Posts Tagged stroke rehabilitation

[Abstract] Effects of a 3D-printed orthosis compared to a low-temperature thermoplastic plate orthosis on wrist flexor spasticity in chronic hemiparetic stroke patients: a randomized controlled trial

The aim of this study was to compare the effects of two kinds of wrist-hand orthosis on wrist flexor spasticity in chronic stroke patients.

This is a randomized controlled trial.

The study was conducted in a rehabilitation center.

A total of 40 chronic hemiparetic stroke patients with wrist flexor spasticity were involved in the study.

Patients were randomly assigned to either an experimental group (conventional rehabilitation therapy + 3D-printed orthosis, 20 patients) or a control group (conventional rehabilitation therapy + low-temperature thermoplastic plate orthosis, 20 patients). The time of wearing orthosis was about 4–8 hours per day for six weeks.

Primary outcome measure: Modified Ashworth Scale was assessed three times (at baseline, three weeks, and six weeks). Secondary outcome measures: passive range of motion, Fugl-Meyer Assessment score, visual analogue scale score, and the swelling score were assessed twice (at baseline and six weeks). The subjective feeling score was assessed at six weeks.

No significant difference was found between the two groups in the change of Modified Ashworth Scale scores at three weeks (15% versus 25%, P = 0.496). At six weeks, the Modified Ashworth Scale scores (65% versus 30%, P = 0.02), passive range of wrist extension (P < 0.001), ulnar deviation (P = 0.028), Fugl-Meyer Assessment scores (P < 0.001), and swelling scores (P < 0.001) showed significant changes between the experimental group and the control group. No significant difference was found between the two groups in the change of visual analogue scale scores (P = 0.637) and the subjective feeling scores (P = 0.243).

3D-printed orthosis showed greater changes than low-temperature thermoplastic plate orthosis in reducing spasticity and swelling, improving motor function of the wrist and passive range of wrist extension for stroke patients.

via Effects of a 3D-printed orthosis compared to a low-temperature thermoplastic plate orthosis on wrist flexor spasticity in chronic hemiparetic stroke patients: a randomized controlled trial – Yanan Zheng, Gongliang Liu, Long Yu, Yanmin Wang, Yuan Fang, Yikang Shen, Xiuling Huang, Lei Qiao, Jianzhong Yang, Ying Zhang, Zikai Hua,

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[Abstract] QM-FOrMS: A portable and cost-effective upper extremity rehabilitation system

Abstract

Long-term rehabilitation opportunities are critical for millions of individuals with chronic upper limb motor deficits striving to improve their motor performance. While formal rehabilitation is well organized in the acute stages of stroke, there is minimal professional support of rehabilitation across the lifespan. In this paper, we introduce an upper extremity rehabilitation system, the Quality of Movement Feedback-Oriented Measurement System (QM-FOrMS), by integrating cost-effective portable sensors and clinically verified motion quality analysis towards individuals with upper limb motor deficits. Specifically, QM-FOrMS is comprised of an eTextile pressure sensitive mat, named Smart Mat, a sensory can, named Smart Can, and a mobile device. A personalizable and adaptive upper limb rehabilitation program is developed, including both unilateral and bilateral functional activities which can be selected from a list or custom designed to further tailor the program to the individual.

 

via QM-FOrMS: A portable and cost-effective upper extremity rehabilitation system – ScienceDirect

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[ARTICLE] Influence of New Technologies on Post-Stroke Rehabilitation: A Comparison of Armeo Spring to the Kinect System – Full Text

Abstract

Background: New technologies to improve post-stroke rehabilitation outcomes are of great interest and have a positive impact on functional, motor, and cognitive recovery. Identifying the most effective rehabilitation intervention is a recognized priority for stroke research and provides an opportunity to achieve a more desirable effect. Objective: The objective is to verify the effect of new technologies on motor outcomes of the upper limbs, functional state, and cognitive functions in post-stroke rehabilitation. Methods: Forty two post-stroke patients (8.69 ± 4.27 weeks after stroke onset) were involved in the experimental study during inpatient rehabilitation. Patients were randomly divided into two groups: conventional programs were combined with the Armeo Spring robot-assisted trainer (Armeo group; n = 17) and the Kinect-based system (Kinect group; n = 25). The duration of sessions with the new technological devices was 45 min/day (10 sessions in total). Functional recovery was compared among groups using the Functional Independence Measure (FIM), and upper limbs’ motor function recovery was compared using the Fugl–Meyer Assessment Upper Extremity (FMA-UE), Modified Ashworth Scale (MAS), Hand grip strength (dynamometry), Hand Tapping test (HTT), Box and Block Test (BBT), and kinematic measures (active Range Of Motion (ROM)), while cognitive functions were assessed by the MMSE (Mini-Mental State Examination), ACE-R (Addenbrooke’s Cognitive Examination-Revised), and HAD (Hospital Anxiety and Depression Scale) scores. Results: Functional independence did not show meaningful differences in scores between technologies (p > 0.05), though abilities of self-care were significantly higher after Kinect-based training (p < 0.05). The upper limbs’ kinematics demonstrated higher functional recovery after robot training: decreased muscle tone, improved shoulder and elbow ROMs, hand dexterity, and grip strength (p < 0.05). Besides, virtual reality games involve more arm rotation and performing wider movements. Both new technologies caused an increase in overall global cognitive changes, but visual constructive abilities (attention, memory, visuospatial abilities, and complex commands) were statistically higher after robotic therapy. Furthermore, decreased anxiety level was observed after virtual reality therapy (p < 0.05). Conclusions: Our study displays that even a short-term, two-week training program with new technologies had a positive effect and significantly recovered post-strokes functional level in self-care, upper limb motor ability (dexterity and movements, grip strength, kinematic data), visual constructive abilities (attention, memory, visuospatial abilities, and complex commands) and decreased anxiety level.

1. Introduction

Insufficient motor control compromises the ability of Stroke Patients (SP) to perform activities of daily living and will likely have a negative impact on the quality of life. Improving Upper Limb (UL) function is an important part of post-stroke rehabilitation in order to reduce disability []. Recovery in the context of motor ability may refer to the return of pre-stroke muscle activation patterns or to compensation involving the appearance of alternative muscle activation patterns that attempt to compensate for the motor function deficit []. The past decades have seen rapid development of a wide variety of assistive technologies that can be used in UL rehabilitation. These include electromyographic biofeedback, virtual reality, electromechanical and robotic devices, electrical stimulation, transcranial magnetic stimulation, direct current stimulation, and orthoses []. Currently, two effective technologies that provide external feedback to SP during training, improve the retention of learned skills, and may be able to enhance the motor recovery are discussed [].

Virtual Reality (VR): The Microsoft TM Kinect-based system provides feedback on movement execution and/or goal attainment []. Incorporating therapy exercises into virtual games can make therapy more enjoyable and more realistic, such that task-based exercises have increased applicability in the clinical environment [,], increasing motivation and therefore adherence, which are useful for navigating this virtual environment; this has been identified as the most feasible for future implementation [].

Electromechanical and robotic devices can move passive UL along more secure movement trajectories and provide either assistance or resistance to movement of a single joint or control of inter-segmental coordination. Recent technological advances have the ability to control multiple joints accurately at the same time, enabling them to produce more realistic task-based exercises for SP []. Compared to manual therapy, robots have the potential to provide intensive rehabilitation consistently for a longer duration []. Recovery of sensorimotor function after CNS damage is based on the exploitation of neuroplasticity, with a focus on the rehabilitation of movements needed for self-independence. This requires physiological limb muscle activation, which can be achieved through functional UL movement exercises and activation of the appropriate peripheral receptors []. The Armeo Spring robot-assisted trainer device may improve UL motor function recovery as predicted by reshaping of cortical and transcallosal plasticity, according to the baseline cortical excitability []. Knowledge of the potential brain plasticity reservoir after brain damage constitutes a prerequisite for an optimal rehabilitation strategy [,]. There is evidence that robot training for the hand is superior; during post-stroke rehabilitation, hand training is likely to be the most useful [,].

Previous studies have shown that the use of systems based on VR environments, motion sensors, and robotics can improve motor function. Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions [,,].

The objectives of the study are to clarify in which area of functional UL recovery these new technologies are more suitable and effective and how much these interventions affect functional state and cognitive functions.

We raise the hypothesis that a robot-assisted device and virtual reality both have a positive effect on functional independence recovery in stroke-affected patients; however, having a different influence on UL motor function and cognitive changes. We assume that the robot-assisted device is more efficient and more accurately allows selecting tasks for developing specific motor function (range of motion, strength or dexterity of the affected arm), while Kinect-based games provide more free movements that are less suitable for specific motor function development and may be more targeted for cognitive functions.

 

Continue —>  Influence of New Technologies on Post-Stroke Rehabilitation: A Comparison of Armeo Spring to the Kinect System

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[Abstract] Effects of kinesio taping on hemiplegic hand in patients with upper limb post-stroke spasticity: a randomized controlled pilot study

Abstract

BACKGROUND: Post-stroke spasticity is a common complication in patients with stroke and a key contributor to impaired hand function after stroke.
AIM: The purpose of this study was to investigate the effects of kinesio taping on managing spasticity of upper extremity and motor performance in patients with subacute stroke.
DESIGN: A randomized controlled pilot study.
SETTING: A hospital center.
POPULATION: Participants with stroke within six months.
METHODS: Thirty-one participants were enrolled. Patients were randomly allocated into kinesio taping (KT) group or control group. In KT group, Kinesio Tape was applied as an add-on treatment over the dorsal side of the affected hand during the intervention. Both groups received regular rehabilitation 5 days a week for 3 weeks. The primary outcome was muscle spasticity measured by modified Ashworth Scale (MAS). Secondary outcomes were functional performances of affected limb measured by using Fugl-Meyer assessment for upper extremity (FMA-UE), Brunnstrom stage, and the Simple Test for Evaluating Hand Function (STEF). Measures were taken before intervention, right after intervention (the third week) and two weeks later (the fifth week).
RESULTS: Within-group comparisons yielded significant differences in FMA-UE and Brunnstrom stages at the third and fifth week in the control group (P=0.003-0.019). In the KT group, significant differences were noted in FMA-UE, Brunnstrom stage, and MAS at the third and fifth week (P=0.001-0.035), and in the proximal part of FMA-UE between the third and fifth week (P=0.005). Between-group comparisons showed a significant difference in the distal part of FMA-UE at the fifth week (P=0.037).
CONCLUSIONS: Kinesio taping could provide some benefits in reducing spasticity and in improving motor performance on the affected hand in patients with subacute stroke.
CLINICAL REHABILITATION IMPACT: Kinesio taping could be a choice for clinical practitioners to use for effectively managing post-stroke spasticity.

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via Effects of kinesio taping on hemiplegic hand in patients with upper limb post-stroke spasticity: a randomized controlled pilot study – European Journal of Physical and Rehabilitation Medicine 2019 October;55(5):551-7 – Minerva Medica – Journals

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[Abstract] Virtual reality for stroke rehabilitation: characteristics of protocols, pilot and feasibility studies

Abstract

Introduction: Virtual reality (VR) for stroke rehabilitation is a therapeutic intervention expected to follow the randomized control trials (RCTs) requirements. This study aimed to identify the characteristics of protocols, pilot and feasibility studies reporting stroke rehabilitation with VR methods.

Materials and methods: A systematic study was conducted regarding publications reporting on the use of VR for stroke rehabilitation. PubMed, Web of Science, and Institute of Electrical and Electronics Engineers bibliographic databases were searched on March 2019. The keywords were (“stroke” or “stroke rehabilitation” or “neurological rehabilitation”) and (“virtual reality” or “virtual reality game” or “computer-aided therapy” or “assisted therapy”) and (“quality of life” or “activities of daily living”). All eligible studies published in English were included. The following were collected: experimental design, inclusion criteria for participants, age range, VR intervention, comparative intervention, the primary and secondary outcome.

Results: Title and abstract screening stage had 326 studies, 60 entered the full-text screening stage. Five study protocols of RCTs, 1 protocol for feasibility study, 3 pilot studies and 2 feasibility studies were fully evaluated. All articles provided a structured abstract, 7 were registered in a RCT registry. All RCTs were assessor-blinded, with one exception. The upper extremity in adults was the target of the VR rehabilitation in 9/10 cases, only 2 provided the diagnostic criteria. The settings of intervention were community-dwelling (3 papers), hospital (2) or patient’s home (1). Data were collected at least twice (pre- and post-treatment). The lack of details on randomization and the VR intervention did not allow for study reproducibility, despite 9/10 papers presenting randomization procedure. Four study protocols provided information regarding the sample size calculation, sample size varying between 26 and 59.

Conclusion: Not all VR for stroke interventions were registered in a trial registry, insufficient details were provided regarding randomization and/or VR intervention.

via Virtual reality for stroke rehabilitation: characteristics of protocols, pilot and feasibility studies | Applied Medical Informatics.

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[Abstract] Myoelectric Computer Interface Training for Reducing Co-Activation and Enhancing Arm Movement in Chronic Stroke Survivors: A Randomized Trial

Background. Abnormal muscle co-activation contributes to impairment after stroke. We developed a myoelectric computer interface (MyoCI) training paradigm to reduce abnormal co-activation. MyoCI provides intuitive feedback about muscle activation patterns, enabling decoupling of these muscles.

Objective. To investigate tolerability and effects of MyoCI training of 3 muscle pairs on arm motor recovery after stroke, including effects of training dose and isometric versus movement-based training.

Methods. We randomized chronic stroke survivors with moderate-to-severe arm impairment to 3 groups. Two groups tested different doses of isometric MyoCI (60 vs 90 minutes), and one group tested MyoCI without arm restraint (90 minutes), over 6 weeks. Primary outcome was arm impairment (Fugl-Meyer Assessment). Secondary outcomes included function, spasticity, and elbow range-of-motion at weeks 6 and 10.

Results. Over all 32 subjects, MyoCI training of 3 muscle pairs significantly reduced impairment (Fugl-Meyer Assessment) by 3.3 ± 0.6 and 3.1 ± 0.7 (P < 10−4) at weeks 6 and 10, respectively. Each group improved significantly from baseline; no significant differences were seen between groups. Participants’ lab-based and home-based function also improved at weeks 6 and 10 (P ≤ .01). Spasticity also decreased over all subjects, and elbow range-of-motion improved. Both moderately and severely impaired patients showed significant improvement. No participants had training-related adverse events. MyoCI reduced abnormal co-activation, which appeared to transfer to reaching in the movement group.

Conclusions. MyoCI is a well-tolerated, novel rehabilitation tool that enables stroke survivors to reduce abnormal co-activation. It may reduce impairment and spasticity and improve arm function, even in severely impaired patients.

 

via Myoelectric Computer Interface Training for Reducing Co-Activation and Enhancing Arm Movement in Chronic Stroke Survivors: A Randomized Trial – Emily M. Mugler, Goran Tomic, Aparna Singh, Saad Hameed, Eric W. Lindberg, Jon Gaide, Murad Alqadi, Elizabeth Robinson, Katherine Dalzotto, Camila Limoli, Tyler Jacobson, Jungwha Lee, Marc W. Slutzky, 2019

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[ARTICLE] Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review – Full Text

ABSTRACT

Background: Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.

Objective: Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.

Methods: We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.

Results: The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.

Conclusions: We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.

Introduction

Background

Stroke has become a global problem [1]. One new case is reported every 2 seconds, and the number of stroke patients is predicted to increase by 59% over the next 20 years [2]. In the United Kingdom alone, more than 100,000 stroke cases are reported annually [1], with impairment or disability affecting two-thirds of the 1.2 million stroke survivors [1]. In the United Kingdom, only 77% of stroke survivors are taken directly to the stroke unit. Due to the high number of patients, in England, for example, the social care costs are almost £1.7 billion per annum. The social care cost varies with the age of the patient: the older the patient, the higher the cost. The cost for a person who has had a stroke was reported in 2017 to be around £22,000 per annum. Thus, cost is one of the main drives for service delivery practices. In that respect, early discharge units have been used due to better outcomes and greater success on rehabilitation. Early discharge units consist of specialized personnel who offer an intensive rehabilitation program to the patient. However, after this intensive program of relatively short duration, the patient is discharged and continues the rehabilitation at home. This is expected to reduce costs by £1600 over 5 years for every patient, according to a 2017 report [1].

Due to increasing pressure to discharge patients early from hospital [3], they rely increasingly on home rehabilitation to improve their condition after discharge. As a result, the need has been increasing for home rehabilitation systems that are not dependent on specialist or clinician operators [1,4,5] while providing service similar to a clinical environment. Technological advances in home rehabilitation have been mainly focused on motor control impairments due to their prevalence in the patient population (85% worldwide [1]).

Rehabilitation in a home environment can prove more efficient than that in a clinical environment, as the home environment supports patient empowerment through self-efficacy [6,7]. The presence of supportive family members and a familiarity with the space are significant contributors to motivation. Additionally, rehabilitation in cooperation or in competition with family members demonstrates higher level of engagement [8].

Though rehabilitation in the comfort of a patient’s home seems an attractive option, home environments have limitations that can affect the use of clinical devices. The most prevalent limitations are related to space and the lack of qualified personnel to operate devices. The number of occupants; the patient’s mobility, individual personality, and mood disorders following stroke; and sound insulation, home modification requirements, and cost [9,10] also contribute to limitations of home rehabilitation. Finally, different age groups react differently to technology and devices; for example, elderly survivors often do not engage with wearable devices or video games [11]. As a result, stroke rehabilitation requires a person-centric approach that is suitable for the home environment and that does not require infrastructure change in the home.

Enhancing Motivation

The success of stroke rehabilitation depends heavily on personal commitment and effort. Recent studies, for example, on applied psychology in behavior change theories for stroke rehabilitation [1214], do support that the self-esteem of the patient is limited after stroke. In addition, there is an extended sedentary period due to disability and, thus, different programs of activities are set to motivate the patients. Thus, the patient’s motivation and engagement have a critical impact on the success of any routine that is to be encouraged [15]. This is especially critical for devices used at home, since patients are usually interacting with them alone without frequent checks. Indeed, if a device does not provide a high level of engagement or motivation enhancement, it is more likely to be abandoned within 90 days [16]. Motivation levels depend on the individual, their achievements, and their needs at each given point in time. For example, once the patients achieve their physiotherapy exercise targets, they lose motivation for further practice. There are 3 main approaches to enhancing patients’ motivation: (1) goal-setting theory, (2) self-efficacy improvement theory, and (3) possible selves theory.

Goal-Setting Theory

This approach has been proved effective for stroke survivors. According to the goal-setting theory, the patient’s motivation can be increased through setting small goals or targets. These need to be realistic, manageable, and well defined for the individual patient. However, they also need to be sufficiently challenging for the patient to be engaged [15,1719]. Figure 1 presents the main components contributing to motivation enhancement based on the goal-setting theory.

Figure 1. The main components of goal-setting theory.

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Continue —>  JBME – Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review | Vourganas | JMIR Biomedical Engineering

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[Abstract + References] Electromyography as a Suitable Input for Virtual Reality-Based Biofeedback in Stroke Rehabilitation – Conference paper

Abstract

Virtual reality (VR)-based biofeedback of brain signals using electroencephalography (EEG) has been utilized to encourage the recovery of brain-to-muscle pathways following a stroke. Such models incorporate principles of action observation with neurofeedback of motor-related brain activity to increase sensorimotor activity on the lesioned hemisphere. However, for individuals with existing muscle activity in the hemiparetic arm, we hypothesize that providing biofeedback of muscle signals, to strengthen already established brain-to-muscle pathways, may be more effective. In this project, we aimed to understand whether and when feedback of muscle activity (measured using surface electromyography (EMG)) might more effective compared to EEG biofeedback. To do so, we used a virtual reality (VR) training paradigm we developed for stroke rehabilitation (REINVENT), which provides EEG biofeedback of ipsilesional sensorimotor brain activity and simultaneously records EMG signals. We acquired 640 trials over eight 1.5-h sessions in four stroke participants with varying levels of motor impairment. For each trial, participants attempted to move their affected arm. Successful trials, defined as when their EEG sensorimotor desynchronization (8–24 Hz) during a time-limited movement attempt exceeded their baseline activity, drove a virtual arm towards a target. Here, EMG signals were analyzed offline to see (1) whether EMG amplitude could be significantly differentiated between active trials compared to baseline, and (2) whether using EMG would have led to more successful VR biofeedback control than EEG. Our current results show a significant increase in EMG amplitude across all four participants for active versus baseline trials, suggesting that EMG biofeedback is feasible for stroke participants across a range of impairments. However, we observed significantly better performance with EMG than EEG for only the three individuals with higher motor abilities, suggesting that EMG biofeedback may be best suited for those with better motor abilities.

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via Electromyography as a Suitable Input for Virtual Reality-Based Biofeedback in Stroke Rehabilitation | SpringerLink

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[Abstract + References] Multimodal Head-Mounted Virtual-Reality Brain-Computer Interface for Stroke Rehabilitation – Conference paper

Abstract

Rehabilitation after stroke requires the exploitation of active movement by the patient in order to efficiently re-train the affected side. Individuals with severe stroke cannot benefit from many training solutions since they have paresis and/or spasticity, limiting volitional movement. Nonetheless, research has shown that individuals with severe stroke may have modest benefits from action observation, virtual reality, and neurofeedback from brain-computer interfaces (BCIs). In this study, we combined the principles of action observation in VR together with BCI neurofeedback for stroke rehabilitation to try to elicit optimal rehabilitation gains. Here, we illustrate the development of the REINVENT platform, which takes post-stroke brain signals indicating an attempt to move and drives a virtual avatar arm, providing patient-driven action observation in head-mounted VR. We also present a longitudinal case study with a single individual to demonstrate the feasibility and potentially efficacy of the REINVENT system.

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[ARTICLE] Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke – Full Text

Abstract

Upper limb motor deficits in severe stroke survivors often remain unresolved over extended time periods. Novel neurotechnologies have the potential to significantly support upper limb motor restoration in severely impaired stroke individuals. Here, we review recent controlled clinical studies and reviews focusing on the mechanisms of action and effectiveness of single and combined technology-aided interventions for upper limb motor rehabilitation after stroke, including robotics, muscular electrical stimulation, brain stimulation and brain computer/machine interfaces. We aim at identifying possible guidance for the optimal use of these new technologies to enhance upper limb motor recovery especially in severe chronic stroke patients. We found that the current literature does not provide enough evidence to support strict guidelines, because of the variability of the procedures for each intervention and of the heterogeneity of the stroke population. The present results confirm that neurotechnology-aided upper limb rehabilitation is promising for severe chronic stroke patients, but the combination of interventions often lacks understanding of single intervention mechanisms of action, which may not reflect the summation of single intervention’s effectiveness. Stroke rehabilitation is a long and complex process, and one single intervention administrated in a short time interval cannot have a large impact for motor recovery, especially in severely impaired patients. To design personalized interventions combining or proposing different interventions in sequence, it is necessary to have an excellent understanding of the mechanisms determining the effectiveness of a single treatment in this heterogeneous population of stroke patients. We encourage the identification of objective biomarkers for stroke recovery for patients’ stratification and to tailor treatments. Furthermore, the advantage of longitudinal personalized trial designs compared to classical double-blind placebo-controlled clinical trials as the basis for precise personalized stroke rehabilitation medicine is discussed. Finally, we also promote the necessary conceptual change from ‘one-suits-all’ treatments within in-patient clinical rehabilitation set-ups towards personalized home-based treatment strategies, by adopting novel technologies merging rehabilitation and motor assistance, including implantable ones.

Introduction

Stroke constitutes a major public health problem affecting millions of people worldwide with considerable impacts on socio-economics and health-related costs. It is the second cause of death (Langhorne et al., 2011), and the third cause of disability-adjusted life-years worldwide (Feigin et al., 2014): ∼8.2 million people were affected by stroke in Europe in 2010, with a total cost of ∼€64 billion per year (Olesen et al., 2012). Due to ageing societies, these numbers might still rise, estimated to increase 1.5–2-fold from 2010 to 2030 (Feigin et al., 2014).

Improving upper limb functioning is a major therapeutic target in stroke rehabilitation (Pollock et al., 2014Veerbeek et al., 2017) to maximize patients’ functional recovery and reduce long-term disability (Nichols-Larsen et al., 2005Veerbeek et al., 2011Pollock et al., 2014). Motor impairment of the upper limb occurs in 73–88% first time stroke survivors and in 55–75% of chronic stroke patients (Lawrence et al., 2001). Constraint-induced movement therapy (CIMT), but also standard occupational practice, virtual reality and brain stimulation-based interventions for sensory and motor impairments show positive rehabilitative effects in mildly and moderately impaired stroke victims (Pollock et al., 2014Raffin and Hummel, 2018). However, stroke survivors with severe motor deficits are often excluded from these therapeutic approaches as their deficit does not allow easily rehabilitative motor training (e.g. CIMT), treatment effects are negligible and recovery unpredictable (Byblow et al., 2015Wuwei et al., 2015Buch et al., 2016Guggisberg et al., 2017).

Recent neurotechnology-supported interventions offer the opportunity to deliver high-intensity motor training to stroke victims with severe motor impairments (Sivan et al., 2011). Robotics, muscular electrical stimulation, brain stimulation, brain computer/machine interfaces (BCI/BMI) can support upper limb motor restoration including hand and arm movements and induce neuro-plastic changes within the motor network (Mrachacz-Kersting et al., 2016Biasiucci et al., 2018).

The main hurdle for an improvement of the status quo of stroke rehabilitation is the fragmentary knowledge about the physiological, psychological and social mechanisms, their interplay and how they impact on functional brain reorganization and stroke recovery. Positive stimulating and negatively blocking adaptive brain reorganization factors are insufficiently characterized except from some more or less trivial determinants, such as number and time of treatment sessions, pointing towards the more the better (Kwakkel et al., 1997). Even the long accepted model of detrimental interhemispheric inhibition of the overactive contralesional brain hemisphere on the ipsilesional hemisphere is based on an oversimplification and lack of differential knowledge and is thus called into question (Hummel et al., 2008Krakauer and Carmichael, 2017Morishita and Hummel, 2017).

Here, we take a pragmatic approach of comparing effectiveness data, keeping this lack of knowledge of mechanisms in mind and providing novel ideas towards precision medicine-based approaches to individually tailor treatments to the characteristics and needs of the individual patient with severe chronic stroke to maximize rehabilitative outcome.[…]

Continue —>   Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke | Brain | Oxford Academic

Conceptualization of longitudinal personalized rehabilitation-treatment designs for patients with severe chronic stroke. Ideally, each patient with severe chronic stroke with a stable motor recovery could be stratified based on objective biomarkers of stroke recovery in order to select the most appropriate/promising neurotechnology-aided interventions and/or their combination for the specific case. Then, these interventions can be administered in the clinic and/or at home in sequence, moving from one to another only when patient’s motor recovery plateaus. In this way, comparisons of the efficacy of each intervention (grey arrows) are still possible, and if the selected interventions and/or their combination are suitable, motor recovery could increase.

Conceptualization of longitudinal personalized rehabilitation-treatment designs for patients with severe chronic stroke. Ideally, each patient with severe chronic stroke with a stable motor recovery could be stratified based on objective biomarkers of stroke recovery in order to select the most appropriate/promising neurotechnology-aided interventions and/or their combination for the specific case. Then, these interventions can be administered in the clinic and/or at home in sequence, moving from one to another only when patient’s motor recovery plateaus. In this way, comparisons of the efficacy of each intervention (grey arrows) are still possible, and if the selected interventions and/or their combination are suitable, motor recovery could increase.

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