Stroke is the main cause of disability in adulthood. Recent advances in virtual reality (VR) technologies have led to its increased use in the rehabilitation of stroke patients. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to determine the effectiveness of game-based reality on upper limb (UL) motor function and quality of life after stroke. In March 2018, a search of the following databases was performed: PubMed, PEDro, Web of Science, Scopus, The Cochrane Library, and Medline at EBSCO. The selection criteria were all RCTs published in English or Spanish during the past 10 years. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 20 clinical trials were included in the systemic review, of which 15 contributed information to the meta-analysis. Favorable results were found for VR interventions on UL motor function (Fugl-Meyer Assessment for upper extremity, standardized mean difference [SMD] = 1.53, 95% CI [0.51–2.54]) and quality of life (functional independence measure, SMD = 0.77, 95% CI [0.05–1.49]). The results demonstrate the potential benefits of VR interventions on the recovery of UL motor function and on quality of life after stroke.
To investigate the risk of psychiatric disorders following TBI, and to clarify whether the post-TBI rehabilitation was associated with a lower risk of developing psychiatric disorders.
A register-based, retrospective cohort design
Using data from the National Health Insurance Research Database (NHIRD) of Taiwan, we established an exposed cohort with TBI and a nonexposed group without TBI matched by age and year of diagnosis between 2000 and 2015.
This study included 231,894 patients with TBI and 695,682 controls.
Rehabilitation therapies in TBI patients.
Main Outcome Measures
A multivariable Cox proportional hazards regression model was used to compare the risk of developing psychiatric disorders.
The incidence rate of psychiatric disorders was higher in the TBI group when compared with the control group. Compared with the control group, the risk of psychiatric disorders in the TBI group was twofold (HR=2.056, 95% CI:1.940- 2.172, p < 0.001). Among the TBI subjects, 49,270 (21.25%) had received rehabilitation therapy and had a lower risk of psychiatric disorders (HR=0.691, 95% CI: 0.679-0.703, p < 0.001). In the subgroup analysis, the medium- to high-level intensity rehabilitation therapy was associated with lower risks of psychiatric disorder (HR=0.712 and 0.568, respectively), but there was no significant finding in the low-intensity group.
We found that TBI was associated with a high risk for developing psychiatric disorders, and that the post-TBI rehabilitation significantly reduced the risk of psychiatric disorders in a dose-dependent manner.
The latest Physiopedia MOOC is up and running today!
If you’re new to the term MOOC it is an acronym for Massive Online Open Course and each year Physiopedia has one for you to take part in for free. The courses Physiopedia have hosted have been hugely successful and have covered a diverse range of topics. This year the topic is Traumatic Brain Injury and it starts today!
The 2019 MOOC aims to provide a basic theoretical understanding of the management of traumatic brain injury in order to equip physiotherapists with sufficient knowledge to manage a person following a traumatic brain injury. This includes assessing impairments, activity limitations and participation restrictions, setting appropriate goals of treatment, formulating an evidence-based treatment plan, implementing treatment and evaluating its success.
Check out the video below to find out more!
How Do I Sign Up?
This is a completely online course which will take place in Physiopedia’s complimentary e-learning platform Physioplus. You will need need to set up a FREE trial account to access the course, you can do that here. The course will become available on the Physioplus site on 21 October 2019, we place the link at the top of this page and also email it to you. If you’d like to know more about the course check out some more details on the PP page dedicated to the MOOC.
Tired of using dumbbells for rehabilitation following distal radius fractures? Looking for new interventions to increase client engagement? Look no further than your patient’s smartphone! Incorporate it into exercise routines to help your patients regain wrist balance and to provide proprioceptive input.
Evidence Supports Proprioceptive Activities
Emerging evidence supports the use of proprioceptive activities for distal radius fracture rehabilitation.1A cross-sectional study involving females treated operatively and non-operatively for a distal radius fracture found that participants had significantly less joint position sense in comparison to study controls.2 The proprioceptive limitations correlated highly with functional impairment on the Patient Rated Wrist Evaluation.3
By addressing proprioceptive deficits while encouraging functional wrist range of motion, smartphone applications complement a traditional hand therapy program for individuals requiring skilled therapy following a distal radius fracture.
Some games to consider:
Chopper Lite – Action packed side-scrolling helicopter game where a tilt of the screen flies the chopper.
Labyrinth – Classic labyrinth game in which you must guide a ball through a labyrinth by moving your device.
Tilt Maze Lite – Maze game where a tilt of your device helps a marble through a maze toward the exit. Use different mazes to test wrist balance and timing. The game stores the player’s best time for each maze so patients can track their performance as their wrist heals.
Water Slide Extreme – Unique water slide game featuring tight corners and huge loops that you must navigate by twisting or leaning your device.
Snail Mail – Kart-style racing game in which the player controls a racing snail on a mission to collect packages and deliver them to the farthest reaches of the universe while dodging obstacles such as laser towers, slugs, asteroids, and salt.
The clinician should consider using smartphones as an intervention following distal radius fractures. Skilled hand therapists can assist with appropriate postural mechanics and provide guidelines for the amount of time a patient should devote to gaming.
Rehabilitation at Your Fingertips
Certain smartphone applications can be used to address client-specific deficits, decrease functional concerns, and achieve client-centered goals. Incorporating smartphone gaming in hand therapy may provide motivation and convenience to your clients.
Kristin Valdes, OTD, OT, CHT, is the owner and director of Hand Works Therapy in Sarasota, Florida. She is an associate professor at Gannon University and has been in private practice for over twenty years, specializing in the treatment and rehabilitation of the upper extremity. Her clinical expertise includes treatment of the hand, wrist, elbow, shoulder, splinting, and arthritis. Dr. Valdes has published articles in the Journal of Hand Therapy, Hand, Journal of Manipulative and Physiological Therapeutics, and the Journal of Physical Therapy Science. She serves as a member of the Board of the American Society of Hand Therapists and American Association of Hand Surgery.Dr. Valdes has published chapters on hand, elbow, and shoulder fractures and dislocations in Advanced Concepts of Hand Pathology and Surgery. She is an assistant editor of the Journal of Hand Therapy. Dr. Valdes received her OTD degree with a specialization in hand rehabilitation from Rocky Mountain University of Health Care Professions in Provo, Utah. Dr Valdes is member of the Guatemala Healing Hands Medical Mission.
Algar, L., & Valdes, K. (2014). Using smartphone applications as hand therapy interventions. Journal of Hand Therapy, 27(3), 254–257. doi:10.1016/j.jht.2013.12.009
Karagiannopoulos, C., Sitler, M., Michlovitz, S., & Tierney, R. (2014a). A Descriptive Study on Wrist and Hand Sensori-Motor Impairment and Function Following Distal Radius Fracture Intervention. Journal of Hand Therapy, 27(3), e2–e3. doi:10.1016/j.jht.2013.08.006
Virtual reality has plenty of applications for fitness — you’re here, so you already know that. However, it is increasingly becoming a tool for rehabilitation, as well. Neuro Rehab VR aims to make physical therapy more enjoyable, and it promises to help patients more than traditional physical therapy.
Making physical therapy fun
With only about one-third of patients fully adhering to their rehabilitation plans, Neuro Rehab VR’s goal was to create a platform that was more engaging without making things more cumbersome. During the early days of the Oculus Rift, with its many sensors, that was not possible.
This was made possible with the Oculus Quest, which eliminated the need for extra equipment or wires. Neuro Rehab VR provides several different exercise applications that run patients through less-abstract goals, such as going grocery shopping. The applications are available for the entire body, and also include sports and combat.
In addition to being more interesting, VR physical therapy can have more effective results. Because of the brain’s neuroplasticity, Neuro Rehab VR says playing games can establish better connections in the brain as you work toward concrete goals. This can, in turn, lead to more complete recovery. Neuro Rehab VR is partnered with Fort Worth’s Neurological Recovery Center. It has dealt with patients of spinal injuries, brain injuries, strokes, and multiple sclerosis. The team decided to expand and make its systems available elsewhere after seeing its success.
Neuro Rehab VR believes its systems can work not only in hospitals, but also for in-home recovery. The low cost of the Quest itself makes it affordable for rental or purchase by the patient. Therapists can see every movement patients make to determine if they are doing exercises correctly. Once the patient is feeling better, they’ll still have a device capable of helping them stay fit from within their home.
Study investigated the effects of an 8-week rehabilitation exercise program combined with soymilk ingestion immediately after exercise on functional outcomes in chronic stroke patients.
Twenty-two stroke patients were randomly allocated to either the soymilk or the placebo (PLA) group and received identical 8-weeks rehabilitation intervention (3 sessions per week for 120 minutes each session) with corresponding treatment beverages. The physical and functional outcomes were evaluated before, during, and after the intervention. The 8-week rehabilitation program enhanced functional outcomes of participants.
The immediate soymilk ingestion after exercise additionally improved hand grip strength, walking speed over 8 feet, walking performance per unit lean mass, and 6-Minute Walk Test performance compared with PLA after the intervention. However, the improvements in the total score for Short Physical Performance Battery and lean mass did not differ between groups.
This study demonstrated that, compared with rehabilitation alone, the 8-week rehabilitation program combined with immediate soymilk ingestion further improved walking speed, exercise endurance, grip strength, and muscle functionality in chronic stroke patients.
Transcutaneous electrical stimulation (TENS) delivered alongside standard physical therapies could reduce spasticity in the lower limbs following a stroke.
Spasticity is a muscle control disorder characterised by tight muscles. It is common after stroke and accounts for significant disability. TENS is often used to treat pain and can affect nervous stimulation of the muscles.
The main evidence in this systematic review came from five trials which suggested that TENS combined with other physical therapies has moderate effect on lower limb spasticity compared with placebo.
The review has limitations, with small studies and little evidence on use for upper limbs or comparing with other therapies. However, TENS machines are portable, inexpensive and widely accessible making them an appealing addition to other care.
NICE does not currently recommend the use of TENS in stroke rehabilitation, though guidance covers use of other types of electrical stimulation in certain other contexts.
Why was this study needed?
More than 1.2 million people in the UK are living with the effects of stroke. About two-thirds of stroke survivors leave hospital with residual disability and one quarter experience spasticity.
Electrical stimulation is sometimes used as treatment after a stroke. It includes functional electrical stimulation and neuromuscular electrical stimulation, which both focus on muscle contraction. Transcutaneous electrical stimulation (TENS) targets the sensory nerves in a different way.
Transcutaneous electrical stimulation has been suggested as an adjunct to other rehabilitation therapy to try and reduce spasticity. The device is portable and can be self-administered at home, so its potential for managing spasticity is appealing.
There have been a number of small studies of TENS with conflicting results. This review aimed to combine the results to see if there was evidence for its use to treat spasticity after stroke.
What did this study do?
This systematic review identified 15 studies (10 randomised controlled trials) reporting the effectiveness of TENS on spasticity after stroke.
Studies compared TENS, used alone or alongside other therapies such as functional exercises, with placebo, no treatment or other treatments. Thirteen studies assessed lower limb spasticity, with 11 targeting the ability to flex the foot. Most assessed use in the chronic rather than acute phase of stroke.
Transcutaneous electrical stimulation regimen varied widely. Intervention periods ranged from one day to 12 weeks, the number of TENS sessions from one to seven per week, and the duration of sessions ranged from less than 20 minutes up to 60 minutes.
Trials were small with maximum participant size 80. The quality of randomised controlled trials was good overall, with lack of participant blinding being the most likely source of bias. Seven trials were pooled in meta-analysis.
What did it find?
Transcutaneous electrical stimulation used alongside other physical therapies was moderately effective in reducing spasticity in the lower limbs compared with placebo (standard mean difference [SMD] -0.64, 95% confidence interval [CI] -0.98 to -0.31). This was from meta-analysis of five trials (221 adults) with broadly similar results.
Pooled results of two trials (60 adults) also found that TENS alongside other physical therapies was more effective at reducing spasticity than no TENS (SMD -0.83, 95% CI -1.51 to -0.15).
Five studies assessed longer-term effects on spasticity. Three studies found the effects were maintained for a period of two to five weeks whilst two studies found the effects lasted for less than a day and that spasticity returned to baseline levels immediately following the intervention.
None of the studies reported any adverse effects of TENS.
What does current guidance say on this issue?
The NICE guideline on stroke rehabilitation (2013) does not currently include recommendations for use of TENS. NICE advises against the routine use of electrical stimulation for the hand and arm but suggests a trial of treatment may be considered if there is sign of muscle contraction, and the person cannot move their arm against resistance.
NICE guidance from 2009 advises that there is sufficient evidence that functional electrical stimulation can improve walking in people with drop foot following a stroke, provided the normal arrangements are in place for clinical governance, consent and audit.
What are the implications?
This review suggests that TENS, when delivered alongside other physical therapies, could be considered for lower limb spasticity as part of a stroke rehabilitation programme.
The findings are similar to a 2015 systematic review which found that electrical stimulation gave small but significant improvements in spasticity following stroke. Again this earlier review was limited by small sample sizes, varied treatment regimens and few studies that could be pooled in meta-analysis.
There was insufficient evidence to support use for upper limbs.
Cost was not assessed, but TENS is a non-invasive therapy and devices are widely available and could easily be used at home.
Physical therapists often creatively use virtual reality (VR) gaming systems in rehabilitation for patients with neurological deficits. However, therapists need to be aware of what games are applicable to their patient population, as well as how the virtual environment affects patients’ perception of their motion. This study investigated how the game Google Tilt Brush, a 3D painting environment offered on the HTC Vive, could be applied in post-stroke upper limb rehabilitation, and explored limitations of the system through measuring reach distance of healthy subjects. Nine healthy subjects were recruited and asked to perform various reaching and drawing tasks while data on their movement was gathered using a Vicon motion capture system. The data showed that while in simple reaching tasks individual subjects may alter their reach distance by up to 3 cm in the virtual environment, across all subjects there is not a statistically significant change. Moreover, in more complicated drawing tasks, participants could reliably reach to particular points, but most participants missed the exact target by several centimeters. Overall, it seems that the HTC Vive and Google Tilt Brush can be utilized in post-stroke upper limb rehabilitation if therapists monitor patients to ensure they are accomplishing the desired movement.
Purpose: To evaluate the effectiveness of the Bobath concept in sensorimotor rehabilitation after stroke.
Materials and methods: A systematic literature review was conducted on the Bobath concept from the first publication available to January 2018, consulting PUBMED, CENTRAL, CINAHL and PEDro databases. Fifteen clinical trials were selected in two consecutive screenings. Two independent researchers rated the studies according to the PEDro scale from which a best evidence synthesis was derived to determine the strength of the evidence.
Results: The Bobath concept is not more effective than other approaches used in post-stroke rehabilitation. There is moderate evidence for the superiority of other therapeutic approaches such as forced use of the affected upper limb and constraint-induced movement therapy for motor control of the upper limb.
Conclusions: The Bobath concept is not superior to other approaches for regaining mobility, motor control of the lower limb and gait, balance and activities of daily living of patients after stroke. There is moderate evidence regarding the superior results of other approaches in terms of the motor control and dexterity of the upper limb. Due to the limitations concerning the methodological quality of the studies, further well-designed studies are needed.
Implications for rehabilitation
The Bobath concept is not superior to other approaches for patients after stroke.
The treatments that incorporate overuse of the affected upper limb via intensive treatments with high-repetitions with or without robotic aids present greater effectiveness in the motor control of the upper limb and dexterity.
The Cochrane Database of Systematic Reviews is widely considered the “gold standard” for health care professionals who want to know what current, high-quality research says about the efficacy of various interventions. But when it comes to physical therapy, a “researcher or clinician would not necessarily be able to turn to [Cochrane reviews] for a definitive answer” on a treatment strategy, write authors of an article in the International Journal of Rehabilitation Research (abstract only available for free).
Reviewers for the Cochrane Collaboration—an international network of subject-matter groups that produces evidence-based resources—are known for their systematic analysis of evidence obtained from randomized clinical trials and provide recommendations for specific interventions. Like any systematic review, Cochrane reviews (CRs) are based on the existing research, and randomized controlled trials vary in quality.
For the Rehabilitation Research study, a multidisciplinary group of researchers in Japan turned to physical therapy to find out what CRs had to say about various interventions. They examined 283 CRs to evaluate just how conclusive the evidence is with regard to physical therapy, as well as what factors influence the degree of conclusiveness.
Authors classified a CR as “conclusive” if it identified a particular intervention as “superior to another” or found that interventions are “equivalent.” Inconclusive reviews concluded that “no decision can be made.”
While the authors acknowledge that CRs “often show a lack of strong evidence for the efficacy of a particular treatment or strategy,” they found that an overwhelming majority of reviews related to physical therapy—94.3%—were inconclusive and recommended further study, a rate higher than in many other areas of study. Reviews that evaluated a larger number of trials or included greater total numbers of patients were more likely to list conclusive results; still, even among CRs with conclusive results, 68.8% recommended further study.
According to the authors, many factors were associated with recommendations for further research, including low-quality study design, small sample sizes, too few available studies, and not enough data on participant subgroups or on adverse effects.
“The low proportion of conclusive studies may be attributable to the poor quality of evidence” in physical therapy, the authors write, noting, however, that, unlike other areas of study, blinded randomized controlled trials are “often hard to achieve” in physical therapy research.
Authors emphasized that although inconclusive reviews cannot assist in clinical decision making, “high-quality inconclusive reviews…are of great value” to identify gaps in the literature and areas for further study.
And while there’s much work to be done to increase the number of physical therapy-related CRs with conclusive recommendations, authors think the effort is worthwhile—and timely.
“Trials in physiotherapy are worth conducting, as the field is positioned as a new frontier and is receiving much attention,” they write. “Future research in physiotherapy and further development of the [Cochrane Collaboration] are eagerly awaited.”
Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.