[Abstract] Error-augmented bimanual therapy for stroke survivors

Abstract 

BACKGROUND:Stroke recovery studies have shown the efficacy of bimanual training on upper limb functional recovery and others have shown the efficacy of feedback technology that augments error.

OBJECTIVE:In a double-blinded randomized controlled study (N = 26), we evaluated the short-term effects of bilateral arm training to foster functional recovery of a hemiparetic arm, with half of our subjects unknowingly also receiving error augmentation (where errors were visually and haptically enhanced by a robot).

METHODS:Twenty-six individuals with chronic stroke were randomly assigned to practice an equivalent amount of bimanual reaching either with or without error augmentation. Participants were instructed to coordinate both arms while reaching to two targets (one for each arm) in three 45-minute treatments per week for two weeks, with a follow-up visit after one week without treatment.

RESULTS:Subjects’ 2-week gains in Fugl-Meyer score averaged 2.92, and we also observed improvements Wolf Motor Functional Ability Scale average 0.21, and Motor Activity Log of 0.58 for quantity and 0.63 for quality of life scores. The extra benefit of error augmentation over the three weeks became apparent in Fugl-Meyer score only after removing an outlier from consideration.

CONCLUSIONS:This modest advantage of error augmentation was detectable over a short interval encouraging further research in interactive self-rehabilitation systems that can enhance error motor recovery.

via Error-augmented bimanual therapy for stroke survivors – IOS Press

[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

Abstract

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.

Background

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.[…]

Continue —> 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, inves… | BMJ Open

[ARTICLE] Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke? – Full Text HTML

Abstract

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.

Introduction

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.

Continue —> PLOS ONE: Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke?

Fig 1. Control methods and devices trialled. Conventional control mechanisms were trialled using standard tablet and smartphone (A, B). Subjects were required only to move a cursor along a single vertical path, full-range, and then to an indicated vertical level (they were not tested on playing the underlying game). B shows software used for assessing swipe, with varying cursor size. There was no improvement in accessibility using a larger cursor. The novel control mechanism (C) is a wireless grip-force sensor that detects both finger-flexion and extension movements, the latter assisted by a fingerstrap holding the device within a partially-extended hand. Control software for C entailed moving a circle in a vertical plane towards a target star. Cursor and target stimuli dimensions and contrast are similar between all methods.