Posts Tagged self-rehabilitation
[ARTICLE] Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial – Full Text
After discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to “maintenance” rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.
One hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician’s prescription.
The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.
This study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.
The most common motor deficit following stroke is spastic hemiparesis . More than 90% of patients with hemiparesis recover some lower limb function after a stroke, but rarely with a level of ease or speed that would allow for independent and comfortable ambulation in everyday life, outdoors in particular [1, 2, 3]. In the upper limb, the proportion of patients that recover daily use of the arm is estimated between 10 and 30% [4, 5, 6, 7, 8]. Consequently, around half of stroke survivors do not resume professional activities, and two thirds remain chronically disabled .
In parallel, most patients in chronic stages have their rehabilitation discontinued or converted into “maintenance” therapy, as professionals often estimate that they might no longer progress [7, 10, 11, 12, 13, 14, 15]. Others benefit from reinduction periods, prescribed according to subjective or ill-defined criteria. It has not been demonstrated that this conventional rehabilitation system now fits current knowledge on behavior-induced brain plasticity and on the potential for motor recovery in chronic spastic paresis [16, 17, 18]. Indeed, a significant body of evidence demonstrates that high intensity of rehabilitation (the opposite of “maintenance therapy”) correlates with motor function improvement in chronic stages [16, 19, 20]. One way to achieve sufficient amounts of physical treatment might be to adequately guide and motivate the patient into practicing self-rehabilitation [18, 20]. It has been confirmed that programs of exercises given by the therapist to be performed at home are appreciated by patients not only for the structure they give to everyday life, but also as they represent in themselves a source of motivation and hope, particularly when these programs are associated with ongoing professional support [21, 22].
We hypothesize that there is confusion between the lesion-induced plasticity of the central nervous system – essentially during the first 6 months post-lesion – and the behavior-induced plasticity, which lasts indefinitely [16, 17, 23, 24, 25, 26, 27]. The latter justifies initiatives to organize chronic and intense physical rehabilitation work [17, 18, 23, 24, 25, 26, 27, 28]. Even though previous, short-term open studies evaluating self-rehabilitation programs in spastic hemiparesis suggested the possibility of functional improvement, to our knowledge there are no large-scale prospective randomized controlled protocols that test the effectiveness of long term self-rehabilitation programs in spastic hemiparesis as against conventional rehabilitation systems, especially in chronic stages [29, 30, 31, 32, 33, 34, 35, 36].
Technically, which home rehabilitation exercises might be recommended? From a neurophysiological point of view, muscle overactivity chronologically emerges as the third fundamental feature of motor impairment that begins in the subacute phase in hemiparesis, following paresis and soft tissue contracture that appear in the acute phase [37, 38, 39]. One recognizable form of muscle overactivity is spasticity (hyper-reflectivity to phasic stretch), which is potentiated by muscle shortening [37, 38]. Hypersensitivity to stretch in an antagonist muscle also impedes voluntary motoneurone recruitment for the agonist muscle, a phenomenon called “stretch-sensitive paresis” . As none of the three fundamental mechanisms of motor impairment (paresis, muscle shortening, and muscle overactivity) is distributed symmetrically between agonists and antagonists, there are force imbalances around joints, hindering active movements and deforming body postures . Each of these three mechanisms of impairment, particularly the two most important, which are muscle shortening and muscle overactivity, can be specifically targeted with local treatment, muscle by muscle, aiming to rebalance forces, joint by joint . For the less overactive muscles around each joint, an intensive motor training will aim to break the vicious cycle Paresis-Disuse-Paresis . For their shortened and more overactive antagonists most importantly, a daily program of self-stretch postures at high load combined with a program of maximal amplitude rapid alternating movements, potentially associated with botulinum toxin injections, will aim to increase muscle extensibility and reduce cocontraction, breaking the vicious cycle: Muscle shortening-Overactivity-Muscle shortening [28, 42, 43] (www.i-gsc.com). Significant preliminary results obtained using prescription and teaching of self-rehabilitation programs within a Guided Self-rehabilitation Contract (GSC) led us to hypothesize that this method practiced over the long term might enhance active motor function in chronic hemiparesis beyond 1 year following stroke [18, 44, 45, 46, 47, 48].
From a social point of view, stroke is the leading cause of acquired disability in Western countries. For the Steering Committee on Stroke Prevention and Management in France, the yearly cost of stroke is €5.9 billions, the cost of care in medical and social facilities is €2.4 billions and the cost of daily allowances and disability pensions is €125.8 millions . Additionally, several studies have shown that indirect costs were proportional to direct costs . Stroke thus accounts for a large share of health expenditures. In that regard as well, devising a feasible and effective guided self-rehabilitation program might offer financial advantages for our health systems.[…]
[ARTICLE] Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study -Full Text
Introduction Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke.
Methods and analysis 220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored.
Strengths and limitations of this study
This study is the first to assess the effects of a self-rehabilitation in addition of usual treatments over a long period (6 months).
This study will include a large sample with patients from 16 hospitals across all the country.
The design of this study (randomised, controlled, assessor blinded study) tends to meet the highest level of evidence.
This study would permit to apply recommendations to improve patients limitations with little additional cost to the already limited health system budget.
Stroke is the second highest cause of death worldwide and the fourth leading cause of lost productivity (disability-adjusted life years) according to WHO. The annual incidence is around 130 000 new cases each year in France.1 Around half of survivors are left with some functional limitations as a result of multiple impairments including motor impairments with a loss of strength, stereotyped movements and changes in muscle tone.2 3 Following stroke, about one-third of people with motor deficits have complete upper limb recovery, one-third have a partial recovery, with capacity to carry a bag or to point to an object and, one-third have little to no recovery of function with often dependence for activities of daily living.4 Among impairments, positive signs of the upper motor neuron syndrome (spasticity, cocontraction and dystonia) are associated with active motor dysfunction and disabilities to use arm in daily living activities.5 6 Gait limitations following symptoms of upper motor neuron syndrome reduce also displacements and participation of patients with stroke.7 8 Although 65%–85% of stroke survivors regain the capacity to walk, their gait is slower and their cadence, step length and single support phase of gait cycle are reduced in comparison with healthy subjects.9 These spatio-temporal changes are associated with joint kinematics changes, such as reduced peak hip flexion,10 reduced peak knee flexion during swing (stiff knee gait)10 11 and reduced ankle dorsiflexion (equinus).10 Motor impairments are largely involved in these kinematic abnormalities, particularly spasticity of quadriceps reducing knee flexion in stiff knee gait11 and spasticity of the ankle plantar flexors contributing to the equinus.12
Physiotherapy has been shown to be effective for the treatment of motor impairment and the improvement of function following stroke.13 14 Different techniques have been developed, however, one has not been shown more effective than another.15 16 Nevertheless, it has been demonstrated that the intensity, the frequency and the specificity (to train specifically the task to improve) of physiotherapy is positively correlated with recovery.17–20 To increase the duration and the specificity of physiotherapy lead indeed to greater improvements in impairments and functional limitations. French et al 21 published a systematic review relating positive effects of repetitive functional task practice on upper and lower limb function in 1078 patients with stroke.21 Van de Port et al 22 showed indeed that intensive circuit training organised in specific workstations induced greater locomotor improvements than usual physiotherapy in 250 chronic outpatients with stroke.22 This likely suggests that patients do not attempt their maximal potential of recovery when they benefit of usual care. This means also that an adjuvant care might permit to the patients to reach their maximal capacity and thus reducing the impact of impairments and functional limitations. Moreover, many studies highlighted that improvements continue and are effective in chronic patients with stroke who follow intensive active rehabilitation.13 23 Currently, because of the constraints within the French health system, patients with stroke living at home usually receive only 1.7 sessions of 20–30 min of physiotherapy per week.24 These sessions, which last about 30 min, usually only consist of stretching and strengthening exercises. This contrasts with recommendations of intensive rehabilitation for chronic patients due to functional deteriorations observed when patients decrease or stop their rehabilitation.19 20 25 This suggests the necessity to develop novel approaches which could increase the intensity and specificity of rehabilitation for chronic patients with stroke living at home. A self-rehabilitation (SR) programme appears a relevant approach to increase the intensity of the oriented rehabilitation which is needed and further improve recovery of these patients.
The treatment commonly used to reduce spasticity and increase functions in patients with stroke is botulinum toxin injections (BTIs).12 26–28 In the upper limb, BTI appear associated with a global moderate treatment effect and depends of the parameters studied. A meta-analysis carried out by Foley et al 29 showed a relatively large effect size for the reduction of spasticity and the improvement of passive function and, a small effect size for the improvement of active functions such as prehension.29 This confirms the results of a previous international consensus statement in which authors consider BTI as effective for reduction of pain, deformity and improvement of washing and dressing (class I evidence, recommendation level A), but no clear benefit in active function (class III evidence, recommendations C).30 In the lower limb, several studies have evaluated the effects of BTI in the rectus femoris (RF) and triceps surae muscles in patients with stroke. Studies have shown that BTI in the triceps surae reduced passive resistance to ankle dorsiflexion, pain and the requirement of a gait aid and increased gait speed of patients with hemiparesis.31 32 An open-label study found a significant increase of 8° peak knee flexion during swing following BTI in the RF in patients with hemiparesis with inappropriate RF activity in mid-swing.33 However, there were no significant improvements in functional tests of gait capacity (gait speed, gait distance assessed during the 6 min walking test, stairs). Taken together, the results obtained in the upper and lower limbs after a single BTI session suggest that, although this treatment reduces muscle tone and increases passive function, its impact on active function is low and it does not improve activities of daily living. Some authors state that conventional outcome measures used in these previous studies are not suitable.30 34 35 They suggest using an individually based approach such as the Goal Attainment Scaling (GAS) which showed significant improvements following BTI.34 35 GAS determined the primary treatment goal which is the main treatment objective determined jointly by the patient and the therapist.
Several studies showed moreover that repeated BTI induce better improvements of muscle tone, active movements, functions and quality of life of patients with stroke than single injection.27 36–38
In view of all these studies, it appears essential to develop a combined therapy approach to improve the treatment of spasticity and functional activities in daily life. To increase the intensity of the oriented rehabilitation following BTI would be indeed relevant. Sun et al 39 highlighted greater improvements of spasticity, active function and use of the paretic upper limb of patients with stroke when a constraint-induced therapy is coupled with BTI in comparison with less intensive rehabilitation.39 Similarly, Roche et al showed that a 30 min daily SR programme of 4 weeks coupled with a single session of BTI in the lower limb significantly improved several gait-related activities compared with BTI alone.40 The SR programme was developed to combine safe and feasible exercises combining 10 min of strengthening, 10 min of stretching and 10 min of task-oriented gait-related exercises. Eighty-three per cent of the patients in the SR group carried out 33 min exercises per day more than 5 days per week.40 These results show that combining SR at home with BTI seems effective, well accepted and well tolerated. Results of these pilot studies with restricted sample suggest effectiveness of adding sessions of specific exercises following BTI in patients with stroke, which corresponds to the conclusions of two recent reviews.41 42 These reviews recommend however further study with large sample size, long duration and robust methodology.
The aim of this study is to assess the effects of a 6 months SR programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity having a stroke. All previous results lead us to the hypothesis that the addition of a specific 30 min SR programme to repeated BTI and usual physiotherapy should increase the proportion of patients who attain their primary treatment goal (impairments and functions assessed with GAS) more than usual care (involving repeated BTI and conventional physiotherapy), in poststroke outpatients with spasticity. Secondary objectives are to compare the effects of the two therapeutic strategies on impairments and functional status, on quality of life, mood, fatigability and fatigue of patients with stroke and evaluate the time course of the effects. Another aim is to assess compliance with, and tolerability of the SR programme, and to define the characteristics of compliant and non-compliant patients.[…]
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[ARTICLE] Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke? – Full Text HTML
Motor-training software on tablets or smartphones (Apps) offer a low-cost, widely-available solution to supplement arm physiotherapy after stroke. We assessed the proportions of hemiplegic stroke patients who, with their plegic hand, could meaningfully engage with mobile-gaming devices using a range of standard control-methods, as well as by using a novel wireless grip-controller, adapted for neurodisability. We screened all newly-diagnosed hemiplegic stroke patients presenting to a stroke centre over 6 months. Subjects were compared on their ability to control a tablet or smartphone cursor using: finger-swipe, tap, joystick, screen-tilt, and an adapted handgrip. Cursor control was graded as: no movement (0); less than full-range movement (1); full-range movement (2); directed movement (3). In total, we screened 345 patients, of which 87 satisfied recruitment criteria and completed testing. The commonest reason for exclusion was cognitive impairment. Using conventional controls, the proportion of patients able to direct cursor movement was 38–48%; and to move it full-range was 55–67% (controller comparison: p>0.1). By comparison, handgrip enabled directed control in 75%, and full-range movement in 93% (controller comparison: p<0.001). This difference between controllers was most apparent amongst severely-disabled subjects, with 0% achieving directed or full-range control with conventional controls, compared to 58% and 83% achieving these two levels of movement, respectively, with handgrip. In conclusion, hand, or arm, training Apps played on conventional mobile devices are likely to be accessible only to mildly-disabled stroke patients. Technological adaptations such as grip-control can enable more severely affected subjects to engage with self-training software.
The most important intervention shown to improve physical function after stroke is repetitive, task-directed exercises, supervised by a physiotherapist, with higher intensity leading to faster and greater recovery. In practice, access to physiotherapy is significantly limited by resource availability . For example, 55% of UK stroke in-patients receive less than half the recommended physiotherapy time of 45 minutes per day.
One solution to inadequate physiotherapy is robotic technology, that enables patients to self-practice, with mechanical assistance, via interaction with adapted computer games. While a range of rehabilitation robotics have been marketed over the last decade, and shown to be efficacious, they are not widely used due to factors such as high-cost (typically, $10,000–100,000), cumbersome size, and restriction to patients with high baseline performance, and who have access to specialist rehabilitation centres.
An alternative approach to self-rehabilitation, are medical applications (Apps), or gaming software, run on mobile media devices e.g. tablets or smartphones. Because such devices are low-cost ($200–500), and ubiquitous, they have the potential to democratize computerized-physiotherapy, especially in under-resourced settings, e.g. chronically-disabled in the community. Furthermore, their portability enables home use, while their employment of motivational gaming strategies can potentiate high-intensity motor practice. Accordingly, increasing numbers of motor-training Apps for mobile devices have been commercialised in recent years, and clinical trials are under way. However, since these devices are designed for able-person use, it is questionable as to how well disabled people can access them, and engage meaningfully and repeatedly with rehabilitation software.
This study assesses the degree of motor interaction that can be achieved by hemiplegic stroke patients using four types of conventional hand-control methods (finger swipe, tap, joystick and tilt) for mobile devices. An adapted controller of the same mobile devices, whose materials cost ~$100, was evaluated alongside. Since the latter interface exploits the fact that handgrip is relatively spared in stroke hemiplegia, and is sensitive to subtle forces, we expected that this would increase the range of arm-disability severities able to achieve meaningful computer-game control. In order to assess motor control, with minimal cognitive confounding (given that many softwares also have cognitive demands), we used a simple 1-dimensional motor assessment for all controller types.