–7.3; P =0.015) and 1-month follow-up (95% CI, 0.6–8.4; P =0.025). Only the active stimulation condition was associated with (1) statistically significant within-group benefit on all outcomes at 1-month follow-up and (2) improvement exceeding minimal detectable change, as well as minimal clinically significant difference, on ≥1 outcomes at ≥1 time points after intervention.
Conclusions— After stroke, active peripheral nerve stimulation paired with intensive task–oriented training can effect significant improvement in severely impaired upper extremity movement function. Further confirmatory studies that consider a larger group, as well as longer follow-up, are needed.
[Abstract] Plasticity and Reorganization in the Rehabilitation of Stroke. The Constraint-Induced Movement Therapy (CIMT) Example
Abstract. This paper outlines some actual developments in the behavioral treatment and rehabilitation of stroke and other brain injuries in post-acute and chronic conditions of brain lesion. It points to a number of processes that demonstrate the enormous plasticity and reorganization capacity of the human brain following brain lesion. It also highlights a series of behavioral and neuroscientific studies that indicate that successful behavioral rehabilitation is paralleled by plastic changes of brain structures and by cortical reorganization and that the amount of such plastic changes is obviously significantly determining the overall outcome of rehabilitation.
[Abstract] Ipsilesional anodal tDCS enhances the functional benefits of rehabilitation in patients after stroke.
Stimulating motor recovery in stroke
Rehabilitation of movement after stroke requires repeated practice and involves learning and brain changes. In a new study, Allman et al. tested whether delivering brain stimulation during a 9-day course of hand and arm training improved movement in patients after stroke. The authors found greater improvements in movement in patients who received real compared to sham (placebo) brain stimulation. Better scores in patients who received real stimulation were still present 3 months after training ended. These findings suggest that brain stimulation could be added to rehabilitative training to improve outcomes in stroke patients.
Anodal transcranial direct current stimulation (tDCS) can boost the effects of motor training and facilitate plasticity in the healthy human brain. Motor rehabilitation depends on learning and plasticity, and motor learning can occur after stroke.
We tested whether brain stimulation using anodal tDCS added to motor training could improve rehabilitation outcomes in patients after stroke. We performed a randomized, controlled trial in 24 patients at least 6 months after a first unilateral stroke not directly involving the primary motor cortex. Patients received either anodal tDCS (n = 11) or sham treatment (n = 13) paired with daily motor training for 9 days. We observed improvements that persisted for at least 3 months post-intervention after anodal tDCS compared to sham treatment on the Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT) but not on the Upper Extremity Fugl-Meyer (UEFM) score.
Functional magnetic resonance imaging (MRI) showed increased activity during movement of the affected hand in the ipsilesional motor and premotor cortex in the anodal tDCS group compared to the sham treatment group. Structural MRI revealed intervention-related increases in gray matter volume in cortical areas, including ipsilesional motor and premotor cortex after anodal tDCS but not sham treatment. The addition of ipsilesional anodal tDCS to a 9-day motor training program improved long-term clinical outcomes relative to sham treatment in patients after stroke.
A rehabilitation device, comprising a movement element capable of controlling at least one motion parameter of a portion of a patient; a brain monitor which generates a signal indicative of brain activity; and circuitry including a memory having stored therein rehabilitation information and which inter-relates said signal and movement of said movement element as part of a rehabilitation process which utilizes said rehabilitation information.
[ARTICLE] The application of virtual reality in neuro-rehabilitation: motor re-learning supported by innovative technologies – Full Text PDF
The motor function impairment resulting from a stroke injury has a negative impact on autonomy, the activities of daily living thus the individuals affected by a stroke need long-term rehabilitation. Several studies have demonstrated that learning new
motor skills is important to induce neuroplasticity and functional recovery.
Innovative technologies used in rehabilitation allow one the possibility to enhance training throughout generated feedback. It seems advantageous to combine traditional motor rehabilitation with innovative technology in order to promote motor re-learning and skill re-acquisition by means of enhanced training.
An environment enriched by feedback involves multiple sensory modalities and could promote active patient participation. Exercises in a virtual environment contain elements necessary to maximize motor learning, such as repetitive and differentiated task practice and feedback on the performance and results. The recovery of the limbs motor function in post-stroke subjects is one of the main therapeutic aims for patients and physiotherapist alike.
Virtual reality as well as robotic devices allow one to provide specific treatment based on the reinforced feedback in a virtual environment (RFVE), artificially augmenting the sensory information coherent with the real-world objects and events. Motor training based on RFVE is emerging as an effective motor learning based techniques for the treatment of the extremities.
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Abstract. We present ReHoblet; a physical rehabilitation game on tablets, designed to be used in a residential setting. ReHoblet trains two gross motor movements of the upper limbs by lifting (up-down) and transporting (leftright) the tablet to control a simple platform game. By using its accelerometers and gyroscope, the tablet is capable of detecting movements made by the user and steer the interaction based on this data. A formative evaluation with five Multiple Sclerosis (MS) patients and their therapists showed high appreciation for ReHoblet. Patients stated they liked ReHoblet not only to improve their physical abilities, but to train on performing technology-related tasks. Based on the results, we reflect on tablet-based games in home-based rehabilitation…