Posts Tagged review

[ARTICLE] Agent-based systems for telerehabilitation: strengths, limitations and future challenges (PDF Download Available) – Full Text

Abstract
Telerehabilitation in older adults is most needed in the patient environments, rather than in formal ambulatories or hospitals. Supporting such practices brings significant advantages to patients, their family, formal and informal caregivers, clinicians, and researchers. Several techniques and technologies have been developed aiming at facilitating and enhancing the effectiveness of telerehabilitation. This paper gives a quick overview of the state of the art, investigating video-based, wear-able, robotic, distributed, and gamified telerehabilitation solutions. In particular, agent-based solutions are analyzed and discussed addressing strength, limitations, and future challenges. Elaborating on functional requirements expressed by professional physiotherapists and researchers, the need for extending multi-agent systems (MAS) peculiarities at the sensing level in wearable solutions establishes new research challenges. Employed in cyber-physical scenarios with users-sensors and sensors-sensors interactions, MAS are requested to handle timing constraints, scarcity of resources and new communication means, which are crucial for providing real-time feedback and coaching.
1 Introduction
Healthcare institutions are facing the strain of a significantly larger elderly population [1]. Lengthening life expectancy is met by an increasing demand for medical and technological contributions to extend the ”good-health”, and disability free period.
The major factor catalyzing the elderly’s impairing process is the progres-
sive reduction of mobility, due to the natural aging process, inactivity, dis-
eases such as osteoarthritis, stroke or other neurological conditions, falls with its consequences, such as fear of falls (leading to inactivity), or fractures (needing surgery).Despite the emergence of less-invasive surgical techniques, post-intervention rehabilitation still requires extended periods and tailored therapies, which usually involve complications. Performing traditional rehabilitative practices is leading to a significant increase in public-health costs and, in some cases a lack of resources, thus worsening the services’ quality. Rehabilitation is often a long process and needs to be sustained long after the end of the acute care. Simplifying the access to health services [2] can raise the number of patients, maintaining (or even increasing) the quality of care. For example, patients requiring support, such as continuous or selective monitoring, can benefit from systems that automatically transmit the information gathered in their domestic environment to the health clinics, thus enabling telemonitoring on their health conditions [3].
Although in traditional solutions telemonitoring is a self-contained practice
limited to passively observing the patients, the need for remote sensing is crucially coupled with the need for coaching older adults in their daily living [4,5].
For example, a critical activity such as telerehabilitation cannot be limited
to observing the patients’ behaviors. Indeed, patient adherence and acceptability of rehabilitative practices need to be actively enhanced, overcoming pitfalls due to motor (e.g., endurance), non-motor (e.g., fatigue, pain, dysautonomic symptoms, and motivational), and cognitive deficits. According to Rodriguez et al. [6], telerehabilitation can be formally defined as:
“the application of telecommunication, remote sensing and operation tech-
nologies, and computing technologies to assist with the provision of med-
ical rehabilitation services at a distance.”
Patients, physiotherapists, and health institutes can gain several benefits
from an extensive adoption of telerehabilitation systems [7]. Considering the
economical point of view, Mozaffarian et al. [8] figured out that the total cost
of stroke in the US was estimable to be 34.3 billion dollars in 2008, rising up to 69.1 billion dollars in 2016.
Even though to date they are not precisely quantifiable due to insufficient evidence [9], Mutingi et al. [10] presented as “inevitable advantages”
(i) a substantial cost saving primarily due to the reduction of specialized human resources,
(ii) an enhancement of patient comfort and lifestyle, and (iii) improvements of therapy and decision making processes. Moreover, Morreale et al. [11] mentioned one of the most appreciated benefits: the increase of adherence to rehabilitation protocols.
The multitude of scientific contributions fostering telerehabilitation exploits
new technologies and various architectures to better understand and serve user requirements. However, due to technological or technical limitations, physiotherapists’ needs have not yet been completely satisfied. To fill this gap, a system evolution is required. For example, telerehabilitation systems cannot offer the same behavior to users with diverse conditions. Viceversa, according to the environment condition, they must rather be able to adapt themselves to the user needs [6].
Telerehabilitation is characterized by a very delicate equilibrium between
environment, devices, and users. Thus, the capabilities such as self adaptation, flexibility, and ubiquity are crucial to facilitate and promote the usability and then the actual practices.
Agent-based systems for telerehabilitation: strengths, limitations and future challenges (PDF Download Available). Available from: https://www.researchgate.net/publication/316790326_Agent-based_systems_for_telerehabilitation_strengths_limitations_and_future_challenges [accessed May 26, 2017].

Continue —> Agent-based systems for telerehabilitation: strengths, limitations and future challenges (PDF Download Available)

Fig. 2. Agent-based sensing: future challenge for telerehabilitation MAS. 

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[ARTICLE] Visual Impairment Following Stroke – The Impact on Quality of Life: A Systematic Review – Full Text PDF

ABSTRACT

Background: The visual impairments caused by stroke have the potential to affect the ability of an individual to perform activities of daily living. An individual with visual impairment may also have reduced level of independence. The purpose of this review was to investigate the impact on quality of life from stroke related visual impairment, using subjective patient reported outcome measures.

Methods: A systematic search of the literature was performed. The inclusion criteria required studies to have adult participants (aged 18 years or over) with a diagnosis of a visual impairment directly resulting from a stroke. Studies which included visual impairment as a result of other intracranial aetiology, were included if over half of the participants were stroke survivors. Multiple scholarly online databases and registers of published, unpublished and ongoing trials were searched, in addition articles were hand searched. MESH terms and alternatives in relation to stroke and visual conditions were used. Study selection was performed by two authors independently. Data was extracted by one author and verified by a second. The quality of the evidence was assessed using a quality appraisal tool and reporting guidelines.

Results: This review included 11 studies which involved 5646 participants, the studies used a mixture of generic and vision-specific instruments. The seven instruments used by the included studies were the EQ-5D, LIFE-H, SF-36, NEI VFQ-25, VA LV VFQ-48, SRA-VFP and DLTV.

Conclusion: A reduction in quality of life was reported by all studies in stroke survivors with visual impairment. Some studies used generic instruments, therefore making it difficult to extract the specific impact of the visual impairment as opposed to the other deficits caused by stroke. The majority of studies (8/11) primarily had participants with visual field loss. This skew towards visual field loss and no studies investigating the impact ocular motility prevented a comparison of the effects on quality of life due to different visual impairments caused by stroke. In order to fully understand the impact of visual impairment following stroke on quality of life, further studies need to use an appropriate vision-specific outcome measure and include all types of visual impairment which can result from a stroke.

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[Abstract] Functional Electrical Stimulation Improves Activity After Stroke: A Systematic Review With Meta-Analysis

Abstract

Objective

To investigate the effect of functional electrical stimulation (FES) in improving activity and to investigate whether FES is more effective than training alone.

Data Sources

Cochrane Central Register of Controlled Trials, Ovid Medline, EBSCO Cumulative Index to Nursing and Allied Health Literature, Ovid EMBASE, Physiotherapy Evidence Database (PEDro), and Occupational Therapy Systematic Evaluation of Effectiveness.

Study Selection

Randomized and controlled trials up to June 22, 2014, were included following predetermined search and selection criteria.

Data Extraction

Data extraction occurred by 2 people independently using a predetermined data collection form. Methodologic quality was assessed by 2 reviewers using the PEDro methodologic rating scale. Meta-analysis was conducted separately for the 2 research objectives.

Data Synthesis

Eighteen trials (19 comparisons) were eligible for inclusion in the review. FES had a moderate effect on activity (standardized mean difference [SMD], .40; 95% confidence interval [CI], .09–.72) compared with no or placebo intervention. FES had a moderate effect on activity (SMD, .56; 95% CI, .29–.92) compared with training alone. When subgroup analyses were performed, FES had a large effect on upper-limb activity (SMD, 0.69; 95% CI, 0.33–1.05) and a small effect on walking speed (mean difference, .08m/s; 95% CI, .02–.15) compared with control groups.

Conclusions

FES appears to moderately improve activity compared with both no intervention and training alone. These findings suggest that FES should be used in stroke rehabilitation to improve the ability to perform activities.

Source: Functional Electrical Stimulation Improves Activity After Stroke: A Systematic Review With Meta-Analysis – Archives of Physical Medicine and Rehabilitation

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[Abstract] Effect of electrical stimulation as an adjunct to botulinum toxin type A in the treatment of adult spasticity: a systematic review

Objective: To investigate whether electrical stimulation (ES) as an adjunct to BTX-A boosts botulinum activity and whether the combined therapeutic procedure is more effective than BTX-A alone in reducing spasticity in adult subjects.

Data sources: A search was conducted in PubMed, EMBASE, Cochrane Central Register, and CINAHL from January 1966 to January 2016.

Study selection: Only randomized controlled studies (RCT) involving the combination of BTX-A and ES were considered. RCTs were excluded if BTX plus ES was investigated in animals or healthy subjects; certain techniques were used as an adjunct to BTX-A, but ES was not used; BTX-A or ES were compared but were not used in combination. ES was divided into neuromuscular stimulation (NMS), functional electrical stimulation (FES), and transcutaneous electrical nerve stimulation (TENS). Two authors independently screened all search results and reviewed study characteristics using the Physiotherapy Evidence Database (PEDro) scale.

Results: Fifteen RCTs were pinpointed and nine studies were included. Trials varied in methodological quality, size, and outcome measures used. ES was used in the form of NMS and FES in seven and two studies, respectively. No study investigating BTX-A plus TENS was found. BTX-A plus ES produced significant reduction in spasticity on the Ashworth Scale (AS) and on the modified AS in seven studies, but only four showed high quality on the PEDro scale. Significant reduction in compound muscular action potential (CMAP) amplitude was detected after BTX-A plus ES in two studies.

Conclusions: ES as an adjunctive therapy to BTX-A may boost BTX-A action in reducing adult spasticity, but ES variability makes it difficult to recommend the combined therapy in clinical practice.

Implications for rehabilitation

  • Electrical stimulation (ES) as adjunct to botulinum toxin type A (BTX-A) injections may boost neurotoxin action in treating adult spasticity.

  • Given the variability of ES characteristics and the paucity of high-quality trials, it is difficult to support definitively the use of BTX-A plus ES to potentiate BTX-A effect in clinical practice.

  • A vast array of rehabilitation interventions combined with BTX-A have been provided in reducing spasticity, but the present evidence is not sufficient to recommend any combined therapeutic strategy.

Source: Effect of electrical stimulation as an adjunct to botulinum toxin type A in the treatment of adult spasticity: a systematic review: Disability and Rehabilitation: Vol 0, No 0

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[REVIEW] Screening methods for post-stroke visual impairment: a systematic review – Full Text

Purpose: To provide a systematic overview of the various tools available to screen for post-stroke visual impairment.

Methods: A review of the literature was conducted including randomised controlled trials, controlled trials, cohort studies, observational studies, systematic reviews and retrospective medical note reviews. All languages were included and translation was obtained. Participants included adults ≥18 years old diagnosed with a visual impairment as a direct cause of a stroke. We searched a broad range of scholarly online resources and hand-searched articles registers of published, unpublished and on-going trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. Study selection was performed by two authors independently. The quality of the evidence and risk of bias were assessed using the STROBE, GRACE and PRISMA statements.

Results: A total of 25 articles (n = 2924) were included in this review. Articles appraised reported on tools screening solely for visual impairments or for general post-stroke disabilities inclusive of vision. The majority of identified tools screen for visual perception including visual neglect (VN), with few screening for visual acuity (VA), visual field (VF) loss or ocular motility (OM) defects. Six articles reported on nine screening tools which combined visual screening assessment alongside screening for general stroke disabilities. Of these, three included screening for VA; three screened for VF loss; three screened for OM defects and all screened for VN. Two tools screened for all visual impairments. A further 19 articles were found which reported on individual vision screening tests in stroke populations; two for VF loss; 11 for VN and six for other visual perceptual defects. Most tools cannot accurately account for those with aphasia or communicative deficits, which are common problems following a stroke.

Conclusion: There is currently no standardised visual screening tool which can accurately assess all potential post-stroke visual impairments. The current tools screen for only a number of potential stroke-related impairments, which means many visual defects may be missed. The sensitivity of those which screen for all impairments is significantly lowered when patients are unable to report their visual symptoms. Future research is required to develop a tool capable of assessing stroke patients which encompasses all potential visual deficits and can also be easily performed by both the patients and administered by health care professionals in order to ensure all stroke survivors with visual impairment are accurately identified and managed.

  • Implications for Rehabilitation
  • Over 65% of stroke survivors will suffer from a visual impairment, whereas 45% of stroke units do not assess vision.

  • Visual impairment significantly reduces the quality of life, such as being unable to return to work, driving and depression.

  • This review outlines the available screening methods to accurately identify stroke survivors with visual impairments.

  • Identifying visual impairment after stroke can aid general rehabilitation and thus, improve the quality of life for these patients.

Continue —> Screening methods for post-stroke visual impairment: a systematic review: Disability and Rehabilitation: Vol 0, No 0

Figure 1. Flowchart for the pathway of included articles.

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[Systematic Review] Increasing the amount of usual rehabilitation improves activity after stroke – Full Text

Abstract

Questions: In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity? What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect? Design: Systematic review with meta-analysis of randomised trials. Participants: Adults aged 18 years or older that had a diagnosis of stroke. Intervention: Extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitations of the lower and/or upper limb. Outcome measures: Activity measured as lower or upper limb ability. Results: A total of 14 studies, comprising 15 comparisons, met the inclusion criteria. Pooling data from all the included studies showed that extra rehabilitation improved activity immediately after the intervention period (SMD = 0.39, 95% CI 0.07 to 0.71, I2 = 66%). When only studies with a large increase in rehabilitation (> 100%) were included, the effect was greater (SMD 0.59, 95% CI 0.23 to 0.94, I2 = 44%). There was a trend towards a positive relationship (r = 0.53, p = 0.09) between extra rehabilitation and improved activity. The turning point on the ROC curve of false versus true benefit (AUC = 0.88, p = 0.04) indicated that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity. Conclusion: Increasing the amount of usual rehabilitation aimed at reducing activity limitations improves activity in people after stroke. The amount of extra rehabilitation that needs to be provided to achieve a beneficial effect is large.


Introduction

Stroke is the leading cause of disability worldwide.1 Difficulty walking and using the arm to complete self-care tasks are the most common activity limitations reported by stroke survivors.2 and 3 Practice is essential for motor learning and needs to be structured to offer a progressive challenge to reduce activity limitations.4, 5, 6 and 7 Consequently, clinical practice guidelines for stroke rehabilitation worldwide recommend that programs deliver a large amount of practice in order to maximise outcome after stroke.8, 9 and 10

Several systematic reviews have explored the effect of the amount of practice on outcome after stroke.5, 6, 7, 11, 12, 13 and 14 Three systematic reviews with meta-analyses have specifically investigated the effect of extra practice on motor outcomes after stroke. Kwakkel et al11 found that extra rehabilitation improved activities of daily living (SMD 0.13, 95% CI 0.03 to 0.23, 24 randomised trials). Verbeek et al6 found that extra lower limb rehabilitation within 6 months of stroke improved walking ability (SMD 0.32, 95% CI 0.11 to 0.52, 11 randomised trials) and walking speed (SMD 0.22, 95% CI 0.01 to 0.43, eight randomised trials). Most recently, Lohse et al5 found that extra rehabilitation improved outcome (SMD 0.35, 95% CI 0.26 to 0.45, 34 randomised trials). Furthermore, previous reviews have suggested that there is a dose-response relationship, where the greater the extra rehabilitation, the greater the benefit,5, 6, 7, 11, 12 and 14 regardless of time after stroke.5

Importantly, however, these previous systematic reviews included trials that did not investigate different doses of the same content of rehabilitation. For example, some of the included trials compared the effect of rehabilitation with no rehabilitation. Other included trials provided extra rehabilitation that was of different content to the usual rehabilitation, thereby confounding the analysis of amount of rehabilitation with type of rehabilitation. Cooke et al12 recognised these limitations and examined seven trials where the extra rehabilitation was delivered on top of usual rehabilitation and was of the same content. A meta-analysis of the seven studies was not performed, but the effect sizes of several trials with the same outcomes suggested that there was some evidence supporting the hypothesis that extra rehabilitation on top of usual rehabilitation improves outcomes after stroke.12

Rehabilitation is resource intensive, both on the part of the patient and the healthcare system. It is therefore important to determine the effect of increasing the amount of usual rehabilitation after stroke, and to ensure that this estimate is not confounded by the effect of extra rehabilitation of different content. Therefore, the aim of this review was to examine the effect of extra rehabilitation of the same content on top of usual rehabilitation.

Therefore, the research questions for this systematic review were:

    1.

    In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity?

    2.

    What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect?

Continue —> Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review

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Figure 1. Flow of studies through the review. a Papers may have been excluded for failing to meet more than one inclusion criterion.

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[Abstract] Effects of Robot-Assisted Therapy for the Upper Limb After Stroke

Abstract

Background. Robot technology for poststroke rehabilitation is developing rapidly. A number of new randomized controlled trials (RCTs) have investigated the effects of robot-assisted therapy for the paretic upper limb (RT-UL).

Objective. To systematically review the effects of poststroke RT-UL on measures of motor control of the paretic arm, muscle strength and tone, upper limb capacity, and basic activities of daily living (ADL) in comparison with nonrobotic treatment.

Methods. Relevant RCTs were identified in electronic searches. Meta-analyses were performed for measures of motor control (eg, Fugl-Meyer Assessment of the arm; FMA arm), muscle strength and tone, upper limb capacity, and basic ADL. Subgroup analyses were applied for the number of joints involved, robot type, timing poststroke, and treatment contrast. Results. Forty-four RCTs (N = 1362) were included. No serious adverse events were reported. Meta-analyses of 38 trials (N = 1206) showed significant but small improvements in motor control (~2 points FMA arm) and muscle strength of the paretic arm and a negative effect on muscle tone. No effects were found for upper limb capacity and basic ADL. Shoulder/elbow robotics showed small but significant effects on motor control and muscle strength, while elbow/wrist robotics had small but significant effects on motor control.

Conclusions. RT-UL allows patients to increase the number of repetitions and hence intensity of practice poststroke, and appears to be a safe therapy. Effects on motor control are small and specific to the joints targeted by RT-UL, whereas no generalization is found to improvements in upper limb capacity. The impact of RT-UL started in the first weeks poststroke remains unclear. These limited findings could mainly be related to poor understanding of robot-induced motor learning as well as inadequate designing of RT-UL trials, by not applying an appropriate selection of stroke patients with a potential to recovery at baseline as well as the lack of fixed timing of baseline assessments and using an insufficient treatment contrast early poststroke.

 

Source: Effects of Robot-Assisted Therapy for the Upper Limb After Stroke

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[Review] Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review – Full Text

Abstract

Question: In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity? What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect?

Design: Systematic review with meta-analysis of randomised trials.

Participants: Adults aged 18 years or older that had a diagnosis of stroke.

Intervention: Extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitations of the lower and/or upper limb.

Outcome measures: Activity measured as lower or upper limb ability.

Results: A total of 14 studies, comprising 15 comparisons, met the inclusion criteria. Pooling data from all the included studies showed that extra rehabilitation improved activity immediately after the intervention period (SMD = 0.39, 95% CI 0.07 to 0.71, I2 = 66%). When only studies with a large increase in rehabilitation (> 100%) were included, the effect was greater (SMD 0.59, 95% CI 0.23 to 0.94, I2 = 44%). There was a trend towards a positive relationship (r = 0.53, p = 0.09) between extra rehabilitation and improved activity. The turning point on the ROC curve of false versus true benefit (AUC = 0.88, p = 0.04) indicated that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity.

Conclusion: Increasing the amount of usual rehabilitation aimed at reducing activity limitations improves activity in people after stroke. The amount of extra rehabilitation that needs to be provided to achieve a beneficial effect is large.

 Introduction

Stroke is the leading cause of disability worldwide.1 Difficulty walking and using the arm to complete self-care tasks are the most common activity limitations reported by stroke survivors.2 and 3 Practice is essential for motor learning and needs to be structured to offer a progressive challenge to reduce activity limitations.4, 5, 6 and 7 Consequently, clinical practice guidelines for stroke rehabilitation worldwide recommend that programs deliver a large amount of practice in order to maximise outcome after stroke.8, 9 and 10

Several systematic reviews have explored the effect of amount of practice on outcome after stroke.5, 6, 7, 11, 12, 13 and 14 Three systematic reviews with meta-analyses have specifically investigated the effect of extra practice on motor outcomes after stroke. Kwakkel et al11 found that extra rehabilitation improved activities of daily living (SMD 0.13, 95% CI 0.03 to 0.23, 24 randomised trials). Verbeek et al6 found that extra lower limb rehabilitation within 6 months of stroke improved walking ability (SMD 0.32, 95% CI 0.11 to 0.52, 11 randomised trials) and walking speed (SMD 0.22, 95% CI 0.01 to 0.43, eight randomised trials). Most recently, Lohse et al5 found that extra rehabilitation improved outcome (SMD 0.35, 95% CI 0.26 to 0.45, 34 randomised trials). Furthermore, previous reviews have suggested that there is a dose-response relationship, where the greater the extra rehabilitation, the greater the benefit,5, 6, 7, 11, 12 and 14 regardless of time after stroke.5

Importantly, however, these previous systematic reviews included trials that did not investigate different doses of the same content of rehabilitation. For example, some of the included trials compared the effect of rehabilitation with no rehabilitation. Other included trials provided extra rehabilitation that was of different content than the usual rehabilitation, thereby confounding the analysis of amount of rehabilitation with type of rehabilitation. Cooke et al12 recognised these limitations and examined seven trials where the extra rehabilitation was delivered on top of usual rehabilitation and was of the same content. A meta-analysis of the seven studies was not performed, but the effect sizes of several trials with the same outcomes suggested that there was some evidence supporting the hypothesis that extra rehabilitation on top of usual rehabilitation improves outcomes after stroke.12

Rehabilitation is resource intensive, both on the part of the patient and the healthcare system. It is therefore important to determine the effect of increasing the amount of usual rehabilitation after stroke, and to ensure that this estimate is not confounded by the effect of extra rehabilitation of different content. Therefore, the aim of this review was to examine the effect of extra rehabilitation of the same content on top of usual rehabilitation.

Therefore, the research questions for this systematic review were:

1.

In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity?

2.

What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect?

Continue —>  Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review

 

 

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[Review] Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery – Full Text PDF

Abstract

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients’ mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients.

This multiple systematic review focuses both on standard treatment methods and on innovating  rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed.

At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some  interventions may be under debate, motor skill learning and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Introduction

The World Health Organisation (WHO) estimates that stroke events in EU countries are likely to increase by 30% between 2000 and 2025 (Truelsen et al., 2006). The most common deficit after stroke is hemiparesis of the contralateral upper limb, with more than 80% of stroke patients experiencing this condition acutely and more than 40% chronically (Cramer et al., 1997).

Common manifestations of upper extremity motor impairment include muscle weakness or contracture, changes in muscle tone, joint laxity and impaired motor control. These impairments induce disabilities in common activities such as reaching, picking up objects, and holding onto objects (for a review on precision grip deficits, see Bleyenheuft and Gordon, 2014).

Motor paresis of the upper extremity may be associated with other neurological manifestations that affect the recovery of motor function and thus require focused therapeutic intervention. Deficits in somatic sensations (body senses such as touch, temperature, pain and proprioception)  after stroke are common with prevalence rates variously reported to be 11%-85% (Carey et al., 1993; Hunter, 2002; Yekutiel, 2000). Functionally, the motor problems resulting from sensory deficits after stroke can be summarized as (1) impaired detection of sensory information, (2) disturbed motor tasks performance requiring somatosensory information, and (3) diminished upper extremity rehabilitation outcomes (Hunter, 2002). Sensation is essential for safety even  if there is adequate motor recovery (Yekutiel, 2000). Also, up to 50% of patients experience  pain of the upper extremity during the first year after stroke, especially shoulder pain and complex regional pain syndrome-type I (CRPS-type I), which may impede adequate early rehabilitation (Jönsson et al., 2006; Kocabas et al., 2007; Lundström et al., 2009; Sackley et al.,2008). Furthermore, joint subluxation and muscle contractures can lead to nociceptive musculoskeletal pain (de Oliveira et al., 2012). Among other complications of stroke the neglect syndrome (Ringman et al., 2004) and spasticity (Sommerfeld et al., 2004; Welmer et al., 2010) affect motor and functional outcomes.

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