To evaluate the effects of home-based rehabilitation on improving physical function in home-dwelling patients after a stroke.
It is estimated that one in 5 women and one in 6 men will sustain a stroke up to the age of 75 years  . The main purpose of rehabilitation in such patients is to achieve the maximum possible personal performance, physical and psychological, with the ultimate goal of regaining a level of functional independence that will allow them to be re-integrated into social life as much as possible  . However, stroke patients often adopt a sedentary lifestyle     . This may be attributed to 1) factors associated with patients themselves, such as depression, lack of interest or motivation, decreased perception, decreased confidence, ignorance that exercise is possible and desirability and fear of falls, of a new stroke or other undesirable effects; 2) practical factors, such as lack of support from family or other social actors, inability to access exercise sites, inadequate public transport, health professionals’ ignorance of the availability of physical activity services; 3) financial cost      . Conversely, exercise in groups may improve patient motivation  .
In 2014, the council of the American Heart Association and the American Stroke association (AHA/ASA) revised the exercise recommendations for stroke patients at all stages of their recovery  . Therefore, the aim of this study was to assess the effect of an exercise programme based on these recommendations on gait kinematics and kinetics of ischaemic stroke patients in the chronic phase of recovery.[…]
To compare participation and subjective experience of participants in both home-based multi-user VR therapy and home-based single-user VR therapy.
Crossover, randomized trial
Initial training and evaluations occurred in a rehabilitation hospital; the interventions took place in participants’ homes
Stroke survivors with chronic upper extremity impairment (n=20)
4 weeks of in-home treatment using a custom, multi-user virtual reality system (VERGE): two weeks of both multi-user (MU) and single-user (SU) versions of VERGE. The order of presentation of SU and MU versions was randomized such that participants were divided into two groups, first multi-user (FMU) and first single-user (FSU).
We measured arm displacement during each session (meters) as the primary outcome measure. Secondary outcome measures include: time participants spent using each MU and SU VERGE, and Intrinsic Motivation Inventory (IMI) scores. Fugl-Meyer Upper-Extremity (FMUE) score and compliance with prescribed training were also evaluated. Measures were recorded before, midway, and after the treatment. Activity and movement were measured during each training session.
Arm displacement during a session was significantly affected the mode of therapy (MU: 414.6m, SU: 327.0m, p=0.019). Compliance was very high (99% compliance for MU mode and 89% for SU mode). Within a given session, participants spent significantly more time training in the MU mode than in the SU mode (p=0.04). FMUE score improved significantly across all participants (Δ3.2, p=0.001).
Multi-user VR exercises may provide an effective means of extending clinical therapy into the home.
BACKGROUND: Lower limb support ability is important for steady and efficient mobility, but previous data commonly involved training during double stance positions, with or without external feedback, using a complex and costly machine.
AIM: To compare the effects of stepping training with or without external feedback in relation to the lower limb support ability of the affected limb on the functional ability necessary for independence in individuals with stroke.
DESIGN: A single-blinded, randomised controlled trial.
SETTING: Tertiary rehabilitation centres.
POPULATION: Ambulatory participants with stroke who walked independently over at least 10 meters with or without walking devices.
METHODS: Thirty-six participants were randomly arranged to be involved in a program of stepping training with or without external feedback related to the lower limb support ability of the affected limb (18 participants/group) for 30 minutes, followed by overground walking training for 10 minutes, 5 days/week over 4 weeks. The outcomes, including the lower limb support ability of the affected legs during stepping, functional ability and spatial walking data, were assessed prior to training, immediately after the first training session, and after 2- and 4- week training.
RESULTS: Participants demonstrated significant improvement in the amount of lower limb support ability, immediately after the first training with external feedback. Then, these participants showed further improvement in both the amount and duration of lower limb support ability, as well as the timed up and go data after 2 and 4 weeks of training (p < 0.05). This improvement was not found following control training.
CONCLUSIONS: The external feedback relating to lower limb support ability during stepping training effectively improved the movement stability and complex motor activity of ambulatory individuals with stroke who had long post-stroke time (approximately 3 years).
CLINICAL REHABILITATION IMPACT: Stepping training protocols and feedback can be easily applied in various settings using the amount of body-weight from an upright digital bathroom scale. Thus, the findings offer an alternative rehabilitation strategy for clinical, community and home-based settings for stroke individuals.
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via Stepping training with external feedback relating to lower limb support ability effectively improved complex motor activity in ambulatory patients with stroke: a randomized controlled trial – European Journal of Physical and Rehabilitation Medicine 2019 Oct 15 – Minerva Medica – Journals
The rehabilitation effects of the NMES robotic hand and robotic hand were compared.
Both training systems could significantly improve the motor function of upper limb.
The NMES robot was more effective than the pure robot.
NMES applied on distal muscle could benefit the recovery in the entire upper limb.
Upper limb motor deficits are common after stroke, and observed in over 80% of stroke survivors [1,2]. Various rehabilitation devices have been purposed to assist human physical therapists to provide effective long-term rehabilitation programs [, , ]. Among them, rehabilitation robots and neuromuscular electrical stimulation (NMES) are most widely used in stroke rehabilitation practices. Rehabilitation robots have been recognized as efficient in such cases and could represent a cost-effective addition to conventional rehabilitation services because they provide highly intensive and repetitive training [, , , ]. It has been reported that the integration of voluntary effort (e.g. electromyography, EMG) into robotic design could contribute significantly to motor recovery in stroke patients [6,10]. This is because an EMG-driven strategy can maximize the involvement of voluntary effort in the training, and its effectiveness at improving upper limb voluntary motor functions have been proved by many EMG-driven robot-assisted upper-limb training systems [, , ]. However, rehabilitation robots are unable to directly activate the desired muscle groups, which may only assist, or even dominate limb movement such as continuous passive motions (CPM) . In addition, stroke patients usually cooperate with compensatory motions from other muscular activities to activate the target muscles, which may lead to ‘learned disuse’ . However, NMES can effectively limit compensatory motions by stimulating specific muscles via cyclic electrical currents, which provides repetitive sensorimotor experiences . With the advantage of precisely activating the target muscle, NMES has been reported to be effective in evoking sensory feedback, improving muscle force, and thus promoting motor function in stroke patients [17,18]. Nevertheless, training programs assisted by NMES alone are also suboptimal due to the difficulty of controlling movement trajectories and the early appearance of fatigue [19,20].
Accordingly, various NMES robot-assisted upper-limb training programs which combine these two unique techniques have been proposed to integrate the benefits and minimize the disadvantages [7,12,14,21,22]. The rehabilitation effectiveness of these combined systems has been investigated and reported to be effective in improving motor recovery. Several studies have compared the training outcomes of NMES robot-assisted training and other training programs. For example, Qian et al.  reported that NMES-robot-assisted upper-limb training could achieve better motor outcomes when compared with conventional therapies for subacute stroke patients. Meanwhile, another study which compared the training effects between robot-aided training with NMES and robot-aided training solely using the InMotion ARM™ Robot in the subacute period demonstrated that the active ranges of motion of the NMES robot-training group were significantly higher compared with the robot-training group . Coincidentally, investigations into applications in chronic stroke patients have also been carried out. For instance, Hu et al.  proposed an EMG-driven NMES robot system for wrist training; this combined device improved muscle activation levels related to the wrist and reduced compensatory muscular activities at the elbow, while these training outcomes were absent for the EMG-driven robot-assisted training alone. Indeed, a similar study by another research group also achieved better rehabilitation outcomes on some clinical assessments using the combined system compared to robot-assisted therapy alone .
In the literature, most studies on current rehabilitation devices combining the NMES and robotic systems targeted the elbow and wrist joints [7,, , ], while very few focused on the hand and fingers . In addition, a comparison of the training effects for hand rehabilitation between the NMES robot and other hand rehabilitation devices has not yet been adequately conducted. Indeed, the primary upper-limb disability post-stroke is the loss of hand function, and rehabilitation of the distal joints after stroke is much more difficult than the motor recovery of the proximal joints due to the compensatory motions from the proximal joints . Hence, developing effective rehabilitation devices to minimize compensatory movements for hand motor recovery is especially meaningful for stroke rehabilitation. In our previous work, we developed an EMG-driven NMES robotic hand and suggested it for use in hand rehabilitation after stroke . Our device provides fine control of hand movements and activates the target muscles selectively for finger extension/flexion, and its feasibility and effectiveness have been verified by a single group trial . However, whether the long-term rehabilitation effect of this EMG-driven NMES robotic hand is comparable or even better than other hand rehabilitation devices are still unclear and need to be investigated quantitively. Therefore, the objective of this study is to compare the training effects of hand rehabilitation assisted by an NMES robotic hand and by a pure robotic hand though a randomized controlled trial with a 3-month follow-up (3MFU).
This work was approved by the Human Subjects Ethics Sub-Committee of the Hong Kong Polytechnic University. A total of 53 stroke survivors were screened for the training from local districts. 30 participants with chronic stroke satisfied the following inclusion criteria: (1) The participants were at least 6 months after the onset of a singular and unilateral brain lesion due to stroke, (2) both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints could be extended to 180° passively, (3) muscle spasticity during extension at the finger joints and the wrist joint was below 3 as measured by the Modified Ashworth Scale (MAS) , ranged from 0 (no increase in muscle tone) to 4 (affected part rigid), (4) detectable voluntary EMG signals from the driving muscle on the affected side (three times of the standard deviation (SD) above the EMG baseline), and (5) no visual deficit and able to understand and follow simple instructions as assessed by the Mini-Mental State Examination (MMSE > 21) .
This work involved a randomized controlled trial with a 3-month follow-up (3MFU). The potential participants were first told that the training program they would receive could be either NMES robotic hand training or pure robotic hand training, and all recruited participants submitted their written consent before randomization. Then, the recruited participants were randomly assigned into two groups according to a computer-based random number generator, i.e., the computer program generated either “1” (denoting the NMES robotic hand training group) or “2” (the pure robotic hand group) with an equal probability of 0.5 (Matlab, 2017, Mathworks, Inc.). Fig. 1 shows the Consolidated Standards of Reporting Trials flowchart of the training program.
For both groups, each participant was invited to attend a 20-session robotic hand training with an intensity of 3–5 sessions/week, completed within 7 consecutive weeks. The training setup of both groups is shown in Fig. 2. This robotic hand training system can assist with finger extension and flexion of the paretic limb for patients after stroke. In this work, real-time voluntary EMG detected from the abductor pollicis brevis (APB) and extensor digitorum (ED) muscles were used to control the respective hand closing and opening movements, and the threshold level of each motion phase was set at three times the SD above the EMG baseline at resting state . For example, during the motions of finger flexion, once the EMG activation level of the APB muscle reached a preset threshold, the robotic hand would provide mechanical assistance for hand closing. Similarly, during the motions of finger extension, the robotic hand would assist with hand opening when the EMG activation level of the ED muscle reached a preset threshold. For the NMES robot group, synchronized support from the NMES and the robot were both provided. The NMES electrode pair (30 mm diameter; Axelgaard Corp., Fallbrook, CA, USA) was attached over the ED muscle to provide stimulation during finger extension. The outputs of NMES were square pulses with a constant amplitude of 70 V, a stimulation frequency of 40 Hz, and a manually adjustable pulse width in the range 0–300 μs. Before the training, the pulse width was set at the minimum intensity, which achieved a fully extended position of the fingers in each patient. During the training, NMES would be triggered by the EMG from the ED muscle first and then provided stimulation to the ED muscle to assist hand-opening motions for the entire phase of finger extension, while no assistance from NMES was provided during finger flexion to avoid the possible increase of finger spasticity after stimulation . For the pure robot group, the difference between the two groups was that no NMES was applied in the pure robot group. A detailed account of the working principles of the robotic hand have been described in our previous work [12,30,31].
Continue —-> A comparison of the rehabilitation effectiveness of neuromuscular electrical stimulation robotic hand training and pure robotic hand training after stroke: A randomized controlled trial – ScienceDirect
Background. Robot-assisted therapy provides high-intensity arm rehabilitation that can significantly reduce stroke-related upper extremity (UE) deficits. Motor improvement has been shown at the joints trained, but generalization to real-world function has not been profound.
Objective. To investigate the efficacy of robot-assisted therapy combined with therapist-assisted task training versus robot-assisted therapy alone on motor outcomes and use in participants with moderate to severe chronic stroke-related arm disability.
Methods. This was a single-blind randomized controlled trial of two 12-week robot-assisted interventions; 45 participants were stratified by Fugl-Meyer (FMA) impairment (mean 21 ± 1.36) to 60 minutes of robot therapy (RT; n = 22) or 45 minutes of RT combined with 15 minutes therapist-assisted transition-to-task training (TTT; n = 23). The primary outcome was the mean FMA change at week 12 using a linear mixed-model analysis. A subanalysis included the Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS), with significance P <.05.
Results. There was no significant 12-week difference in FMA change between groups, and mean FMA gains were 2.87 ± 0.70 and 4.81 ± 0.68 for RT and TTT, respectively. TTT had greater 12-week secondary outcome improvements in the log WMFT (-0.52 ± 0.06 vs -0.18 ± 0.06; P = .01) and SIS hand (20.52 ± 2.94 vs 8.27 ± 3.03; P = .03).
Conclusion. Chronic UE motor deficits are responsive to intensive robot-assisted therapy of 45 or 60 minutes per session duration. The replacement of part of the robotic training with nonrobotic tasks did not reduce treatment effect and may benefit stroke-affected hand use and motor task performance.
To investigate the effects of water-based exercise on functioning and quality of life in poststroke persons.
We searched the following electronic database: MEDLINE, PeDro, Scielo, and the Cochrane Central Register of Controlled Trials up to September 2018 Study Selection: Only randomized controlled trials were included. Two review authors screened the titles and abstracts and selected the trials independently.
Two review authors independently extracted data of the included trials, using standard data-extraction model. We analyzed the pooled results using weighted mean differences, and standardized mean difference and 95% confidence intervals (CIs) were calculated.
Twenty-four studies met the study criteria, but only 15 studies were included on meta-analyses. The studies presented moderate methodological quality, due to the lack of blinding of subjects and therapists and the nonperformance of the intention-to-treat analysis. Water-based exercise compared with land exercise had a positive impact on: muscle strength balance gait speed and mobility aerobic capacity and functional reach. Combined water-based exercise and land exercise was more effective than land exercise for improving balance, gait speed, and functional reach. The meta-analysis showed significant improvement in role limitations due to physical functioning and emotional problems, in vitality general mental health, social functioning, and bodily pain for participants in the water-based exercise and land exercise group versus land exercise group.
Water-based exercise may improve muscle strength, balance, mobility, aerobic capacity, functional reach, joint position sense, and quality of life in poststroke persons and could be considered for inclusion in rehabilitation programs.
Virtual reality (VR)-based rehabilitation is considered a beneficial therapeutic option for stroke rehabilitation. This pilot study assessed the clinical feasibility of a newly developed VR-based planar motion exercise apparatus (Rapael Smart Board™ [SB]; Neofect Inc., Yong-in, Korea) for the upper extremities as an intervention and assessment tool.
This single-blinded, randomized, controlled trial included 26 stroke survivors. Patients were randomized to the intervention group (SB group) or control (CON) group. During one session, patients in the SB group completed 30 min of intervention using the SB and an additional 30 min of standard occupational therapy; however, those in the CON group completed the same amount of conventional occupational therapy. The primary outcome was the change in the Fugl–Meyer assessment (FMA) score, and the secondary outcomes were changes in the Wolf motor function test (WMFT) score, active range of motion (AROM) of the proximal upper extremities, modified Barthel index (MBI), and Stroke Impact Scale (SIS) score. A within-group analysis was performed using the Wilcoxon signed-rank test, and a between-group analysis was performed using a repeated measures analysis of covariance. Additionally, correlations between SB assessment data and clinical scale scores were analyzed by repeated measures correlation. Assessments were performed three times (baseline, immediately after intervention, and 1 month after intervention).
All functional outcome measures (FMA, WMFT, and MBI) showed significant improvements (p < 0.05) in the SB and CON groups. AROM showed greater improvements in the SB group, especially regarding shoulder abduction and internal rotation. There was a significant effect of time × group interactions for the SIS overall score (p = 0.038). Some parameters of the SB assessment, such as the explored area ratio, mean reaching distance, and smoothness, were significantly associated with clinical upper limb functional measurements with moderate correlation coefficients.
The SB was available for improving upper limb function and health-related quality of life and useful for assessing upper limb ability in stroke survivors.
Virtual reality (VR)-based rehabilitation is being increasingly used for post-stroke rehabilitation . A recent systematic review mentioned that VR is an emerging treatment option for upper limb rehabilitation among stroke patients . The benefits of VR include real-time feedback, easy adaptability, and the provision of safe environments that mimic the real world [3, 4]. The gaming property of VR allows patients to experience fun, active participation, positive emotions, and engagement [5, 6]. Therefore, rehabilitation with VR enables more intense and repetitive training, which is important for rehabilitation and the promotion of neural plasticity .
VR systems commonly used in the entertainment industry, such as Wii and Kinect, could be used for rehabilitation. However, these game-like systems are only applicable to patients with muscle strength above a certain value, thus limiting their use by more affected patients. Therefore, adjunct therapies, such as functional electrical stimulation and robotics, have been combined with these systems [8, 9, 10, 11]. However, those adjunct therapies are costly and require continuous monitoring by healthcare professionals because of safety concerns [12, 13]. Therefore, their use is restricted to clinical settings, and they are not actively used for telerehabilitation or home-based rehabilitation. A non-motorized or non-assisted device is required for more active use of VR for rehabilitation.
We developed the Rapael Smart Board™ (SB; Neofect Inc., Yong-in, Korea), which is a VR-based rehabilitation device incorporating planar motion exercise that does not require additional gravity compensation. This two-dimensional planar movement with full gravitational support, which lessens the need for antigravity muscle facilitation, allows for much easier participation than three-dimensional movement under gravity. Additionally, it is known to be safe and easy to learn, and it has been shown to improve motor ability with less aggravation of shoulder pain and spasticity; therefore, it is useful to patients with reduced motor ability . Planar motion exercises provoke less maladaptive compensatory movements. Additionally, the nearly zero friction of the linear guides enable a wide range of repetitive active range of motion (AROM) exercises. Furthermore, the SB adopted Rapael Clinic software that was originally developed for patients with disabilities and has proven efficacy for stroke rehabilitation [9, 15]. Therefore, the SB, which has multiple advantages because of its hardware and software, might be beneficial for the functional improvement of the upper extremities. Moreover, the SB could have a role as an assessment tool because VR has been reported to be useful for objective kinematic measurements of the upper extremities .
The present pilot study aimed to assess the availability of this newly developed VR-based rehabilitation device incorporating planar exercises for the upper extremities as an intervention and assessment tool among stroke patients in the chronic phase of recovery. To assess the availability in terms of clinical effectiveness, we compared the effects of an intervention involving the SB and that involving dose-matched occupational therapy (OT) on upper extremity function and health-related quality of life (HRQoL). We also investigated the correlations between kinematic data from the SB and data from clinical scales regarding upper extremity function.
Continue —> Effects of virtual reality-based planar motion exercises on upper extremity function, range of motion, and health-related quality of life: a multicenter, single-blinded, randomized, controlled pilot study | SpringerLink