Posts Tagged rehabilitation

[Abstract] Portable and Reconfigurable Wrist Robot Improves Hand Function for Post-Stroke Subjects  

Abstract:

Rehabilitation robots have become increasingly popular for stroke rehabilitation. However, the high cost of robots hampers their implementation on a large scale. This study implements the concept of a modular and reconfigurable robot, reducing its cost and size by adopting different therapeutic end effectors for different training movements using a single robot. The challenge is to increase the robot’s portability and identify appropriate kinds of modular tools and configurations. Because literature on the effectiveness of this kind of rehabilitation robot is still scarce, this paper presents the design of a portable and reconfigurable rehabilitation robot and describes its use with a group of post-stroke patients for wrist and forearm training. Seven stroke subjects received training using a reconfigurable robot for 30 sessions, lasting 30 minutes per session. Post-training, statistical analysis showed significant improvement of 3.29 points (16.20%, p = 0.027) on the Fugl-Meyer Assessment Scale for forearm and wrist components (FMA-FW). Significant improvement of active range of motion (AROM) was detected in both pronation-supination (75.59%, p = 0.018) and wrist flexion-extension (56.12%, p = 0.018) after the training. These preliminary results demonstrate that the developed reconfigurable robot could improve subjects’ wrist and forearm movement.

Source: Portable and Reconfigurable Wrist Robot Improves Hand Function for Post-Stroke Subjects – IEEE Xplore Document

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[REVIEW] Interactive wearable systems for upper body rehabilitation: a systematic review – Full Text PDF

Abstract

Background: The development of interactive rehabilitation technologies which rely on wearable-sensing for upper body rehabilitation is attracting increasing research interest. This paper reviews related research with the aim: 1) To inventory and classify interactive wearable systems for movement and posture monitoring during upper body rehabilitation, regarding the sensing technology, system measurements and feedback conditions; 2) To gauge the wearability of the wearable systems; 3) To inventory the availability of clinical evidence supporting the effectiveness of related technologies.

Method: A systematic literature search was conducted in the following search engines: PubMed, ACM, Scopus and IEEE (January 2010–April 2016).

Results: Forty-five papers were included and discussed in a new cuboid taxonomy which consists of 3 dimensions: sensing technology, feedback modalities and system measurements. Wearable sensor systems were developed for persons in: 1) Neuro-rehabilitation: stroke (n = 21), spinal cord injury (n = 1), cerebral palsy (n = 2), Alzheimer (n = 1); 2) Musculoskeletal impairment: ligament rehabilitation (n = 1), arthritis (n = 1), frozen shoulder (n = 1), bones trauma (n = 1); 3) Others: chronic pulmonary obstructive disease (n = 1), chronic pain rehabilitation (n = 1) and other general rehabilitation (n = 14). Accelerometers and inertial measurement units (IMU) are the most frequently used technologies (84% of the papers). They are mostly used in multiple sensor configurations to measure upper limb kinematics and/or trunk posture. Sensors are placed mostly on the trunk, upper arm, the forearm, the wrist, and the finger. Typically sensors are attachable rather than embedded in wearable devices and garments; although studies that embed and integrate sensors are increasing in the last 4 years. 16 studies applied knowledge of result (KR) feedback, 14 studies applied knowledge of performance (KP) feedback and 15 studies applied both in various modalities. 16 studies have conducted their evaluation with patients and reported usability tests, while only three of them conducted clinical trials including one randomized clinical trial.

Conclusions: This review has shown that wearable systems are used mostly for the monitoring and provision of feedback on posture and upper extremity movements in stroke rehabilitation. The results indicated that accelerometers and IMUs are the most frequently used sensors, in most cases attached to the body through ad hoc contraptions for the purpose of improving range of motion and movement performance during upper body rehabilitation. Systems featuring sensors embedded in wearable appliances or garments are only beginning to emerge. Similarly, clinical evaluations are scarce and are further needed to provide evidence on effectiveness and pave the path towards implementation in clinical settings.

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[Abstract] Hand strengthening exercises in chronic stroke patients: Dose-response evaluation using electromyography

Abstract

Study Design

Cross-sectional.

Purpose of the Study

This study evaluates finger flexion and extension strengthening exercises using elastic resistance in chronic stroke patients.

Methods

Eighteen stroke patients (mean age: 56.8 ± 7.6 years) with hemiparesis performed 3 consecutive repetitions of finger flexion and extension, using 3 different elastic resistance levels (easy, moderate, and hard). Surface electromyography was recorded from the flexor digitorum superficialis (FDS) and extensor digitorum (ED) muscles and normalized to the maximal electromyography of the non-paretic arm.

Results

Maximal grip strength was 39.2 (standard deviation: 12.5) and 7.8 kg (standard deviation: 9.4) in the nonparetic and paretic hand, respectively. For the paretic hand, muscle activity was higher during finger flexion exercise than during finger extension exercise for both ED (30% [95% confidence interval {CI}: 19-40] vs 15% [95% CI: 5-25] and FDS (37% [95% CI: 27-48] vs 24% [95% CI: 13-35]). For the musculature of both the FDS and ED, no dose-response association was observed for resistance and muscle activity during the flexion exercise (P > .05).

Conclusion

The finger flexion exercise showed higher muscle activity in both the flexor and extensor musculature of the forearm than the finger extension exercise. Furthermore, greater resistance did not result in higher muscle activity during the finger flexion exercise. The present results suggest that the finger flexion exercise should be the preferred strengthening exercise to achieve high levels of muscle activity in both flexor and extensor forearm muscles in chronic stroke patients. The finger extension exercise may be performed with emphasis on improving neuromuscular control.

Level of Evidence

4b.

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[WEB SITE] Repetitive task training can help recovery after stroke

Repetitive task training can help recovery after stroke

Why was this study needed?

There are over 1.2 million stroke survivors in the UK, with around 152,000 cases reported every year. Stroke is the leading cause of long-term neurological disability, affecting balance, coordination and mobility. According to figures quoted by the Stroke Association, around 77% of stroke patients experience arm weakness and 72% experience leg weakness. It is important to understand which rehabilitation interventions might offer the best outcomes for patients to improve independence and quality of life. Repetitive task training is currently a component of stroke care so it is important to validate its effectiveness.

This Cochrane review is an update of an earlier review, last updated in 2007. Since then, 19 new trials have published results and the reporting standards have improved so these were added to the evidence base.

What did this study do?

This updated Cochrane systematic review included 32 randomised controlled trials and one quasi-randomised trial, involving 1,853 participants in all.

The trials were from various countries, including the UK, Australia, Canada and Korea.  Repetitive task training consisted of repeating a series of movements, with the aim of being able to perform a functional task. The training might involve the whole task, such as lifting a cup, or part of a task, such as grasping a cup. Most therapy interventions under evaluation lasted two to four weeks for between 10 to 21 hours.

Due to poor reporting in many of the original trials, it is difficult to assess the risk of bias. In addition, a wide range of interventions were used in the comparison groups. These factors mean researchers had a low to moderate degree of confidence in the main results.

What did it find?

  • For arms, repetitive task training had a small impact on improving function (standardised mean difference [SMD] 0.25, 95% confidence interval [CI] 0.01 to 0.49) – 11 studies, 749 participants.
  • For legs, repetitive task training provided small improvements in metres walked over six minutes (mean difference 34.8m, 95% CI 18.19m to 51.41m); walking ability (SMD 0.35, 95% CI 0.04 to 0.66); leg function (SMD 0.29, 95% CI 0.10 to 0.48); standing up from sitting (SMD 0.35, 95% CI 0.13 to 0.56) and standing balance (SMD 0.24, 95% CI 0.07 to 0.42).
  • There were no differences in functional ability after treatment according to the number of hours of training, the time from stroke to training or in the type of training delivered.
  • Repetitive task training was effective in the first six months, but no difference between groups was seen after six months.
  • Few trials reported on falls and other adverse effects making it difficult to assess the risks.

What does current guidance say on this issue?

Guidance from Royal College of Physicians in 2016 and NICE in 2013 recommends people are offered repetitive task training to improve arm and leg weakness, using activities such as reaching, grasping, sit to stand transfers and walking. The guidance recommends physiotherapists support people with movement difficulties and that rehabilitation continues until the person is able to maintain or improve functionality on their own or with the help of family or support staff.

What are the implications?

Given the range of participants included in these trials, repetitive task training could be appropriate for most people with weakness following a stroke. Clinicians and healthcare providers currently deliver repetitive task training as part of routine rehabilitation and through one-to-one or group training sessions.

There is insufficient information to draw conclusions on the optimal duration of sessions and the impact of current practices on therapist resource. The review suggests training is well received though it may be worthwhile to work with local patient groups to better understand their needs and preferences. Mechanisms to ensure adverse effects are reported and monitored are important.

An overview of NIHR funded research on stroke was published in March 2017, including aspects of recovery and rehabilitation after stroke. This can be downloaded free here.

Citation and Funding

French B, Thomas LH, Coupe J, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016; (11):CD006073.

This project was funded by the National Institute for Health Research Cochrane Review Incentive Scheme and the Department of Health Research and Development Health Technology Assessment Programme.

Bibliography

French B, Leathley M, Sutton C, et al. systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness. Health Technol Assess. 2008;12(30).

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

RCP. National clinical guidelines for stroke. London; Royal College of Physicians, Intercollegiate Stroke Working Party; 2016.

Stroke Association. State of the Nation. Stroke statistics 2016. London: Stroke Association; 2015.

Source: NIHR DC | Signal – Repetitive task training can help recovery after stroke

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[Abstract] Hand strengthening exercises in chronic stroke patients: Dose-response evaluation using electromyography

Abstract

Study Design

Cross-sectional.

Purpose of the Study

This study evaluates finger flexion and extension strengthening exercises using elastic resistance in chronic stroke patients.

Methods

Eighteen stroke patients (mean age: 56.8 ± 7.6 years) with hemiparesis performed 3 consecutive repetitions of finger flexion and extension, using 3 different elastic resistance levels (easy, moderate, and hard). Surface electromyography was recorded from the flexor digitorum superficialis (FDS) and extensor digitorum (ED) muscles and normalized to the maximal electromyography of the non-paretic arm.

Results

Maximal grip strength was 39.2 (standard deviation: 12.5) and 7.8 kg (standard deviation: 9.4) in the nonparetic and paretic hand, respectively. For the paretic hand, muscle activity was higher during finger flexion exercise than during finger extension exercise for both ED (30% [95% confidence interval {CI}: 19-40] vs 15% [95% CI: 5-25] and FDS (37% [95% CI: 27-48] vs 24% [95% CI: 13-35]). For the musculature of both the FDS and ED, no dose-response association was observed for resistance and muscle activity during the flexion exercise (P > .05).

Conclusion

The finger flexion exercise showed higher muscle activity in both the flexor and extensor musculature of the forearm than the finger extension exercise. Furthermore, greater resistance did not result in higher muscle activity during the finger flexion exercise. The present results suggest that the finger flexion exercise should be the preferred strengthening exercise to achieve high levels of muscle activity in both flexor and extensor forearm muscles in chronic stroke patients. The finger extension exercise may be performed with emphasis on improving neuromuscular control.

Level of Evidence

4b.

Source: Hand strengthening exercises in chronic stroke patients: Dose-response evaluation using electromyography – Journal of Hand Therapy

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[WEB SITE] Spasticity, Motor Recovery, and Neural Plasticity after Stroke – Full Text

Spasticity and weakness (spastic paresis) are the primary motor impairments after stroke and impose significant challenges for treatment and patient care. Spasticity emerges and disappears in the course of complete motor recovery. Spasticity and motor recovery are both related to neural plasticity after stroke. However, the relation between the two remains poorly understood among clinicians and researchers. Recovery of strength and motor function is mainly attributed to cortical plastic reorganization in the early recovery phase, while reticulospinal (RS) hyperexcitability as a result of maladaptive plasticity, is the most plausible mechanism for post-stroke spasticity. It is important to differentiate and understand that motor recovery and spasticity have different underlying mechanisms. Facilitation and modulation of neural plasticity through rehabilitative strategies, such as early interventions with repetitive goal-oriented intensive therapy, appropriate non-invasive brain stimulation, and pharmacological agents, are the key to promote motor recovery. Individualized rehabilitation protocols could be developed to utilize or avoid the maladaptive plasticity, such as RS hyperexcitability, in the course of motor recovery. Aggressive and appropriate spasticity management with botulinum toxin therapy is an example of how to create a transient plastic state of the neuromotor system that allows motor re-learning and recovery in chronic stages.

Introduction

According to the CDC, approximately 800,000 people have a stroke every year in the United States. The continued care of seven million stroke survivors costs the nation approximately $38.6 billion annually. Spasticity and weakness (i.e., spastic paresis) are the primary motor impairments and impose significant challenges for patient care. Weakness is the primary contributor to impairment in chronic stroke (1). Spasticity is present in about 20–40% stroke survivors (2). Spasticity not only has downstream effects on the patient’s quality of life but also lays substantial burdens on the caregivers and society (2).

Clinically, poststroke spasticity is easily recognized as a phenomenon of velocity-dependent increase in tonic stretch reflexes (“muscle tone”) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex (3). Though underlying mechanisms of spasticity remain poorly understood, it is well accepted that there is hyperexcitability of the stretch reflex in spasticity (47). Accumulated evidence from animal (8) and human studies (918) supports supraspinal origins of stretch reflex hyperexcitability. In particular, reticulospinal (RS) hyperexcitability resulted from loss of balanced inhibitory, and excitatory descending RS projections after stroke is the most plausible mechanism for poststroke spasticity (19). On the other hand, animal studies have strongly supported the possible role of RS pathways in motor recovery (2036), while recent studies with stroke survivors have demonstrated that RS pathways may not always be beneficial (3738). The relation between spasticity and motor recovery and the role of plastic changes after stroke in this relation, particularly RS hyperexcitability, remain poorly understood among clinicians and researchers. Thus, management of spasticity and facilitation of motor recovery remain clinical challenges. This review is organized into the following sessions to understand this relation and its implication in clinical management.

• Poststroke spasticity and motor recovery are mediated by different mechanisms

• Motor recovery are mediated by cortical plastic reorganizations (spontaneous or via intervention)

• Reticulospinal hyperexcitability as a result of maladaptive plastic changes is the most plausible mechanism for spasticity

• Possible roles of RS hyperexcitability in motor recovery

• An example of spasticity reduction for facilitation of motor recovery […]

Continue —> Frontiers | Spasticity, Motor Recovery, and Neural Plasticity after Stroke | Neurology

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[ARTICLE] Influence of physician empathy on the outcome of botulinum toxin treatment for upper limb spasticity in patients with chronic stroke: A cohort study – Full Text

Abstract

Objective: To examine the relationship between patient-rated physician empathy and outcome of botulinum toxin treatment for post-stroke upper limb spasticity.

Design: Cohort study.

Subjects: Twenty chronic stroke patients with upper limb spasticity.

Methods: All patients received incobotulinumtoxinA injection in at least one muscle for each of the following patterns: flexed elbow, flexed wrist and clenched fist. Each treatment was performed by 1 of 5 physiatrists with equivalent clinical experience. Patient-rated physician empathy was quantified with the Consultation and Relational Empathy Measure immediately after botulinum toxin treatment. Patients were evaluated before and at 4 weeks after botulinum toxin treatment by means of the following outcome measures: Modified Ashworth Scale; Wolf Motor Function Test; Disability Assessment Scale; Goal Attainment Scaling.

Results: Ordinal regression analysis showed a significant influence of patient-rated physician empathy (independent variable) on the outcome (dependent variables) of botulinum toxin treatment at 4 weeks after injection, as measured by Goal Attainment Scaling (p < 0.001).

Conclusion: These findings support the hypothesis that patient-rated physician empathy may influence the outcome of botulinum toxin treatment in chronic stroke patients with upper limb spasticity as measured by Goal Attainment Scaling.

Introduction

Stroke is a leading cause of adult disability (1, 2). Damage to the descending tracts and sensory-motor networks results in the positive and negative signs of the upper motor neurone syndrome (UMNS) (1–3). The upper limb is commonly involved after stroke, with up to 69% of patients having arm weakness on admission to hospital (4). Recovery of upper limb function has been found to correlate with the degree of initial paresis and its topical distribution according to the cortico-motoneuronal representation of arm movements (5–9).

Spasticity is a main feature of UMNS. It is defined as a state of increased muscle tone with exaggerated reflexes characterized by a velocity-dependent increase in resistance to passive movement (10). Upper limb spasticity has been found to be associated with reduced arm function, low levels of independence and high burden of direct care costs during the first year post-stroke (11). It affects nearly half of patients with initial impaired arm function, with a prevalence varying from 17% to 38% of all patients at one year post-stroke (11). Up to 13% of patients with stroke need some form of spasticity treatment (drug therapy, physical therapy or other rehabilitation approaches) within 6–12 months post-onset (11, 12). Botulinum toxin type A (BoNT-A) has been proven safe and effective for reducing upper limb spasticity and improving arm passive function in adult patients (13, 14). While current literature reports highly patient-specific potential gains in function after BoNT-A treatment, there is inadequate evidence to determine the efficacy of BoNT-A in improving active function associated with adult upper limb spasticity (13).

Empathy refers to the ability to understand and share the feelings, thoughts or attitudes of another person (15). It is an essential component of the physician-patient relationship and a key dimension of patient-centred care (15, 16). This is even more important in rehabilitation medicine, where persons with disabilities often report encountering attitudinal and environmental barriers when trying to obtain rehabilitative care and express the need for better communication with their healthcare providers (17).

To the best of our knowledge, no previous research has investigated the influence of physician empathy on patient outcome after spasticity treatment. The aim of this study was to examine the relationship between patient-rated physician empathy and clinical outcome of BoNT-A treatment for upper limb spasticity due to chronic stroke. […]

Continue —> Journal of Rehabilitation Medicine – Influence of physician empathy on the outcome of botulinum toxin treatment for upper limb spasticity in patients with chronic stroke: A cohort study – HTML

 

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[Abstract] Linking of the quality of life in neurological disorders (Neuro-QoL) to the international classification of functioning, disability and health

Abstract

Background

The quality of life in neurological disorders (Neuro-QoL) is a U.S. National Institutes of Health initiative that produced a set of self-report measures of physical, mental, and social health experienced by adults or children who have a neurological condition or disorder.

Objective

To describe the content of the Neuro-QoL at the item level using the World Health Organization’s international classification of functioning, disability and health (ICF).

Methods

We assessed the Neuro-QoL for its content coverage of functioning and disability relative to each of the four ICF domains (i.e., body functions, body structures, activities and participation, and environment). We used second-level ICF three-digit codes to classify items into categories within each ICF domain and computed the percentage of categories within each ICF domain that were represented in the Neuro-QoL items.

Results

All items of Neuro-QoL could be mapped to the ICF categories at the second-level classification codes. The activities and participation domain and the mental functions category of the body functions domain were the areas most often represented by Neuro-QoL. Neuro-QoL provides limited coverage of the environmental factors and body structure domains.

Conclusions

Neuro-QoL measures map well to the ICF. The Neuro-QoL–ICF-mapped items provide a blueprint for users to select appropriate measures in ICF-based measurement applications.

Source: Linking of the quality of life in neurological disorders (Neuro-QoL) to the international classification of functioning, disability and health | SpringerLink

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[Abstract] Electrically Assisted Movement Therapy in Chronic Stroke Patients With Severe Upper Limb Paresis: A Pilot, Single-Blind, Randomized Crossover Study  

Abstract

Objective

To evaluate the effects of electrically assisted movement therapy (EAMT) in which patients use functional electrical stimulation, modulated by a custom device controlled through the patient’s unaffected hand, to produce or assist task-specific upper limb movements, which enables them to engage in intensive goal-oriented training.

Design

Randomized, crossover, assessor-blinded, 5-week trial with follow-up at 18 weeks.

Setting

Rehabilitation university hospital.

Participants

Patients with chronic, severe stroke (N=11; mean age, 47.9y) more than 6 months poststroke (mean time since event, 46.3mo).

Interventions

Both EAMT and the control intervention (dose-matched, goal-oriented standard care) consisted of 10 sessions of 90 minutes per day, 5 sessions per week, for 2 weeks. After the first 10 sessions, group allocation was crossed over, and patients received a 1-week therapy break before receiving the new treatment.

Main Outcome Measures

Fugl-Meyer Motor Assessment for the Upper Extremity, Wolf Motor Function Test, spasticity, and 28-item Motor Activity Log.

Results

Forty-four individuals were recruited, of whom 11 were eligible and participated. Five patients received the experimental treatment before standard care, and 6 received standard care before the experimental treatment. EAMT produced higher improvements in the Fugl-Meyer scale than standard care (P<.05). Median improvements were 6.5 Fugl-Meyer points and 1 Fugl-Meyer point after the experimental treatment and standard care, respectively. The improvement was also significant in subjective reports of quality of movement and amount of use of the affected limb during activities of daily living (P<.05).

Conclusions

EAMT produces a clinically important impairment reduction in stroke patients with chronic, severe upper limb paresis.

Source: Electrically Assisted Movement Therapy in Chronic Stroke Patients With Severe Upper Limb Paresis: A Pilot, Single-Blind, Randomized Crossover Study – Archives of Physical Medicine and Rehabilitation

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[BOOK + References] Adaptation and Rehabilitation in Patients with Homonymous Visual Field Defects

Abstract

Hemianopia leads to severe impairment of spatial orientation and mobility. In cases without macular sparing an additional reading disorder occurs. Persistent visual deficits require rehabilitation. The goal is to compensate for the deficits to regain independence and to maintain the patient’s quality of life. Spontaneous adaptive mechanisms, such as shifting the field defect towards the hemianopic side by eye movements or eccentric fixation, are beneficial, but often insufficient. They can be enhanced by training, e.g., saccadic training to utilize the full field of gaze in order to improve mobility and by special training methods to improve reading performance. At present only compensatory interventions are evidence-based.

References (71)

Source: Adaptation and Rehabilitation in Patients with Homonymous Visual Field Defects – Springer

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