[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF

Abstract

Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.

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[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF

Abstract

Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.

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[ARTICLE] Noninvasive spinal stimulation improves walking in chronic stroke survivors: a proof-of-concept case series – Full Text

Abstract

Background

After stroke, restoring safe, independent, and efficient walking is a top rehabilitation priority. However, in nearly 70% of stroke survivors asymmetrical walking patterns and reduced walking speed persist. This case series study aims to investigate the effectiveness of transcutaneous spinal cord stimulation (tSCS) in enhancing walking ability of persons with chronic stroke.

Methods

Eight participants with hemiparesis after a single, chronic stroke were enrolled. Each participant was assigned to either the Stim group (N = 4, gait training + tSCS) or Control group (N = 4, gait training alone). Each participant in the Stim group was matched to a participant in the Control group based on age, time since stroke, and self-selected gait speed. For the Stim group, tSCS was delivered during gait training via electrodes placed on the skin between the spinous processes of C5–C6, T11–T12, and L1–L2. Both groups received 24 sessions of gait training over 8 weeks with a physical therapist providing verbal cueing for improved gait symmetry. Gait speed (measured from 10 m walk test), endurance (measured from 6 min walk test), spatiotemporal gait symmetries (step length and swing time), as well as the neurophysiological outcomes (muscle synergy, resting motor thresholds via spinal motor evoked responses) were collected without tSCS at baseline, completion, and 3 month follow-up.

Results

All four Stim participants sustained spatiotemporal symmetry improvements at the 3 month follow-up (step length: 17.7%, swing time: 10.1%) compared to the Control group (step length: 1.1%, swing time 3.6%). Additionally, 3 of 4 Stim participants showed increased number of muscle synergies and/or lowered resting motor thresholds compared to the Control group.

Conclusions

This study provides promising preliminary evidence that using tSCS as a therapeutic catalyst to gait training may increase the efficacy of gait rehabilitation in individuals with chronic stroke.

Trial registration NCT03714282 (clinicaltrials.gov), registration date: 2018-10-18.

Background

Stroke is the leading cause of adult-onset disability [1]. Despite many advances in gait research in the last decade, about 35% of stroke survivors fail to regain independence in performing activities of daily living due to the impaired function of their affected leg, and about 70% have gait deficits, including reduced walking speeds, asymmetrical walking patterns, and motor coordination issues [2,3,4].

Walking deficits after stroke mostly derive from a disruption of the corticospinal pathways that play an important role in transmitting sensory–motor commands [5, 6]. To address this, most interventions using non-invasive electrical pulses focus on stimulation of the motor cortex to activate dormant or new pathways [2, 7, 8]. However, while supra-spinal regions can facilitate fine locomotor control, spinal networks ultimately generate the basic locomotor pattern [9, 10]. More interestingly, a recent study using functional MRI showed increased blood-oxygen-level dependent activities in motor cortex following transcutaneous spinal cord stimulation (tSCS) in individuals with stroke [11]. Therefore, we hypothesized that tSCS would facilitate an improvement of gait after stroke. Our previous work, in collaboration with additional researchers, established anatomical and physiological changes in the spinal cord after stroke [12, 13], offering a theoretical basis for testing our hypothesis of targeting the spinal circuits for post-stroke recovery.

Recently, Moshonkina et al. reported functional improvements in post-stroke individuals after 2 weeks of tSCS with standard physical therapy, achieving the minimum clinical important differences (MCID) in the 6 min walk test and comfortable walking speed [14]. The same investigators reported immediate improvements in walking kinematics after a single tSCS session [15, 16]. Notably, however, none of the studies mentioned above investigated the effects of more than 4 weeks of training nor tried to explore the potential neurophysiological differences accompanied with gait outcomes. Consequently, it remains unclear whether tSCS can exert a lasting impact on restoration of function following a stroke.

We investigated whether tSCS combined with symmetry-focused gait training has a sustained effect on gait recovery after chronic stroke. We hypothesized that longer-term gait training (24 sessions) with tSCS would lead to greater sustained improvements in walking function compared to control treatment focused solely on gait training. Specifically, we focused on gait symmetry since such improvements can have lasting effects on balance and overall mobility of stroke survivors [6]. We also expected that gait improvements would be associated with physiological changes in muscle coordination measured from electromyography (EMG) of the paretic side, and spinal excitability determined by the spinal motor evoked responses (sMERs). […]

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Study protocol and stimulation setup. A Overall experimental protocol. B Top–down view of position of the legs extended beyond the edge of the table and supported with vertically cables during the side-lying training of a participant (Stim 2). C tSCS delivered using surface electrodes on the skin between the C5–6, T11–12, and L1–2 spinous processes (cathode) and a surface electrode on each anterior crest (anode, not shown). D Schematic representation of biphasic pulse sequence used for tSCS. tSCS transcutaneous spinal cord stimulation, OG overground walking, 10MWT 10-m walk test, 6MWT 6-min walk test

[Abstract] Electrotherapy in stroke rehabilitation can improve lower limb muscle characteristics: a systematic review and meta-analysis

Abstract

Purpose

This review assesses the effect of electrotherapy (e.g. functional electrical stimulation (FES), motor and sensor therapeutic electrical stimulation (TES)) on muscle strength and skeletal muscle characteristics in individuals post-stroke compared to conventional or sham therapy.

Methods

A systematic literature search was conducted in MEDLINE, SCOPUS, and Web of Science, focusing on randomized controlled trials investigating the effect of electrotherapy. Data of interest was extracted from eligible studies, and risk of bias was assessed.

Results

In total, 23 studies (933 people post-stroke) were included, of which 17, which mainly focus on patients in a chronic stage of stroke recovery and the implementation of FES, were incorporated in the meta-analysis. A significant increase in muscle strength was found favoring electrotherapy over conventional therapy (SMD 0.63, 95% CI 0.34–0.91, I² = 37%, p = 0.07) and over sham therapy (SMD 0.44, 95% CI 0.20–0.68, I² = 38%, p = 0.08). Three studies investigated the effect on muscle thickness and found a significant increase in favor of electrostimulation when compared to conventional therapy (MD 0.11 cm, 95% CI 0.06–0.16, I² = 0%, p = 0.50).

Conclusion

Current evidence suggests electrotherapy in combination with physiotherapy has positive effects on lower limb muscle strength and skeletal muscle characteristics in patients recovering from stroke.

IMPLICATION FOR REHABILITATION

• As stroke is known to cause long term disability, the implementation of strengthening interventions in rehabilitation becomes an indispensable part to optimize recovery.
• Peripheral electrical stimulation might be a useful intervention since it has the potential to repetitively activate the sensory-motor system via electrical pulses to nerves and muscles of the paretic limb.
• Results of the meta-analysis indicate a beneficial effect of electrotherapy on muscle strength when compared to conventional and sham therapy, and muscle thickness when compared to conventional therapy.

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[Preprint] Feasibility of Simultaneous Transcranial Direct Current Stimulation During Gait Training in Chronic Stroke Patients: A Randomized Double-blind Pilot Clinical Trial

Abstract

Background
Transcranial direct current stimulation (tDCS) is a therapeutic tool for improving post-stroke gait
disturbances, with ongoing research focusing on specific protocols for its application. We evaluated the
feasibility of a rehabilitation protocol that combines tDCS with conventional gait training.

Methods
This was a randomized, double-blind, single-center pilot clinical trial. Patients with unilateral hemiplegia
due to ischemic stroke were randomly assigned to either the tDCS with gait training group or the sham
stimulation group. The anodal tDCS electrode was placed on the tibialis anterior area of the precentral
gyrus while gait training proceeded. Interventions were administered 3 times weekly for 4 weeks.
Outcome assessments, using the 10-meter walk test, Timed Up and Go test, Berg Balance Scale,
Functional Ambulatory Scale, Modified Barthel Index, and EQ-5D-3L, were conducted before and after the
intervention and again at the 8-week mark following its completion. Repeated-measures ANOVA was used for comparisons between and within groups.

Results
Twenty-six patients were assessed for eligibility, and 20 were enrolled and randomized. No significant
differences were observed between the tDCS with gait training group and the sham stimulation group in
gait speed after the intervention. However, the tDCS with gait training group showed significant
improvement in balance performance in both within-group and between-group comparisons. In the
subgroup analysis of patients with elicited motor-evoked potentials, comfortable pace gait speed
improved in the tDCS with gait training group. No serious adverse events occurred throughout the study.

Conclusions
Simultaneous tDCS during gait training is a feasible rehabilitation protocol for chronic stroke patients
with gait disturbances.

Introduction
Impairment of independent gait is one of the most disabling consequences after a stroke [1]. Gait
abnormality in stroke patients arises from a complex interplay of factors, including lower limb motor
weakness and decreased balance. Some individuals may not be entirely incapable of walking, but they
may still require gait aids or assistance from caregivers. Gait disturbances pose a greater risk of further
injury due to falls. It is well known that fall-associated fractures result in significant socioeconomic costs
[2]. Additionally, gait disturbances lead to limitations in social activity, thereby reducing the quality of life
of stroke patients. Therefore, improving gait performance in stroke patients has long been a desire shared
by patients and physicians.
Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that aims to
modulate the human brain by delivering low-intensity electrical current through the scalp. The mechanism of tDCS is explained by 2 principles: (1) the enhancement of cortical activity through a polarity shift in the resting membrane potential and (2) the upregulation of neural plasticity through long-term potentiation [3]. Applying anodal tDCS to patients with subacute stroke has been associated with beneficial effects on motor function [4]. However, inconsistent results have emerged across studies, with some failing to observe significant improvements in patients who underwent tDCS compared to sham stimulation [5].
Additionally, there has been substantial variability in factors, such as stimulation area, intensity, duration,
and the number of sessions among different tDCS protocols, highlighting the need for further research to
establish an optimal tDCS protocol for maximizing the effect of conventional gait training methods.
Studies focusing on stimulation timing suggest that combining tDCS with gait training simultaneously
shows more promising results in improving gait performance compared to protocols that administer gait
training and tDCS separately [6].
This study aimed to evaluate the feasibility of a rehabilitation protocol that combines simultaneous tDCS
with conventional gait training and to investigate its impact on gait performance in chronic stroke
patients.[…]

Source

[ARTICLE] Stroke patients’ motivation for home-based upper extremity rehabilitation with eHealth tools – Full Text

Abstract

Purpose

eHealth-based exercise therapies were developed to increase stroke patients’ adherence to home-based motor rehabilitation. However, these eHealth tools face a rapid decrease in use after a couple of weeks. This study investigates stroke patients’ motivation for home-based upper extremity rehabilitation with eHealth tools and their relation with Basic Psychological Needs.

Materials and methods

This is a qualitative study using thematic analysis. We conducted semi-structured interviews with stroke patients with upper extremity motor impairments, who were discharged home from a rehabilitation centre, after they interacted with a novel eHealth coach demonstrator in their homes for five consecutive days.

Results

We included ten stroke patients. Thematic analysis resulted in eight themes for home-based rehabilitation motivation: Curiosity, Rationale, Choice, Optimal challenge, Reference, Encouragement, Social Support and Trustworthiness. Those themes are embedded into three Basic Psychological Needs: “Autonomy”, “Competence”, and “Relatedness”.

Conclusion

Eight motivational themes related to the three Basic Psychological Needs describe stroke patients’ motivation for home-based upper extremity rehabilitation. We recommend considering those themes when developing a home-based eHealth intervention for stroke patients to increase the alignment of eHealth tools to the patient’s needs and reduce motivational decreases in home-based rehabilitation.

Implications for rehabilitation

• Stroke patients show motivational decreases and decreased use of eHealth tools in home-based rehabilitation after a couple of weeks.
• Eight motivational themes describe home-based rehabilitation motivation in stroke patients: Curiosity, Rationale, Choice, Optimal challenge, Reference, Encouragement, Social Support and Trustworthiness.
• Those themes are embedded into three Basic Psychological Needs: “Autonomy”, “Competence”, and “Relatedness”.
• Those themes should be considered when developing a home-based eHealth intervention for stroke patients to increase the alignment of eHealth tools to the patient’s needs and reduce motivational decreases in home-based rehabilitation.

Introduction

Over two-thirds of stroke survivors experience upper extremity (UE) motor impairment, limiting capacity and resulting in significant daily functioning limitations and decreased quality of life [Citation1]. Rehabilitation programs involve stimulation of UE use and intensive UE exercises (e.g. a high number of repetitions per time unit) [Citation2]. Adherence to intensive daily UE use and exercise is essential to optimise UE capacity and daily life functioning [Citation3–5]. Exercise adherence may be specifically challenging for patients discharged from the controlled and supportive environment of a rehabilitation facility and expected to continue exercising at home [Citation6–8].

One of the most common perceived barriers to adherence to rehabilitation exercises and physical activity in stroke patients is a lack of motivation [Citation9]. Motivation can be generally explained as a fundamental “drive” towards change. According to Deci and Ryan’s Self Determination Theory (SDT), motivation has three underlying Basic Psychosocial Needs (BPNs): Autonomy, Competence and Relatedness (10). The need for autonomy refers to the belief in being agentic and volitional in your actions, and it implies self-initiation and a choice over your behaviour. The need for competence refers to feeling capable and effective in the physical and social environment. The need for relatedness refers to connecting to a community or group and having a secure relational base [Citation10]. These three BPNs are critical resources for psychological well-being and autonomous, self-determined motivation and satisfying them increases motivation to pursue desired behaviour [Citation10]. Literature shows that higher motivation levels positively correlate with higher adherence to a rehabilitation program [Citation11,Citation12] and better rehabilitation outcomes [Citation3,Citation4,Citation13].

Various motivational strategies targeting at least one of the three BPNs are used in face-to-face sessions between therapists and patients [Citation14,Citation15]. Examples of this are the application of patients’ preferences (increasing autonomy), control of task difficulty (increasing competence) and involvement of a family member (increasing relatedness) [Citation14,Citation15]. During home-based rehabilitation, patients’ motivational needs are expected to differ from inpatient rehabilitation since there is no direct supervision, less face-to-face contact between patients and therapists and more distraction from the physical and social environment. Besides, stroke often affects the social relationships and roles of the patient in their home environment, for example, family members may become informal caregivers, and patients are less involved in community activities [Citation16,Citation17].

Recently, a Delphi study was conducted to identify strategies to facilitate adherence to home-based exercises after a stroke [Citation18]. Multiple strategies were classified, including using eHealth applications to prescribe exercises, provide feedback and motivate patients to follow home-based rehabilitation. However, the expert panel in this study did not include stroke survivors, and the study does not provide insights into patients’ needs [Citation18]. Since many eHealth applications face a rapid decrease in use and low adherence in the home environment [Citation19], a better understanding of their motivational needs regarding using home-based rehabilitation eHealth tools is needed.

To increase the understanding of motivation in stroke patients, evaluating the BPNs in combination with patient-specific contextual and personal factors that influence motivation is important. Multiple studies documented motivation as the interplay of individual characteristics, including individual factors such as personality, psychological attributes and health status, and contextual factors, which are the social context and the culturally enforced norms [Citation11,Citation14,Citation20,Citation21]. BPNs, as described by Deci and Ryan, are generic and do not specifically take into account these personal and contextual factors. Moreover, the feeling of autonomy, competence, and social roles and relationships change due to a chronic disabling condition, such as stroke [Citation22]. Thus, a specific patient population’s characteristics and home environment should not be neglected when providing or developing home-based rehabilitation.

This study investigates stroke patients’ motivation for home-based UE rehabilitation using eHealth tools and how this is embedded in the three BPNs. To account for the specific personal and contextual factors, we choose a qualitative study design, allowing us to acquire rich personal and contextual data conducted within a representative group of stroke patients at their own homes. With this knowledge, we expect to better align eHealth tools to the patient’s needs, resulting in increased therapy adherence. […]

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Figure 1 of 1
Figure 1. The interactive demonstrator “EDO” and the three exercises included in the interface: (a) cylinder grasp, (b) pinch grasp, and (c) lifting and tilting movement.
A three-panel figure shows a tablet, a cylindrical-shaped object, and the arm and hand of a person performing three different exercises. In panel a), the person’s hand holds the object with a cylindrical grasp, and the object turns orange. Panel b) shows the person’s hand performing a pinch grip on top of the cylindrical object while the object turns green. In panel c), the person’s hand holds the object in a horizontal position without ground support, while the object turns green.

[WEB] Internet or In-Person PT?

PHOTO CAPTION: Telehealth PT treatment can provide long-term relief and improvement of function in patients with various conditions.

As more clinics begin opening their doors to patients after relying on remote options, it’s worth considering whether one is better than the other.

By Therese Casey, PT, DPT, and Gerald Dolce, PT, DPT, Cert-DRN, COMT, OCS

Telehealth’s Impact on Healthcare and Physical Therapy

Telemedicine, aka telehealth, has been rapidly growing over the past 5 years. Due to the COVID-19 pandemic, we have seen even more of an increase in demand for this service. While the pandemic is starting to slow, telehealth should remain an option for patients, as it accommodates travel and busy schedules. Rapidly evolving telemedicine has been able to provide increased access to high-quality healthcare and is cost-effective.

Further Reading: Overcoming Telehealth Barriers for Stroke Survivors

According to the Centers for Medicare and Medicaid Services (CMS), telemedicine is “a service that seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician at a distant site.”¹ The concern in the physical therapy field remains: Which is better, telemedicine or in-clinic care? In order to answer this question, we have to dive into different diagnoses as well as visit how it may impact the care performed at home and in the clinic.

Benefits of In-Person Treatment

For certain conditions, in-person treatment has invaluable effects. The three major benefits of in-person treatment include manual therapy techniques, patient education, and ensuring proper body mechanics.

Manual Therapy

Manual therapy can consist of joint mobilizations, soft tissue mobilization, massage, scar mobilization, trigger point dry needling, Graston Technique, cupping, and more. These techniques require the skills of a licensed healthcare professional to be effective and safely completed. This is arguably the most skilled part of physical therapy and can make a significant impact on a patient’s pain management and recovery.

For example, a patient may require ankle joint mobilizations to improve motion needed to go down stairs. An individual with chronic headaches would likely benefit from a suboccipital release or dry needling to cervical muscles. Or a PT completing the Epley’s maneuver can fully resolve problems with dizziness for a patient who suffers from vertigo. These are techniques only a professional can perform and, ultimately, the power of touch helps to build rapport and trust with a patient.

Patient Education

For patients to fully understand their condition and appreciate the relevance of their treatment, education is key. Whether using a spine model, Netter Anatomy book, or layman’s terms, it is a PT’s role to convey the source of the condition and provide guidance on how to effectively manage it. For instance, a patient may not understand how pain in their back is causing numbness or tingling down their leg, or why weakness in their hips is causing pain on their outer knee.

After explaining how these items are interconnected, it is also necessary to ensure the patient understands why they are doing the therapeutic exercises that have been advised. For example, a PT can explain that they are performing sciatic nerve glides to decrease neural tension and subsequent tingling, or performing glute strengthening to prevent hip drop and subsequent knee pain while jogging.

Education can also be provided on self-mobilization techniques and utilization of therapy equipment to promote carryover between sessions and maintenance of therapeutic gains upon discharge. Patient education should start on day one and continue through the entirety of the plan of care.

Body Mechanics

Proper body mechanics are crucial to reduce stress on affected body regions and prevent reinjury. Squat form, gait mechanics on treadmill, and overhead lifts without compensation are examples of functional activities that require a skilled eye. Various views of squat, slow-motion video assessment on treadmill, and tactile cues to reduce excess upper trap activation during lifting help to ensure safe completion of these activities. Demonstration and feedback by a PT allow for improved comprehension of form by a patient.

While it could be argued that aspects of in-person treatment could be accomplished via telehealth, it would not be to the same degree. Personal touch and human interaction act as major drivers to patient success.

In Clinic vs At Home

As we look to expand how telehealth can contribute as a player in the future of healthcare, there are certain diagnoses that may be more advantageous to treat at home versus in the clinic. For example, much of low back research suggests that helping patients participate in functional movement helps improve symptoms over a set period of time, which could be completed at home. On the other hand, postoperative total hip arthroplasty (THA) may be better suited for in-clinic treatment. In the clinic, not only can a physical therapist provide guidance for maintaining hip precautions, but the postoperative THA patient also has access to the manual techniques the PT can perform and to certain equipment that may not be as readily available at home.

Further Reading: Revised Guidelines Regarding Cognitive Rehabilitation After TBI Focus on Telehealth

Whether in the clinic or at home, telehealth physical therapy clearly provides benefits and positive outcomes. It may be able to provide long-term relief and improvement of function for patients with various conditions. For example, in a trial of patients managed with total knee arthroplasty (TKA), a virtual PT program with skilled telerehabilitation was determined to be as effective as traditional PT for addressing function and disability and as safe as traditional PT in terms of pain and rehospitalization.² These findings suggest that virtual PT with a telehealth therapist for remote clinical monitoring and guidance should be considered for patients after TKA.² Overall, early intervention, consistency in treatment, and patient engagement will set up a patient for a successful outcome, regardless of the setting.

For certain conditions, in-person hands-on treatment has invaluable effects.

Equipment for In-Clinic and At Home

At-home equipment can have multiple advantages. First off, a patient can achieve similar results after successfully going through a demonstration in the clinic.

Traction

For example, a patient who is suffering from either cervical or lumbar discogenic pain may be able to obtain home lumbar and cervical traction units. In the clinic, we can utilize equipment such as the Chattanooga TX traction unit from Chattanooga Medical Supply, Chattanooga, Tenn, which can help with decompression, guided by the recommended parameters from the therapist. Fortunately, we can also achieve these same results with units such as ComforTrac CT by Zynex Medical, Englewood, Colo, which is more affordable and available for purchase by the patient. These units may also be covered by insurance, which makes them a more feasible option to continue treatment virtually once proper direction is given by the licensed clinician.

Strength and Conditioning

There are other conditions for which strength and conditioning equipment would be more appropriate. ACL reconstruction, ankle sprains, femoral acetabular impingement, and shoulder impingement are just a handful of conditions that would benefit from a structured program of progressive loading. An example would be increasing strength production after ACL reconstruction. After the initial stages of mini squat, progressing into 90-90 squatting at home with utilization of resistance bands can help make these exercises more challenging for the individual. Specifically, Cando Resistance bands made by Chattanooga Medical Supply can provide resistance to the lower extremities by stepping on the bands, creating a downward resistance effectively working lower extremity musculature.

Large

In-clinic equipment can be expensive and large, making it difficult to have at home. Something such as a simple leg press machine would not only suffice in strength production, but also to help improve knee range of motion for those progressing through ACL reconstruction, THA, and TKA. Having this type of equipment at the clinic is a benefit of attending in-person therapy sessions. The Cybex VR3 Leg Press made by Cybex International, Medway, Mass, is an example of a safe and effective machine that can achieve this in the clinic.

Small

We can also look to smaller equipment that can achieve balance and proprioception goals with this same patient population. The Fitterfirst Rockerboard from Fitterfirst in Calgary, Alberta, Canada, is a piece of equipment that we use in the clinic for this purpose. This is known as a professional device and would not be available to the general population.

Balance is a key ingredient in the treatment plan of patients with various conditions. Specifically, for patients who have a postoperative status, it may be beneficial for them to have a therapist to guard movements when using the Rockerboard as this may be unsafe for a patient to independently perform within their home, even if they did have access to one there. But the lack of availability of certain necessary equipment in patients’ homes is another example of how in-clinic treatment can provide benefits over telehealth.

Transitioning

As we look to achieve the best possible outcomes for our patients, we can select the best pieces of equipment to enhance recovery and advance patients in their treatment program. Once we achieve desired goals utilizing manual therapy, in-clinic equipment with therapist direction, and patient education, we can direct the patient to start to perform similar activities at home. Allowing patients to become independent and assisting them to acquire pieces of equipment that promote established goals set on the initial evaluation date will promote self-efficacy.

A Matter of Choice

To answer the question, “Is telehealth or in-clinic physical therapy superior?” we argue that both have an appropriate place in the healthcare field, but it ultimately depends on a patient’s condition and their access to technology as well as therapeutic equipment. A patient should select whichever treatment method allows them to feel most comfortable while at the same time maximizes their outcomes. PTP

Therese Casey, PT, DPT, is a physical therapist and clinic director at ATI Physical Therapy in Chicago. She received her Doctorate in Physical Therapy from Marquette University in 2017 and has been practicing as a PT at ATI for 4 years.

Gerald Dolce, PT, DPT, Cert-DRN, COMT, OCS, is a physical therapist and clinic director at ATI Physical Therapy in Las Vegas, specializing in advanced orthopedic conditions. A graduate from the Touro University Nevada physical therapy program, Dolce has been a practicing PT since 2017. For more information, contact PTPEditor@medqor.com.

References

1. Kichloo A, Albosta M, Dettloff K, et al. Telemedicine, the current COVID-19 pandemic and the future: a narrative review and perspectives moving forward in the USA. Fam Med Community Health. 2020;8(3):e000530 doi: 10.1136/fmch-2020-000530
2. Prvu Bettger J, Green CL, Holmes DN, et al. Effects of virtual exercise rehabilitation in-home therapy compare with traditional care after total knee arthroplasty. J Bone Joint Surg. 2020;102(2):101-109.

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[Abstract + References] Combined noninvasive brain stimulation virtual reality for upper limb rehabilitation poststroke: A systematic review of randomized controlled trials

Abstract

Upper limb impairments are common consequences of stroke. Noninvasive brain stimulation (NIBS) and virtual reality (VR) play crucial roles in improving upper limb function poststroke. This review aims to evaluate the effects of combined NIBS and VR interventions on upper limb function post-stroke and to provide recommendations for future studies in the rehabilitation field. PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. Randomized controlled trials (RCTs) encompassed patients with a confirmed stroke diagnosis, administrated combined NIBS and VR compared with passive (i.e., rest) or active (conventional therapy), and included at least one outcome assessing upper limb function (i.e., strength, spasticity, function) were selected. The quality of the included studies was assessed using the Cochrane Collaboration tool. Seven studies met the eligibility criteria. In total, 303 stroke survivors (Mean age: 61.74 years) were included in this review. According to the Cochrane Collaboration tool, five studies were classified as “high quality,” while two were categorized as “moderate quality”. There are mixed findings for the effects of combined NIBS and VR on upper limb function in stroke survivors. The evidence for the effects of combined transcranial direct current stimulation and VR on upper limb function post-stroke is promising. However, the evidence regarding the effects of combined repetitive transcranial magnetic stimulation and VR on upper limb function is limited. Further randomized controlled trials with long-term follow-up are strongly warranted.

References

1. Mortality and global health estimates (2019) Who.int. https://www.who.int/data/gho/data/themes/topics/topicdetails/GHO/gho-ghe-mortality-and-global-health-estimates
2. Buma FE, Kwakkel G, Ramsey NF (2013) Understanding upper limb recovery after stroke. Restor Neurol Neurosci 31(6):707–722. https://doi.org/10.3233/rnn-130332Article PubMed Google Scholar 
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[Abstract] Exergames as a rehabilitation tool to enhance the upper limbs functionality and performance in chronic stroke survivors: a preliminary study

Post-stroke hemiplegia commonly occurs in stroke survivors, negatively impacting the quality of life. Despite the benefits of initial specific post-acute treatments at the hospitals, motor functions and physical mobility need to be constantly stimulated to avoid regression and subsequent hospitalizations for further rehabilitation treatments. This preliminary study proposes using gamified tasks in a virtual environment to stimulate and maintain upper limb mobility through a single RGB-D camera-based vision system (using Microsoft Azure Kinect DK). This solution is suitable for easy deployment and use in home environments. A cohort of 10 post-stroke subjects attended a 2-week gaming protocol consisting of Lateral Weightlifting (LWL) and Frontal Weightlifting (FWL) gamified tasks and gait as the instrumental evaluation task. Despite its short duration, there were statistically significant results (p < 0.05) between the baseline (T0) and the end of the protocol (TF) for Berg Balance Scale and Time Up-and-Go (9.8% and -12.3%, respectively). LWL and FWL showed significant results for unilateral executions: rate in FWL had an overall improvement of 38.5% (p < 0.001) and 34.9% (p < 0.01) for the paretic and non-paretic arm, respectively; similarly, rate in LWL improved by 19.9% (p < 0.05) for the paretic arm and 29.9% (p < 0.01) for non-paretic arm. Instead, bilateral executions had significant results for rate and speed: considering FWL, there was an improvement in rate with p < 0.01 (31.7% for paretic arm and 37.4% for non-paretic arm), whereas speed improved by 31.2% (p < 0.05) and 41.7% (p < 0.001) for the paretic and non-paretic arm, respectively; likewise, LWL showed improvement in rate with p < 0.001 (29.% for paretic arm and 27.8% for non-paretic arm) and in speed with 23.6% (p < 0.05) and 23.5% (p < 0.01) for the paretic and non-paretic arms, respectively. No significant results were recorded for gait task, although an overall good improvement was detected for arm swing asymmetry (-22.6%). Hence, this study suggests the potential benefits of continuous stimulation of upper limb function through gamified exercises and performance monitoring over medium-long periods in the home environment, thus facilitating the patient’s general mobility in daily activities.

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[Abstract + References] Effects of robotic-assisted gait training on physical capacity, and quality of life among chronic stroke patients: A randomized controlled study

Abstract

Background

Even though robotic therapy is becoming more commonly used in research protocols for lower limb stroke rehabilitation, there still is a significant gap between research evidence and its use in clinical practice. Therefore, the present study was designed assuming that the wearable mobile gait device training for chronic stroke patients might have different effects on functional independence when compared to training with a stationary gait device. The present study aims to examine the effects of gait training with ExoAthlet exoskeleton and Lokomat Free-D on functional independence, functional capacity, and quality of life in chronic stroke patients.

Methods

The present study included 32 chronic stroke patients. Participants were randomly divided into two groups. Functional independence of patients was evaluated by using Functional Independence Measure (FIM), physical function was assessed by using the 30-second chair stand test (30-CST), functional capacity was measured by using the 6-Minute Walk Test (6MWT), and quality of life was assessed by using Short Form 36 (SF36). All participants underwent a conventional physiotherapy program for eight weeks, three sessions per week, and each session lasted 60 min. After the physiotherapy program, one group received gait training by using ExoAthlet exoskeleton (ExoAtlet 1 model/2019, Russia), while the other group received training by using Lokomat Free-D (Hocoma, Lokomat Pro Free-D model/2015, Switzerland). Participants were assessed at baseline and post-intervention.

Results

Results achieved in this study revealed that there was a statistically significant difference between FIM, 30-CST, 6MWT, and SF36 scores before and after the treatment in both groups (p < 0.05).There was no difference in FIM, 30-CST, and 6MWT results between Exoskeleton ExoAthlet and Lokomat Free-D groups (p > 0.05). However, there was a statistically significant difference between Exoskeleton ExoAthlet and Lokomat Free-D groups in terms of SF-36 sub-parameters “vitality”, “mental health”, “bodily pain”, and “general health perception” (p < 0.05).

Conclusions

This study demonstrated that the use of ExoAthlet exoskeleton and Lokomat Free-D in addition to conventional physiotherapy, was effective in improving functional independence, physical function, functional capacity, and quality of life among chronic stroke patients. Incorporation of robotic gait aids into rehabilitation for chronic stroke patients might offer significant advantages.

Introduction

Stroke is defined as a condition that develops due to a disturbance in brain functions, either in a specific location or in the whole brain, rapidly manifests symptoms, and these symptoms persist for one day or longer, or result in death [1]. Motor functions are affected in 65 % of chronic stroke patients, and the majority of these patients experience a reduced level of functional independence [2]. It is believed that the most prominent challenges faced by chronic stroke patients are the distance walked in 6 min and the decrease in functional capacity [3]. In addition, cohort studies also reported that 22 % of chronic stroke patients did not regain any walking function [4].

A significant portion of chronic stroke patients suffer not only from physical disability but also from cognitive and emotional disorders [5]. General predictors of the poor quality of life after a stroke were reported to include medical comorbidities, loss of physical function, social role difficulties, emotional involvement, and depression [6], [7], [8].

In recent years, robotic technology has exhibited notable advancement thanks to faster and more powerful computers, innovative computational methodologies, and a broader range of electromechanical components. This technological advancement also made robotics suitable for rehabilitation interventions, and robotic rehabilitation is a promising method for treating patients with motor disorders. Its significance lies in its the potential to increase and carefully control the dosage of therapy [9], [10]. However, robotic rehabilitation does not solely focus on augmenting the quantity and intensity of treatment.

Robotic systems not only generate simple and repetitive stereotypical movement patterns but can also be utilized in order to provide patients with more intricate and controlled multisensory stimuli [11]. It can be seen that the effect of rehabilitation technology on functional outcomes can be optimized by affording the nervous system greater opportunities to experience genuine activity-related sensorimotor input [12]. Nevertheless, there are ongoing studies examining the therapeutic effectiveness of robotic rehabilitation. In clinical rehabilitation practices addressing chronic stroke patients, robotic technologies are employed for gait training, providing opportunities to move freely on a stationary or mobile basis. Robotic devices are utilized as assistive, rehabilitative, and augmentative instruments in lower extremity rehabilitation for neurological conditions [13]. Considering the lower extremity rehabilitation, the Lokomat, utilized as a stationary device, was demonstrated to be effective in improving walking quality, speed, and balance in conditions such as Multiple Sclerosis, Cerebral Palsy, Parkinson’s disease, Brown-Sequard syndrome, and vascular dementia [14]. Moreover, Lokomat was also reported to be an effective approach used in the rehabilitation of chronic stroke patients. In the literature, a retrospective case-control study examined the efficacy of Lokomat Free-D on functional independence, functional capacity, and balance in chronic stroke patients [15]. It was also reported that Lokomat Free-D is effective in chronic stroke individuals, not only affecting motor functions such as walking, balance, muscle strength, walking ability, and speed but also cognitive and emotional status. [14]. However, to the best of our knowledge, there is no study examining the effectiveness of Lokomat on the quality of life in chronic stroke individuals could be found. Another method utilized for lower extremity rehabilitation is the use of mobile gait devices. Devices such as MIRAD, XoR, and ExoAthlet exoskeleton are some of them [13]. The ExoAthlet exoskeleton was found to increase gait speed and stability, as well as reducing body sway, in conditions such as Multiple Sclerosis and spinal cord injuries [16], [17]. In a randomized controlled study comparing ExoAthlet exoskeleton and traditional physiotherapy in chronic stroke patients, the ExoAthlet exoskeleton group exhibited significant improvements when compared to the traditional physiotherapy group. The ExoAthlet exoskeleton group had a decrease in hemiparesis severity, an increase in paretic limb muscle strength, improvement in balance, and notable enhancements in the walking process and speed [18]. However, there is no study available that examines the effectiveness of the ExoAthlet exoskeleton on quality of life in chronic stroke patients. In both literature and clinical practice, there are gaps concerning the effectiveness of Lokomat Free-D and ExoAthlet exoskeleton on different parameters. There is no study available that has comparing these two different methods among chronic stroke patients. Finally, this study aims to examine the effects of gait training with the ExoAthlet exoskeleton and Lokomat Free-D on functional independence, functional capacity, and quality of life in chronic stroke patients, as well as to investigate whether there are any different effects.

Section snippets

Study design and ethics

Study design: Randomized Controlled Study.

Ethics: The study protocol was approved by from the institutional ethics board of Üsküdar University’s Non-Interventional Ethics Committee (Approval no = 61351342/February 2021-66/26.02.2021). The present study was carried out in accordance with the principles outlined in the Declaration of Helsinki. Participants, who voluntarily agreed to participate in this study, signed a written consent form. The paper is registered with ClinicalTrials.gov, and the

Results

Initially, 40 chronic stroke patients were involved in the study, and 8 individuals did not meet the inclusion criteria. Thus, the study was completed with a total of 32 individuals. The flow chart of the study is presented in Fig. 3.

The sociodemographic characteristics of the chronic stroke patients included in the study are shown in Table 1.

The results of this study showed that there was a statistically significant difference between functional independence, functional capacity, and quality

Discussion

Significant advancements have been achieved in robotic technology, especially in the last ten years, and the use of robotic technology in healthcare has increased. The use of robotic technology increased in post-stroke rehabilitation due to its advantages such as performing movements very similar to normal activity, providing continuous stimulation of the central nervous system, and creating treatment options with appropriate intensity and dosage for the patient during the rehabilitation

Limitations and future directions

The study has some limitations. The long-term effects of robotic-assisted gait training were not evaluated in this study. Additionally, different psychometric properties that would affect the quality of life were ignored. Future studies taking these parameters into consideration may provide different perspectives on the interpretation of results.

Conclusion

In conclusion, the results achieved in this study showed that gait training with Exoskeleton ExoAthlete and gait training with Lokomat Free-D for eight weeks administered in addition to conventional physiotherapy have positive effects on functional independence, functional capacity, and quality of life parameters in post-stroke patients. Training with Exoskeleton ExoAthlet had a more positive effect on the quality-of-life sub-parameters, such as vitality, mental health, bodily pain, and general 

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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