Posts Tagged physical rehabilitation

[Abstract] Applications of Head-Mounted Displays for Virtual Reality in Adult Physical Rehabilitation: A Scoping Review – Review


Importance: Head-mounted displays for virtual reality (HMD–VR) may be used as a therapeutic medium in physical rehabilitation because of their ability to immerse patients in safe, controlled, and engaging virtual worlds.

Objective: To explore how HMD–VR has been used in adult physical rehabilitation.

Data Sources: A systematic search of MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO, and ERIC produced 11,453 abstracts, of which 777 underwent full-text review.

Study Selection and Data Collection: This scoping review includes 21 experimental studies that reported an assessment or intervention using HMD–VR in a physical rehabilitation context and within the scope of occupational therapy practice.

Findings: HMD–VR was used for assessment and intervention for patients with a range of disorders, including stroke, multiple sclerosis, spinal cord injury, and Parkinson’s disease.

Conclusions and Relevance: HMD–VR is an emerging technology with many uses in adult physical rehabilitation. Higher quality clinical implementation studies are needed to examine effects on patient outcomes.

What This Article Adds: We review existing research on how immersive virtual reality (e.g., using head-mounted displays) has been used for different clinical populations in adult physical rehabilitation and highlight emerging opportunities in this field for occupational therapists.

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[Abstract] Remote Monitoring of Physical Rehabilitation of Stroke Patients using IoT and Virtual Reality


The statistics highlights that physical rehabilitation are required nowadays by increased number of people that are affected by motor impairments caused by accidents or aging. Among the most common causes of disability in adults are strokes or cerebral palsy. To reduce the costs preserving the quality of services new solutions based on current technologies in the area of physiotherapy are emerging. The remote monitoring of physical training sessions could facilitate for physicians and physical therapists’ information about training outcome that may be useful to personalize the exercises helping the patients to achieve better rehabilitation results in short period of time process. This research work aims to apply physical rehabilitation monitoring combining Virtual Reality serious games and Wearable Sensor Network to improve the patient engagement during physical rehabilitation and evaluate their evolution. Serious games based on different scenarios of Virtual Reality, allows a patient with motor difficulties to perform exercises in a highly interactive and non-intrusive way, using a set of wearable devices, contributing to their motivational process of rehabilitation. The system implementation, system validation and experimental results are included in the paper.


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[Abstract] Chronic post-stroke deficits in gross and fine motor control of the ipsilesional upper extremity


Individuals with stroke often experience contralesional and ipsilesional arm motor deficits.


Compare fine and gross motor hand dexterity of the ipsilesional hand post-stroke with controls, normative values, and the contralesional hand.


Data were collected from right-handed individuals with chronic stroke (n = 20), age/sex matched controls (n = 10), and normative values (n = 20) performing the Nine Hole Peg Test and the Box and Blocks Test.


Individuals with stroke demonstrated poorer performance with the ipsilesional arm relative to both the control group (mean difference [95% CI]: Nine Hole Peg Test (s): 3.4 [-0.5, 7.3]; Box and Blocks Test (# blocks): -12.3 [-20.3, -4.2]) and normative values (mean difference [95% CI]: Nine Hole Peg Test (s): 6.5 [4.0, 9.1]; Box and Blocks Test (# blocks): -15.3 [-20.1, -10.5]). Ipsilesional arm performance was significantly better than performance with the contralesional arm (mean difference [95% CI]: Nine Hole Peg Test (s): -9.4 [-20.2, 1.4]; Box and Blocks Test (# blocks): 33.2 [20.9, 45.5]).


These findings identify residual deficits in fine and gross dexterity of the ipsilesional hand in commonly used outcome measures of hand manipulation among individuals with chronic stroke. Possible underlying mechanisms and clinical relevance are discussed.


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[Abstract] Motor imagery as a complementary technique for functional recovery after stroke: a systematic review.


Background: Stroke is the leading cause of disability in adults, producing a major personal and economic impact on those affected. The scientific evidence regarding the use of Motor Imagery (MI) as a preparatory process for motor control reinforces the need to explore this method as a complement to physical therapy.

Objectives: The objectives of this systematic review were to determine the effectiveness of MI for functional recovery after stroke and to identify a possible intervention protocol, according to the level of existing scientific evidence.

Methods: A comprehensive literature search was performed using Medline, Cochrane Library and PEDro databases. Studies were limited to those published between 2007 and 2017, and restricted to English and/or Spanish language publications.

Results: Thirteen randomized clinical trials that met the inclusion criteria were included. The methodological quality of studies was determined using the Critical Review Form for Quantitative Studies, obtaining scores of 9-13 points out of 15. The level of evidence and strength of recommendations were assessed using the U.S. Preventive Services Task Force (USPSTF) assessment, obtaining levels IA and II-B1. Significant improvements were found in outcome measures evaluating upper limb functionality, balance and kinematic gait parameters.

Conclusions: The use of MI combined with conventional rehabilitation is an effective method for the recovery of functionality after stroke. Due to the great heterogeneity in the scientific literature available, new lines of research are necessary, in order to include well-designed studies of good methodological quality and to establish a consensus regarding the most appropriate protocols.


via Motor imagery as a complementary technique for functional recovery after stroke: a systematic review. – PubMed – NCBI

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[Abstract] A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.

Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.

Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.

Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.

  • Implications for Rehabilitation
  • Low-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.

  • Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.

  • Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.

  • The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.

via A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries: Disability and Rehabilitation: Vol 0, No 0

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[WEB SITE] These Friendly Helpful Robots Will Likely Be Your Future Rehabilitation Partners

A new study has revealed that socially assistive robots (SARs), though already in use, will continue to see a rise as they become more suited to human relations.

By  August, 20th 2018

From K5s who patrols our local streets and parking areas to a host of bots which serve as personal assistants at home and on the go, programmable machines are increasingly entering our lives in new and dynamic ways. Still, the challenge of integrating robotics into heavily human-dependent labor such as retail and medical assistance remains a challenge.

Rehabilitation robots

A multidisciplinarian team of researchers at Freiburg University assessed the potential impact of robots in the area of physical rehabilitation in the future. The study, led by Dr. Philipp Kellmeyer, a neuroscientist in the University’s Medical Center, and Prof. Dr. Oliver Müller, a professor from the philosophy department found that socially assistive robots (SARs), though already in use, by all indications will be used increasingly more.

As the world’s population continues to grow, and with improved medical procedures improving post-op recovery rates and extending people’s average lifespan, SAR demand will inevitably increase.

Beyond continuing the research and development process to improve the technical capabilities of these helpful bots, much attention, the team concluded, should be given to developing strategies for how to create a relationship between SARs and patients. Few of us, especially those who have gone through the pain and frustration involved in physical rehabilitation, would disagree that the rapport with a health services professional becomes the main factor in maintaining the patient’s motivation.

These Friendly Helpful Robots Will Likely Be Your Future Rehabilitation Partners
Source: RAPP

Are we setting the bar too high for SARs?

Though SARs still serve as assistants in the rehabilitation process, not the main role, it is still crucial to clearly define just what that role will be, and what it will look like throughout the rehabilitation process. This is key as SARs assist patients in three different areas: people with cognitive disabilities, people who require rehabilitation, and ageing or elderly patients.

In a previous study titled “The Grand Challenges in Socially Assistive Robotics”, a team of researchers classified the most important components for effective SAR design in six categories:

The robot’s physical embodiment (including physical, responsive and cultural aspects)

Personality, which is, in essence, the main factor in achieving successful human-robot interactions

Empathy, which is a relative concept, is central. The researchers shared from their observations: “Machines cannot feel empathy. However, it is possible to create robots that display overt signs of empathy. In order to emulate empathy, a robotic system should be capable of recognizing the user’s emotional state, communicating with people, displaying emotion, and conveying the ability of taking perspective.”

The relative level of engagement with patients, which includes verbal and non-verbal communication

Adaptation, which involves learning from an environment and quickly implementing lessons into the patient interaction.

Transfer, which focuses on long-term behavioral changes of the SAR.

Though by no means trying to build the perfect robots or a human replacement, due to the delicate nature of this work, it’s important for those involved in SAR design to continue to have discussions about small to significant ways to improve the patient experience.

With a title that truly gets to the heart of the matter, the study  “Social robots in rehabilitation: A question of trust” is published in the Science Robotics journal this month.

via These Friendly Helpful Robots Will Likely Be Your Future Rehabilitation Partners

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[VIDEO] NAO performs physical rehabilitation with CP and OBPP patients (P2) – YouTube

The patient is a male of 9 years old with Brachial Plexus Palsy and a degree of dystonia where muscle contractions cause him twisting and unintentional movements.

This video belongs to a set of evaluations of our autonomous robotic system in the Hospital Virgen del Rocio (Sevilla, Spain) while performing rehabilitation sessions with Cerebral Palsy (CP) and Obstetric Brachial Plexus Palsy (OBPP) patients.

Planning and Learning Group

More info Therapist:

via NAO performs physical rehabilitation with CP and OBPP patients (P2) – YouTube

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[Abstract] Virtual Reality Interventions for Personal Development: A Meta-Analysis of Hardware and Software


Virtual reality (VR) has been repeatedly applied for personal development purposes, ranging from learning and training (cognitive outcomes), to psychological therapies (emotional outcomes), to physical rehabilitation (physical outcomes). Several factors lead to a successful VR intervention, most notably the hardware and software. In the current article, a meta-analysis is performed to test the effect of specialized input hardware (e.g motion sensors, floor pads, etc.), advanced output hardware (i.e., head-mounted displays, surround-screen displays, etc.), and game elements (i.e., score, competition, etc.) across and within the three noted applications of VR intervention. When analyzing the overall effects, only game elements had a significant impact on outcomes. When analyzing specific applications, input hardware did not have a notable impact on outcomes for any application; output hardware had a notable impact on cognitive and emotional outcomes but not physical; and game elements had a notable impact on cognitive outcomes but not emotional or physical. From these results, the current article provides direct suggestions for future research and practice. Particularly, certain mediating mechanisms are suggested to explain the impact of output hardware and game elements on VR intervention outcomes, sparking possible new directions for research and practice. Copyright © 2018 Taylor & Francis Group, LLC

via Scopus preview – Scopus – Document details

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[BLOG POST] Physical rehabilitation after stroke – Evidently Cochrane

Physical rehabilitation after stroke

In this blog for stroke survivors, their families and clinical staff, Mark Smith, Consultant Physiotherapist in Stroke Rehabilitation, looks at Cochrane evidence on physical rehabilitation approaches for the recovery of function and mobility following stroke and explores the importance of the findings with respect to service delivery in an ever changing landscape of health and social care.

Stroke is often termed a “recovering neurological condition”, but how much recovery can we expect in response to what sorts of intervention and in what doses? Strokes happen as a result of a disturbance of the blood supply to the brain, mostly in older people and mostly due to the blocking of arteries supplying oxygenated blood to the brain. But less commonly, strokes can affect younger people (and children) and may also be the result of a burst blood vessel causing a haematoma (collection of blood) within the brain mass.

Acting FAST

The stroke “pathway” extends from the initial hyper-acute episode, usually the first minutes and hours post onset of symptoms in the community setting, emphasising that “time is brain” through the “FAST” (Face, Arm, Speech, Time to call 999) campaign supported by the main UK stroke charities, Stroke Association and Chest, Heart & Stroke Scotland. The aim is to deliver patients with a suspected stroke to appropriately specialist hospital/stroke unit care as soon as possible in order to receive life saving and disability reducing hyper-acute interventions such as thrombolysis (using clot-busting drugs) and more recently thrombectomy (breaking and removing the clot with tools) in patients who meet the necessary criteria.

ambulance emergency

This hyper-acute stage of the pathway is highly evidence-based, medicalised and thoroughly audited across the UK by the two main stroke audits – Sentinel Stroke National Audit Programme (SNNAP) in England and Wales, and the Scottish Stroke Care Audit (SSCA) in Scotland, with a view to time critical delivery to all eligible patients. However, the subsequent audit around rehabilitation interventions can be less thorough despite a growing body of evidence to support physical interventions.

Ongoing physical rehabilitation: what should we do?

Most patients with stroke will need some kind of ongoing physical rehabilitation to assist them in achieving best outcomes possible (with respect to the severity of the stroke but also with respect to the resource available) and we are increasingly becoming aware that there are some critical elements in achieving that. But can we, and do we, deliver what patients should receive in our publicly funded UK health and social care system and is the evidence sufficiently persuasive to argue strongly for this? How do we ensure that a health condition such as stroke which spans a pathway from the community through hyper-acute medical hospital care, possibly downstream in-patient rehabilitation and back to the community via health and social care is fit for purpose? And how do we remove the diagnostic stroke “badge” and simply allow an individual to function again in society with the support they need to manage their long term condition?

Perhaps there is a persuasive argument for delivering evidence-based stroke rehabilitation with appropriate levels of quality and intensity as it is considered a human right in many societies?

The evidence for physical rehabilitation after stroke

Evidence for physical interventions relating to walking and physical rehabilitation after stroke is becoming increasingly available in the form of high quality systematic reviews that can inform clinical guidelines as well as high level government strategy with respect to stroke. We tend to find it mostly relating to physical therapy and exercise/fitness interventions.

Updating Cochrane evidence: a novel approach

Pollock et al (2014a) revisited an older Cochrane Review (Pollock et al 2009). Previous versions of the review had focussed on physiotherapy interventions for the lower limb and walking after stroke but they decided to use a novel approach in the reappraisal of the literature and update of the evidence. The review was subsequently re-titled Physical Rehabilitation Approaches for the Recovery of Function, Balance and Walking following Stroke. The academic elements of reviewing papers followed the usual Cochrane protocol.

Seeking “real world” views on the evidence

In order to gauge the relevance of the evidence for clinical practice, but also critically for stroke survivors and carers, in parallel with revisiting the evidence through systematic review,co Pollock and colleagues also convened a multi key stakeholder short life working group comprised of stroke survivors, carers and clinical staff. This group was charged with sense-checking and “validating” the evidence as being clinically relevant as it emerged, using formal group consensus methods based on nominal group techniques. This involved a system of voting which focussed the group in reaching consensus. The academic researchers involved in the systematic review attended the working group meetings and presented the various options in directing the review, but did not vote themselves so as to minimise bias. This arm of the project culminated in a presentation at the 2014 Cochrane UK and Ireland Symposium, held in Manchester, in which key stakeholders in the review led a workshop on user-involvement in writing Cochrane Reviews. The dual aims of this work were to determine if physical treatment approaches are effective in the recovery of function and mobility in patients with stroke and to see whether any one physical treatment approach is more effective than any other approach.

The presentation of the updated evidence as a result

Ninety six studies, involving 10,401 stroke were included in the review (Pollock et al 2014a). Results of 27 studies (3243 stroke survivors) could be combined comparing physical rehabilitation with no treatment at all. Twenty five of these studies were carried out in China and were unusual in that they compared an active treatment/intervention group to a control group with no clinical intervention. Additional physical rehabilitation versus usual care was described in 12 of these studies demonstrating improved motor function (887 stroke survivors), standing balance (five studies, 246 stroke survivors) and walking speed (14 studies, 1126 stroke survivors). There was also limited evidence of dose intensity for the first time, with treatment durations given between 30 and 60 minutes per day apparently carrying the most significant benefits, but future research needs to verify this.

Key messages:

  • Physiotherapy, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. Treatment sessions of 30-60 minutes, 5-7 days a week may provide a significant beneficial effect.
  • No one approach to physical treatment is any more (or less) effective in promoting recovery of function and mobility after stroke.

Physiotherapists should use their expert clinical reasoning to select individualised, patient-centred, evidence-based physical treatment, with consideration of all available treatment components, and should not limit their practice to a single “named” approach.

physical rehabilitation

Fitness training after stroke

This work is supported by another recently updated Cochrane Review around Fitness Training for Stroke Survivors (Saunders et al 2016) which included 58 trials involving 2797 participants with stroke. These studies were grouped according to the type of fitness training intervention – cardiorespiratory (28 trials, 1408 participants) resistance (13 trials, 432 participants) and mixed training (17 trials, 4342 participants).

Key messages:

  • Cardiovascular fitness training, particularly involving walking, can improve exercise ability and walking after stroke.
  • Mixed training improves walking ability and improves balance.
  • Unable to draw reliable conclusions regarding effects on quality of life, mood or cognitive function.
  • No evidence of injury or other health problems and exercise appears to be a safe intervention.

Circuit Class Therapy

English et al (2017) included 17 trials involving 1297 stroke survivors (most of whom could walk 10 metres) in another recent Cochrane Rcoeview to examine the effectiveness and safety of Circuit Class Therapy (CCT) on mobility in adults with stroke. Ten studies (835 participants) measured walking capacity, demonstrating that CCT was superior to the comparison intervention, eight measured gait speed again finding that CCT was of significant benefit. Their conclusion was that there was moderate evidence to suggest that CCT is effective in improving mobility for people after stroke. These effects may be greater later after the stroke and stroke survivors may be able to walk further, faster, with more independence and confidence in their balance, but further high quality research is required.

Other relevant reviews

There have also been Cochrane Reviews providing low to moderate quality evidence of the rehabilitation benefits of electro mechanically or robotic assisted gait training devices (Mehrholz et al 2017a), treadmill training for stroke patients who could already walk (Mehrholz et al 2017b) and repetitive task training (French et al 2016). A Cochrane overview (a review of systematic reviews) presenting moderate quality evidence for upper limb rehabilitation after stroke, suggested beneficial effects of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice (Pollock et a. 2014b). Again, information was insufficient to reveal the relative effectiveness of different interventions.

So what…

Well, the research evidence, albeit largely of moderate quality, points to the efficacy of a broad range of interventions in the physical rehabilitation of people with stroke, with little detail about which specific interventions are of most value in which settings, and indeed the best delivery mechanisms to make them most easily and effectively implemented. More research is needed to generate higher quality evidence and implementation guidance. Recommendations in stroke guidelines (RCP 2016) and stroke strategies (Scottish Government 2014) have been made on the basis of these findings, particularly with respect to adequate dose. However, given that studies are disparate, have been derived from around the world and as a result conducted within a great variety of different healthcare (and social care/leisure) settings, it is challenging for clinicians to know exactly how to implement the reported findings.

The work of Pollock et al (2014) in engaging multi key stakeholders in making more “real” the findings of their systematic review made an effort to think about how we might implement the evidence, particularly in relation to the views of stroke survivors, carers and therapists. Perhaps we need to be less defensive of historical professional and service silo boundaries and use this evidence in the best interests of the stroke survivors we aim to serve, though imaginative use of commissioning mechanisms, third sector organisations, the leisure industry, healthcare staff resources and the capacity we have to deliver stroke rehabilitation interventions?

The World Health Organisation (WHO) has recently argued that the benefits of rehabilitation are realised beyond the health sector and that delivered appropriately can reduce care costs and enable participation in education and gainful employment (WHO 2017). With respect to the stroke pathway, if we are serious about saving lives at the “front door”, let’s also make them worth living at the “back door” and beyond.

Join in the conversation on Twitter with @CochraneUK #LifeAfterStroke or leave a comment on the blog.

References may be found here.

Mark Smith is a Trustee of the Stroke Association.


via Physical rehabilitation after stroke – Evidently Cochrane

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[Proceeding] Mobile, Exercise-agnostic, Sensor-based Serious Games for Physical Rehabilitation at Home – Full Text PDF

Serious games can improve the physical rehabilitation of patients with different conditions. By monitoring exercises and offering feedback, serious games promote the correct execution of exercises outside the clinic. Nevertheless, existing serious games are limited to specific exercises, which reduces their practical impact. This paper describes the design of three exercise-agnostic games, that can be used for a multitude of rehabilitation scenarios. The developed games are displayed on a smartphone and are controlled by a wearable device, containing inertial and electromyography sensors. Results from a preliminary evaluation with 10 users are discussed, together with plans for future work.

Full Text PDF

via Mobile, Exercise-agnostic, Sensor-based Serious Games for Physical Rehabilitation at Home

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