Posts Tagged Stroke

[ARTICLE] Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial – Full Text

 

Continue —> Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trialClinical Rehabilitation – Alexander J Street, Wendy L Magee, Andrew Bateman, Michael Parker, Helen Odell-Miller, Jorg Fachner, 2017

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Figure 1. Study flow diagram. Data collection occurred at weeks 1, 6, 9, 15 and 18. Cross-over analysis required data from weeks 1, 6, 9 and 15.

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[ARTICLE] Robotic-assisted serious game for motor and cognitive post-stroke rehabilitation – Full Text PDF

 

Abstract

Stroke is a major cause of long-term disability that can cause motor and cognitive impairments. New technologies such as robotic devices and serious games are increasingly being developed to improve post-stroke rehabilitation. The aim of the present project was to develop a ROBiGAME serious game to simultaneously improve motor and cognitive deficits (in particular hemiparesis and hemineglect). In this context, the difficulty level of the game was adapted to each patient’s performance, and this individualized adaptation was addressed as the main challenge of the game development. The game was implemented on the REAplan end-effector rehabilitation robot, which was used in continuous interaction with the game. A preliminary feasibility study of a target pointing game was run in order to validate the game features and parameters. Results showed that the game was perceived as enjoyable, and that patients reported a desire to play the game again. Most of the targets included in the game design were realistic, and they were well perceived by the patients. Results also suggested that the cognitive help strategy could include one visual prompting cue, possibly combined with an auditory cue. It was observed that the motor assistance provided by the robot was well adapted for each patient’s impairments, but the study results led to a suggestion that the triggering conditions should be reviewed. Patients and therapists reported the desire to receive more feedback on the patient’s performances. Nevertheless, more patients and therapists are needed to play the game in order to give further and more comprehensive feedback that will allow for improvements of the serious game. Future steps also include the validation of the motivation assessment module that is currently under development.

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[Abstract] Effects of Transcranial direct current stimulation with sensory modulation on stroke motor rehabilitation: A randomized controlled trial  

 

Abstract

Objective

To test whether a multi-strategy intervention enhanced recovery immediately and longitudinally in patients with severe to moderate upper extremity (UE) paresis.

Design

Double-blind randomized controlled trial with placebo control.

Setting

An outpatient department of a local medical center.

Participants

People (n = 25) with chronic stroke were randomly assigned to 2 groups. Participants in the transcranial direct current stimulation with sensory modulation (tDCS-SM) and in the control group were 55.3±11.5 (n=14) and 56.9±13.5 (n=11) years old, respectively.

Interventions

8-week intervention. The tDCS-SM group received bilateral tDCS, bilateral cutaneous anesthesia, and high repetitions of passive movements on the paretic hand. The control group received the same passive movements but with sham tDCS and sham anesthesia. During the experiment, all participants continued their regular rehabilitation.

Main outcome measures

Voluntary UE movement, spasticity, UE function, and basic activities of daily living. Outcomes were assessed at baseline, at post-intervention, and at 3- and 6-month follow-ups.

Results

No significant differences were found between groups. However, there was a trend that the voluntary UE movement improved more in the tDCS-SM group than in the control group, with a moderate immediate effect (partial η2, ηp2 = 0.14, p = 0.07) and moderate long-term effects (ηp2 =0.17, p = 0.05 and ηp2 = 0.12, p = 0.10). Compared with the control group, the tDCS-SM group had a trend of a small immediate effect (ηp2 = 0.02 – 0.04) on reducing spasticity but no long-term effect. A trend of small immediate and long-term effects in favor of tDCS-SM was found on UE function and daily function recovery (ηp2= 0.02 – 0.09).

Conclusions

Accompanied with traditional rehabilitation, tDCS-SM had a non-significant trend of having immediate and longitudinal effects on voluntary UE movement recovery in patients with severe to moderate UE paresis after stroke, but its effects on spasticity reduction and functional recovery may be limited. (NCT01847157)

Source: Effects of Transcranial direct current stimulation with sensory modulation on stroke motor rehabilitation: A randomized controlled trial – Archives of Physical Medicine and Rehabilitation

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[BOOK] Chapter 9: Neuroscience-Based Rehabilitation for Stroke Patients

The Book: Neuroscience-Based Rehabilitation for Stroke Patients | InTechOpen, Published on: 2017-05-10. Authors: Takayuki Kodama and Hideki Nakano

Chapter 9: Neuroscience-Based Rehabilitation for Stroke Patients

Abstract

Hitherto, physical therapy for rehabilitating patients with cerebral dysfunction has focused on acquiring and improving compensatory strategies by using the remaining functions; it has been presumed that once neural functions have been lost, they cannot be restored. However, neuroscience-based animal research and neuroimaging research since the 1980s have demonstrated that recovery arises from plastic changes in the central nervous system and reconstruction of neural networks; this research is ushering in a new age of neuroscience-based rehabilitation as a treatment for cerebral dysfunction (such as stroke). In this paper, in regard to mental practices using motor imagery and kinaesthetic illusion, we summarize basic discoveries and theories relating to motor function therapy based on neuroscientific theory; in particular, we outline a novel rehabilitation method using kinaesthetic illusion induced by vibrational stimulus, which the authors are currently attempting in stroke patients.

1. Introduction

Conventional physical therapy (PT) for the rehabilitation of patients with brain dysfunction focuses on the acquisition of function through alternative means by using and improving the patients’ existing functions, and it is based on the assumption that once a neutral function is lost, it can never be recovered [1]. However, animal neuroscience studies [24] that were conducted after the 1980s and neuroimaging studies [5, 6] have shown that recovery can occur as a result of plastic changes in the nervous system or reorganization of the neural network, and rehabilitation (neuroscience-based rehabilitation, NBR) after cerebral dysfunction (e.g. stroke) has reached a new era in treatment. These observations suggest that the plasticity that is observed in patients is related to the characteristic that the more the patient receives therapy in specific parts of their body, the more that the brain areas that control these parts will be functionally as well as anatomically extended.

Functional recovery originally referred to a patient’s recovery from limitations in their behavior, movements, and/or activity [7]. Therefore, the purpose of NBR is not only to induce the reorganization of brain functions through neural plasticity mechanisms but also recover comprehensive bodily motor functions and brain functions for autonomous and active social behavior. What type of treatment strategy is required so that patients feel positively engaged by it, gradually understand its effects, and work toward a goal? Previous studies have revealed important factors in the effects of NBR treatment, such as the amount of therapy [8, 9], rehabilitation implementation environment [10], and performance of neurocognitive rehabilitation [11] through mental practice techniques, such as motor imagery (MI) [12]. Among these factors, treatments involving MI are strongly recommended because MI contributes to the reorganization of neural functions. MI, which is an approach that is based on neuroscientific data and the motor learning theory, is defined as the capacity to internally mimic physical movements without any associated motor output [13]. The cognitive process that occurs during the imagination of movements involves various components, such as mutual understandings between oneself and others (environment), observations of movements, mental manipulations of objects, and psychological time and movement planning. Instead of repeating simple physical movements to receive feedback on outcome in the actual therapy, the practice of voluntary and skill-requiring movements that are geared toward task completion induces the functional recovery [14]. Thus, an important element of the patients’ engagement in the therapy is that it occurs in an active and top-down fashion through the use of MI. However, because MI has a task-specific nature, cognitive functions and memories of motor experiences that equip the patients to perform the task are required. Patients with neurofunctional states that make motor execution (ME) difficulty may suffer not only from impairments in motor-related brain areas but also from modifications in their intracerebral body representations (e.g. somatoparaphrenia) [15, 16]. In such cases, the exploitation of kinaesthetic illusions [1720], which can be induced in the brain by extraneous stimuli, such as vibratory stimulations, becomes important for inputting appropriate motor-sensory information into the brain in a passive and bottom-up fashion. Therefore, the implementation of a mental practice to determine the criteria for adequate treatment according to the states of the patient’s cognitive functions and motor functions is important in order to select and implement the best therapy. Thus, this paper summarizes the basic understanding and theories of mental practices that use MI or kinaesthetic illusion and discusses, in particular, research results concerning kinaesthetic illusions that are induced by vibratory stimulations, which we are currently attempting on stroke patients.

2. What is neuroscience-based rehabilitation?

NBR involves a series of processes that are selected for the intervention according to the current brain function theories that have been revealed by neuroscience and other similar studies and verification of its outcomes. For example, the selection of a NBR strategy for a stroke patient requires a combination of deep clinical reasoning, the experience of the therapist, and a vast understanding of the evidence obtained by studies from wide-ranging academic fields on the factors that support recovery mechanisms and produce particular outcomes. First, the neural basis of brain cell reorganization will be presented.

2.1. Neural basis of brain cell reorganization

The current understanding of neural reorganization after dysfunction is not that the neurons themselves recover after their axons are damaged but rather that damaged functional networks recover due to several processes that induce the recovery of motor and cognitive functions. Cajal [1], who was a proponent of neuron theory, stated that the central nervous system (brain and spinal cord) of adult mammals would not recover once it is damaged. However, studies that have been conducted since the 1980s and that have shown that alterations in the peripheral nervous system, such as denervation and amputation, change somatic sensations and the representations of body parts while they are in motion have revealed that the brain has plasticity. In 1998, Eriksson et al. [21] reported the new formation of neurons in the central nervous system of human beings. These findings raised the question of whether the plastic changes and functional reorganization that occur in subjects with cranial nerve disorders originate from an ischemic state, such as a cerebrovascular disturbance. The underlying mechanisms of the plasticity that occurs after a cortical deficit are thought to involve (i) the redundancy of neuronal connections in the central nervous system, (ii) morphological changes in the neurons, and (iii) changes in synaptic information transmission [22]. If neurons are damaged, astrocytes begin to divide due to the activity of microglia. These glial cells then reinforce the areas that have been damaged by brain lesions and release neurotrophic factors, such as nerve growth factor, to promote neuronal sprouting (it takes around two weeks for synapses to grow after nerve damage [23]). The sprouted neurons are then connected to an existing neural network, which forms a new network. In other words, if neurons are damaged, new neurons begin to reorganize themselves in order to compensate for it. Adequate NBR stimulates the neural network with the neurofunction that is most similar to the predamaged functional state of the neural network, even though the new network is not located in the damaged region. If strong inputs enter the network multiple times, the synaptic connections will be reinforced. However, plasticity will not be induced in synapses with little information (input specificity), and the synapses will be excluded from the network formation [24, 25].

These findings have been confirmed by several famous studies. Nudo et al. [8] caused artificial cerebral infarcts in monkeys in the region of the primary motor cortex (M1) that corresponds to fingers and then forced the monkeys to use fingers with motor deficits. Thus, they reported that the brain region that previously controlled the shoulders and elbows prior to the therapy then controlled the fingers and more distal body parts (Figure 1). Merzenich et al. [26] surgically sutured the fingers of monkeys and then compared the pre- and post-surgical somatotopies of Brodmann area (BA) 3b, which corresponds to the sensorimotor area (SMA). Microelectrodes were used to record the responses in BA3b to finger stimuli. The third and fourth fingers were then surgically sutured, and the responses were recorded again a month later. Thus, the boundary between the third and fourth fingers became unclear. In addition, the results of a study that was conducted in human beings suggested that the plasticity of brain cells depends on sensory input. The results of a magnetoencephalography study that compared the somatotopies of the first and fifth fingers of string players to normal controls showed that a broader cerebral cortical area was activated for string players compared to the controls [6].

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Figure 1. Representation of the distal forelimb in cortical area 4 derived from pre- and post-training mapping procedures [8].

These findings suggest that the size of the intracerebral somatotopic representation, which is vital to ME, is determined by the degree of use of the region. If you try to induce plasticity in specific parts of the bodies of stroke patients, as mentioned above, the induction of neural plasticity in a pathway that allows highly efficient information processing by repeating movements in a pattern like the normal pattern should be possible, provided the patient has retained their motor functions to a certain degree. However, if a patient has the functional level of almost not able to perform movement or is only able to perform the movement in an abnormal pattern, the stimulation of the plasticity for the formation of a neural network that is required to be able to regain normal motor function may not be possible. Ward et al. [27] chronologically examined the relationships between motor function recovery scores and task-related brain activities for approximately 12 months after the onset of stroke with functional magnetic resonance imaging. They found a negative correlation between motor function recovery scores and a decline in the hyperactivity of brain areas in the damaged and undamaged hemispheres (M1, premotor cortex; PMC, supplementary motor cortex; SMC, cerebellum). These findings suggest that a better recovery of motor function is associated with better connectivity between the functional systems of multiple brain regions and that a continuous and long-term approach is required to study the changes in the morphologies and networks of neurons. Thus, a qualitative and continuous approach [28] is required in studies of the recovery of the entire neural system (e.g. transcortical network, M1-PMC neural network [29]) in order to be able to perform movement rather than merely establishing quantitative interventions of movement. Thus, next, we will discuss the current understanding of what is required in interventions for stroke patients.[…]

Continue —> Neuroscience-Based Rehabilitation for Stroke Patients | InTechOpen

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[BOOK] Chapter 7: After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation – Full Text

 

 “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s)

Chapter 7: After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation

Abstract

This chapter presents a review of the rehabilitation technologies for people who have suffered a stroke, comparing and analyzing the impact that these technologies have on their recovery in the short and long term. The problematic is presented, and motor impairments for upper and lower limbs are characterized. The goal of this chapter is to show novel trends and research for the assistance and treatment of motor impairment caused by strokes.

1. Introduction

Stroke is the most common acquired neurological disease in the adult population worldwide (15 million every year [1]). Based on recently published studies, incidence of stroke in Europe at the beginning of the twenty-first century ranged from 95 to 290/100,000 per year [37]. Between 2000 and 2010, the relative rate of stroke deaths dropped by 35.8% in the United States and other countries. However, each year stroke affects nearly 800,000 individuals, becoming the first cause of chronic disability and the third cause of death. It is a global public health problem worldwide that generates a significant burden of illness for healthy life years lost due to disability and premature death.

One-third of stroke survivors achieve only a poor functional outcome 5 years after the onset of stroke. Although there is great progress in the management of acute stroke, most of the care to reduce dependence on post-stroke patients depends on rehabilitation. Optimal functional recovery is the ultimate goal of neurorehabilitation after acute brain injury, mainly by optimizing sensorimotor performance in functional actions. New brain imaging techniques are making it clear that the neurological system is continually remodeling throughout life and after damage through experience and learning in response to activity and behavior.

Rehabilitation in stroke patients seeks to minimize the neurological deficit and its complications, encourage family, and facilitate social reintegration of the individual to ultimately improve their quality of life. Stroke rehabilitation is divided into three phases. The acute phase usually extends for the 1st weeks, where patients get treated and stabilized in a hospital and get stabilized. Subacute phase (1–6 months) is the phase where the rehabilitation process is more effective for recovering functions. In chronic phase (after 6 months), rehabilitation is meant to treat and decrease motor sequels.

The potential ability of the brain to readapt after injury is known as neuroplasticity, which is the basic mechanism underlying improvement in functional outcome after stroke. Therefore, one important goal of rehabilitation of stroke patients is the effective use of neuroplasticity for functional recovery [38].

As mentioned before, neural plasticity is the ability of nervous system to reorganize its structure, function, and connections in response to training. The type and extent of neural plasticity is task—specific, highly time-sensitive and strongly influenced by environmental factors as well as motivation and attention.

Current understanding of mechanisms underlying neural plasticity changes after stroke stems from experimental models as well as clinical studies and provides the foundation for evidence-based neurorehabilitation. Evidence accumulated during the past 2 decades together with recent advances in the field of stroke recovery clearly shows that the effects of neurorehabilitation can be enhanced by behavioral manipulations in combination with adjuvant therapies that stimulate the endogenous neural plasticity.

Nowadays, a large toolbox of training-oriented rehabilitation techniques has been developed, which allows the increase of independence and quality of life of the patients and their families [39]. The recovery of function has been shown to depend on the intensity of therapy, repetition of specified-skilled movements directed toward the motor deficits and rewarded with performance-dependent feedback.

The use of technological devices not only helps to increase these aspects but also facilitates the work of therapists in order to enhance the abilities of patients and a higher level of functional recovery. They create environments with a greater amount of sensorimotor stimuli that enhance the neuroplasticity of patients, translating into a successful functional recovery. The use of technological devices can transfer the effects of rehabilitation to the different environments where patients spend their daily life allowing a favorable social reintegration. In this chapter, a review of technologies for rehabilitation of mobility in upper and lower extremity is presented.[…]

Continue —>  After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation | InTechOpen

Figure 1. Mechanical treatment devices. (a) Armeo Spring and (b) Saebo ReJoyce.

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[ARTICLE] Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation – Full Text

 

Abstract

Background

Arm-hand rehabilitation programs applied in stroke rehabilitation frequently target specific populations and thus are less applicable in heterogeneous patient populations. Besides, changes in arm-hand function (AHF) and arm-hand skill performance (AHSP) during and after a specific and well-described rehabilitation treatment are often not well evaluated.

Method

This single-armed prospective cohort study featured three subgroups of stroke patients with either a severely, moderately or mildly impaired AHF. Rehabilitation treatment consisted of a Concise_Arm_and_hand_ Rehabilitation_Approach_in_Stroke (CARAS). Measurements at function and activity level were performed at admission, clinical discharge, 3, 6, 9 and 12 months after clinical discharge.

Results

Eighty-nine stroke patients (M/F:63/23; mean age:57.6yr (+/-10.6); post-stroke time:29.8 days (+/-20.1)) participated. All patients improved on AHF and arm-hand capacity during and after rehabilitation, except on grip strength in the severely affected subgroup. Largest gains occurred in patients with a moderately affected AHF. As to self-perceived AHSP, on average, all subgroups improved over time. A small percentage of patients declined regarding self-perceived AHSP post-rehabilitation.

Conclusions

A majority of stroke patients across the whole arm-hand impairment severity spectrum significantly improved on AHF, arm-hand capacity and self-perceived AHSP. These were maintained up to one year post-rehabilitation. Results may serve as a control condition in future studies.

Introduction

One of the most common deficits following stroke is a persistent impairment of the arm and hand due to a hemiparesis, which has a significant impact on performance in daily life activities [1]. Recovery of arm-hand function and skills is a major rehabilitation and health care challenge. Motor rehabilitation approaches for arm-hand performance after stroke has been changing substantially over the last decades. However, an integral arm-hand skill training approach, accommodating both the heterogeneity of the patient population and its associated patterns and levels of recovery directly post-stroke seems to be absent. A large number of well-explored and well-investigated examples of training approaches in specific (sub) populations have been identified [2] like, for instance, task-oriented training [3], mental practice [4] and constraint-induced movement therapy (CIMT) [5]. In task-oriented approaches specific functional, skill-related tasks are trained. This is done preferably by using real-life objects [6], thereby teaching patients to solve specific problems related to, e.g., anticipatory motor adjustments or cognitive processing by using efficient goal-oriented movement strategies [7, 8].

Existing task-oriented arm-hand programs (e.g. [916]) are valuable contributions to rehabilitation practice and may offer a stable point of departure for clinicians to select the most appropriate therapy for a particular patient.

However, several aspects make it difficult for clinicians to choose the most appropriate arm-hand therapy intervention(s) for a particular patient: 1) Most studies or programs target specific populations (in particular those with some preservation of wrist and/or finger extension) and thus are less applicable for patients with a more severely affected arm-hand as seen in the heterogeneous populations of many rehabilitation centres [17]. 2) Programs are focused on either the arm or the hand alone. 3) Most of the current studies in research projects feature strictly protocolled interventions, which cannot be easily adopted in the clinicians’ daily practice. 4) The lack of information about the proportional improvement or deterioration to be expected in stroke survivors in the sub-acute phase after stroke may lead to difficulties for clinicians to make decisions about arm-hand treatment objectives and concomitant prognostics regarding arm-hand skill performance.

In order to overcome these four drawbacks a Concise Arm and hand Rehabilitation Approach in Stroke (acronym: CARAS) [18] was developed in order to guide clinicians, during their daily practice, in systematically designing a patient’s optimal arm-hand rehabilitation program. CARAS is based on four constructs: a) stratification of the patient population is based on the severity of arm–hand impairment for which the Utrechtse Arm-hand Test (UAT) is used [19], b) clear focus on the individual’s rehabilitation goals and concomitant potential rehabilitation treatment outcomes, c) principles of self-efficacy, and d) possibility to systematically incorporate (new) technology and new evidence-based training elements swiftly. CARAS has proven to be feasible in a number of stroke units of rehabilitation centres throughout the Netherlands.

In the present study, the term ‘arm–hand function’ (AHF) refers to the ICF ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF activity level, covering both capacity and performance [20].

The present paper focusses on two aspects.

Firstly, during rehabilitation AHF and AHSP may improve to a certain level. However, once a stroke patient has left the rehabilitation program, his arm-hand capacity and performance may deteriorate [21]. Whereas stroke patients with mild to moderate initial impairments show an almost fixed amount of recovery after stroke, ranging up to 70% [22, 23], stroke patients with a more severely affected arm-hand, i.e. absence of finger extension combined with large motor impairments, strongly lag behind this recovery percentage. Four years after stroke, 67% of stroke survivors still experience non-use or disuse of the moderately or severely affected arm–hand [24].

However, it is neither well understood at what rate such deterioration (or improvement) occurs, nor in which patient categories, i.e. patients with a certain level of arm-hand severity, this is most prominent. Answers to these questions are essential for the development of more adequate, personalised and cost-effective interventions that may augment and/or maintain arm-hand skill performance (AHSP) levels in stroke patients living in their home environment.

Secondly, the risk of losing the opportunity to clearly define ‘therapy-as-usual’ (TAU) is becoming a problem in AHSP research in stroke patients. In the myriad of studies evaluating newly developed training protocols aimed at improving AHF and/or AHSP, each of these new training approaches is contrasted to some kind of TAU, the latter of which may vary widely between clinics and institutes. Even worse, often TAU is not clearly defined at all.

As the implementation of many of the tested experimental treatments progresses, the concept of ‘therapy-as-usual’ inevitably will be lost.

The aim of the present study was to evaluate the course AHF and AHSP take in a broad range of sub-acute stroke patients during and after rehabilitation involving a therapy-as-usual (i.e. CARAS) [18].

Three subgroups, i.e. a subgroup of patients with a severely affected arm-hand, a subgroup of patients with a moderately affected arm-hand and a subgroup of patients with a mildly affected arm-hand, were formed.

The research questions were:

  1. To what extent do arm-hand function and arm-hand skill performance in stroke patients change during and after their rehabilitation involving therapy-as-usual?
  2. To what extent does the rate of improvement or deterioration (over time) of arm-hand function and arm-hand skill performance differ between three subgroups of stroke patients, i.e. patients with either a severely, moderately or mildly affected functional arm-hand, during and after their rehabilitation involving CARAS?[…]

Continue —> Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation

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[ARTICLE] Neural Plasticity in Moderate to Severe Chronic Stroke Following a Device-Assisted Task-Specific Arm/Hand Intervention – Full Text

Currently, hand rehabilitation following stroke tends to focus on mildly impaired individuals, partially due to the inability for severely impaired subjects to sufficiently use the paretic hand. Device-assisted interventions offer a means to include this more severe population and show promising behavioral results. However, the ability for this population to demonstrate neural plasticity, a crucial factor in functional recovery following effective post-stroke interventions, remains unclear. This study aimed to investigate neural changes related to hand function induced by a device-assisted task-specific intervention in individuals with moderate to severe chronic stroke (upper extremity Fugl-Meyer < 30). We examined functional cortical reorganization related to paretic hand opening and gray matter (GM) structural changes using a multimodal imaging approach. Individuals demonstrated a shift in cortical activity related to hand opening from the contralesional to the ipsilesional hemisphere following the intervention. This was driven by decreased activity in contralesional primary sensorimotor cortex and increased activity in ipsilesional secondary motor cortex. Additionally, subjects displayed increased GM density in ipsilesional primary sensorimotor cortex and decreased GM density in contralesional primary sensorimotor cortex. These findings suggest that despite moderate to severe chronic impairments, post-stroke participants maintain ability to show cortical reorganization and GM structural changes following a device-assisted task-specific arm/hand intervention. These changes are similar as those reported in post-stroke individuals with mild impairment, suggesting that residual neural plasticity in more severely impaired individuals may have the potential to support improved hand function.

Introduction

Nearly 800,000 people experience a new or recurrent stroke each year in the US (1). Popular therapies, such as constraint-induced movement therapy (CIMT), utilize intense task-specific practice of the affected limb to improve arm/hand function in acute and chronic stroke with mild impairments (2, 3). Neuroimaging results partially attribute the effectiveness of these arm/hand interventions to cortical reorganization in the ipsilesional hemisphere following training in acute and mild chronic stroke (4). Unfortunately, CIMT requires certain remaining functionality in the paretic hand to execute the tasks, and only about 10% of screened patients are eligible (5), thus disqualifying a large population of individuals with moderate to severe impairments. Recently, studies using device-assisted task-specific interventions specifically targeted toward moderate to severe chronic stroke reported positive clinical results (68). However, these studies primarily focus on clinical measures, but it is widely accepted that neural plasticity is a key factor for determining outcome (911). Consequently, it remains unclear whether moderate to severe chronic stroke [upper extremity Fugl-Meyer Assessment (UEFMA) < 30] maintains the ability to demonstrate neural changes following an arm/hand intervention.

Neural changes induced by task-specific training have been investigated widely using animal models (12). For instance, monkeys or rodents trained on a skilled reach-to-grasp task express enlarged representation of the digits of the hand or forelimb in primary motor cortex (M1) following training as measured by intracortical microstimulation (13, 14). Additionally, rapid local structural changes in the form of dendritic growth, axonal sprouting, myelination, and synaptogenesis occur (1518). Importantly, both cortical and structural reorganization corresponds to motor recovery following rehabilitative training in these animals (19, 20).

The functional neural mechanisms underlying effective task-specific arm/hand interventions in acute and chronic stroke subjects with mild impairments support those seen in the animal literature described above. Several variations of task-specific combined arm/hand interventions, including CIMT, bilateral task-specific training, and hand-specific robot-assisted practice, have shown cortical reorganization such as increased sensorimotor activity and enlarged motor maps in the ipsilesional hemisphere related to the paretic arm/hand (2124). These results suggest increased recruitment of residual resources from the ipsilesional hemisphere and/or decreased recruitment of contralesional resources following training. Although the evidence for a pattern of intervention-driven structural changes remains unclear in humans, several groups have shown increases in gray matter (GM) density in sensorimotor cortices (25), along with increases in fractional anisotropy in ipsilesional corticospinal tract (CST) (26) following task-specific training in acute and chronic stroke individuals with mild impairments.

The extensive nature of neural damage in moderate to severe chronic stroke may result in compensatory mechanisms, such as contralesional or secondary motor area recruitment (27). These individuals show increased contralesional activity when moving their paretic arm, which correlates with impairment (28, 29) and may be related to the extent of damage to the ipsilesional CST (30). This suggests that more impaired individuals may increasingly rely on contralesional corticobulbar tracts such as the corticoreticulospinal tract to activate the paretic limb (29). These tracts lack comparable resolution and innervation to the distal parts of the limb, thus sacrificing functionality at the paretic arm/hand (31). Since this population is largely ignored in current arm/hand interventions, it is unknown whether an arm/hand intervention for these more severely impaired post-stroke individuals will increase recruitment of residual ipsilesional corticospinal resources. These ipsilesional CSTs maintain the primary control of hand and finger extensor muscles (32) and are thus crucial for improved hand function. Task-specific training assisted by a device may reengage and strengthen residual ipsilesional corticospinal resources by training distal hand opening together with overall arm use.

The current study seeks to determine whether individuals with moderate to severe chronic stroke maintain the ability to show cortical reorganization and/or structural changes alongside behavioral improvement following a task-specific intervention. We hypothesize that following a device-assisted task-specific intervention, moderate to severe chronic stroke individuals will show similar functional and structural changes as observed in mildly impaired individuals, demonstrated by (i) a shift in cortical activity related to paretic hand opening from the contralesional hemisphere toward the ipsilesional hemisphere and (ii) an increase in GM density in sensorimotor cortices in the ipsilesional hemisphere.[…]

Continue —> Frontiers | Neural Plasticity in Moderate to Severe Chronic Stroke Following a Device-Assisted Task-Specific Arm/Hand Intervention | Neurology

Figure 5. Statistical maps of gray matter (GM) density changes across all patients. Significant increases (red/yellow) and decreases (Blue) in GM density are depicted on sagittal, coronal, and axial sections (left to right) on Montreal Neurological Institute T1 slices. Sections show the maximum effect on (A) ipsilesioned M1/S1, (B) contralesional M1/S1, and (C) ipsilesional thalamus. Les indicates the side of the lesioned hemisphere. Color maps indicate the t values at every voxel. A statistical threshold was set at p < 0.001 uncorrected.

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[BLOG POST] Home After a Stroke: Reviewing Virtual Reality Rehab

Between September 2011 and May 2017 Dean published 173 posts about the use of virtual reality to provide rehab for stroke survivors.  The results for the hand are depressing.  For six years research focused on a subject’s ability to touch an object on the screen so the computer can move an object or make it disappear.  Enjoying these quick reactions is not enough to justify the cost of this expensive equipment.  It was a good place to start 6 years ago, but progress towards useful gains is disappointing.  Stroke survivors want to manipulate objects with their hand.

There is a glimmer of hope.  Gauthier (1) used video games that make stroke survivors do more than use their shoulder and elbow to reach forward and side to side.  These games require forearm and wrist motions.  This may not sound exciting but these motions orient our hand to the many different positions objects rest in. The photo shows the forearm is halfway between palm up and palm down so the hand can pick up a glass.  Cocking the wrist means the rim of the glass is not pointed at the ceiling but at the person’s mouth.

Unfortunately, Gauthier selected stroke survivors who already had a few degrees of active forearm and wrist movement.  How can subjects make the leap from just reaching to turning their hand palm up to catch a parachute on a video screen?  My OT gave me exercises that helped me regain forearm and wrist motions.  These small motions have made me more independent.  For example, I can turn my hand halfway between palm up and palm down to grab my cane so my sound hand can catch the door before the person in front of me lets it slam shut.  I picture stroke survivors practicing forearm and wrist motions and then immediately trying to turn their hand palm up so they can turn over a card on the computer screen. Fun + repetition is good.
1. Gauthier L, et al. Video game rehabilitation for outpatient stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis. BMC Neurology. 2017;17-109. doi:10.1186/s12883-017-0888-0.

Source: Home After a Stroke: Reviewing Virtual Reality Rehab

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[Abstract] Electrically Assisted Movement Therapy in Chronic Stroke Patients With Severe Upper Limb Paresis: A Pilot, Single-Blind, Randomized Crossover Study

 

Abstract

Objective

To evaluate the effects of electrically assisted movement therapy (EAMT) in which patients use functional electrical stimulation, modulated by a custom device controlled through the patient’s unaffected hand, to produce or assist task-specific upper limb movements, which enables them to engage in intensive goal-oriented training.

Design

Randomized, crossover, assessor-blinded, 5-week trial with follow-up at 18 weeks.

Setting

Rehabilitation university hospital.

Participants

Patients with chronic, severe stroke (N=11; mean age, 47.9y) more than 6 months poststroke (mean time since event, 46.3mo).

Interventions

Both EAMT and the control intervention (dose-matched, goal-oriented standard care) consisted of 10 sessions of 90 minutes per day, 5 sessions per week, for 2 weeks. After the first 10 sessions, group allocation was crossed over, and patients received a 1-week therapy break before receiving the new treatment.

Main Outcome Measures

Fugl-Meyer Motor Assessment for the Upper Extremity, Wolf Motor Function Test, spasticity, and 28-item Motor Activity Log.

Results

Forty-four individuals were recruited, of whom 11 were eligible and participated. Five patients received the experimental treatment before standard care, and 6 received standard care before the experimental treatment. EAMT produced higher improvements in the Fugl-Meyer scale than standard care (P<.05). Median improvements were 6.5 Fugl-Meyer points and 1 Fugl-Meyer point after the experimental treatment and standard care, respectively. The improvement was also significant in subjective reports of quality of movement and amount of use of the affected limb during activities of daily living (P<.05).

Conclusions

EAMT produces a clinically important impairment reduction in stroke patients with chronic, severe upper limb paresis.

Source: Electrically Assisted Movement Therapy in Chronic Stroke Patients With Severe Upper Limb Paresis: A Pilot, Single-Blind, Randomized Crossover Study – Archives of Physical Medicine and Rehabilitation

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[BOOK] Chapter 5: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study – Full Text

THE BOOK:  “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s).

CHAPTER 5: By Marta Rodríguez-Hernández, Carmen Fernández-Panadero, Olga López-Martín and Begoña Polonio-López

 

Abstract

Purpose: The aim is to present an overview of existing tools for hand rehabilitation after brain injury and a pilot study to test HandTutor® in patients with chronic brain damage (CBD).

Method: Eighteen patients with CBD have been selected to test perception on effectiveness, usability and acceptance of the device. This group is a sample of people belonging to a wider study consisting in a randomized clinical trial (RCT) that compares: (1) experimental group that received a treatment that combines the use of HandTutor® with conventional occupational therapy (COT) and (2) control group that receives only COT.

Results: Although no statistical significance has been analysed, patients report acceptance and satisfaction with the treatment, decrease of muscle tone, increase of mobility and better performance in activities of daily life. Subjective perceptions have been contrasted with objective measures of the range of motion before and after the session. Although no side effects have been observed after intervention, there has been some usability problems during setup related with putting on gloves in patients with spasticity.

Conclusions: This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD, but more research is needed to validate this preliminary results.

1. Introduction

According to the World Health Organization [1], cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability. The last update of the global Burden of Ischemic and Haemorrhagic Stroke [2] indicates that although age-standardized rates of stroke mortality have decreased worldwide in the past two decades, the absolute numbers of people who have a stroke every year are increasing. In 2013, there were 10.3 million of new strokes, 6.5 million deaths from stroke, almost 25.7 million stroke survivors and 113 million of people with disability-adjusted life years (DALYs) due to stroke.

One of the most frequent problems after stroke is upper limb (UL) impairments such as muscle weakness, contractures, changes in muscle tone, and other problems related to coordination of arms, hands or fingers [3, 4]. These impairments induce disabilities in common movements such as reaching, picking up or holding objects and difficult activities of daily living (ADLs) such as washing, eating or dressing, their participation in society, and their professional activities [5]. Most of people experiencing this upper limb impairment will still have problems chronically several years after the stroke. Impairment in the upper limbs is one of the most prevalent consequences of stroke. For this reason making rehabilitation is an essential step towards clinical recovery, patient empowerment and improvement of their quality of life. [6, 7].

Traditionally, therapies are usually provided to patients during their period of hospitalization by physical and occupational therapists and consist in mechanical exercises conducted by the therapists. However, in the last decades, many changes have been introduced in the rehabilitation of post-stroke patients. On the one hand, increasingly, treatments extend in time beyond the period of hospitalization and extend in the space, beyond the hospital to the patient’s home [8]. On the other hand, new agents are involved in treatments, health professionals (doctors, nurses) and non-health professionals (engineers, exercise professionals, carers and family). Most of these changes have been made possible thanks to the development of technology [9].

2. Technological devices for upper limb rehabilitation

In the last 10 years, there has been increasing interest in the use of different technological devices for upper limb (UL) rehabilitation generally [5, 9], and particularly hand rehabilitation for stroke patients [10]. These studies have approached the problem from different points of view: (1) on the one hand, by analysing the physiological and psychophysical characteristics of different devices [11], (2) on the other analysing the key aspects of design and usability [12] and (3) finally studying its effectiveness in therapy [13, 14]. According to Kuchinke [12], these technical devices can be organized into two big groups: (1) on the one hand, devices based on virtual reality (VR) and (2) on the other robotic glove-like devices (GDs).

One of the main advantage of VRs and serious games [15] is to promote task-oriented and repetitive movement training of motor skill while using a variety of stimulating environments and facilitates adherence to treatment in the long term [16]. These devices can be used at home and in most cases do not require special investment in therapeutic hardware because they can use game consumables existing at home such as Nintendo(R) Wii1 [17, 18], Leapmotion2 [19, 20] or Kinect sensor3 [21, 22]. Although first systematic studies based in VRs indicate that there is insufficient evidence to determine its effectiveness compared to conventional therapies [8], more recent studies [13, 14, 23] offer moderate evidence on the benefits of VR for UL motor improvement. Most researchers agree that VRs work well as coadjuvant to complement more conventional therapies; however, further studies with larger samples are needed to identify most suitable type of VR systems, to determine if VR results are sustained in the long term and to define the most appropriate treatment frequency and intensity using VR systems in post-stroke patients.

On the other hand, robotic systems and glove-like devices that provide extrinsic feedback like kinaesthetic and/or tactile stimulation have stronger evidence in the literature that improve motion ability of post-stroke patients [10, 24, 25]. Most of the evidences about effectiveness of GDs are based in pilot studies with non-commercial prototypes [2630], but nowadays, there are also several commercial glove-like devices that support hand rehabilitation therapies for these patients such as HandTutor® [31, 32], Music Glove [3335], Rapael Smart Glove [36] or CyberTouch [16, 37]. The main disadvantages of GDs are price, availability, because they are not yet widespread, and in some case the difficulty of setup handling and ergonomics.

As far as we know, there is little evidence in the literature supporting commercial glove-like devices for hand rehabilitation. This chapter presents a randomized clinical study (RCS) to test HandTutor® System in patients with chronic brain damage (CBD). There are some promising studies that show positive results by applying the HandTutor® in different groups of patients with stroke and traumatic brain injury (TBI) [31, 32], but samples include only people who are in the acute or subacute disease or injury but do not include chronic patients. This may be due to the added difficulty of obtaining positive results in interventions aimed at this group, in addition to the characteristics of adaptability and usability of the device that it is also harder for this kind of patients. The present work focuses on hand rehabilitation for chronic post-stroke patients.

3. Experimental design

We have conducted a pilot study (PS) to test acceptance, usability and adaptability of HandTutor® device in patients with chronic brain damage (CBD). This work describes setup, study protocol and preliminary results.

3.1. Participants description

Eligible participants met the following inclusion criteria: (1) At least 18-year age, (2) diagnosed with acquired brain injury: stroke or traumatic brain injury (TBI) and (3) chronic brain damage (more than 24 months from injury). In the final sample, 18 participants aged between 30 and 75 years old, 28% of subjects included in the pilot study are diagnosed with TBI and the remaining 72% of stroke; of these, more than half (56%) have left hemiplegia. The time from injury time exceeds 24 months, reaching 61% of cases 5 years of evolution. All the subjects included in the study attend regularly to a direct care acquired brain injury centre.

3.2. Device description

HandTutor® is a task-oriented device consistent on an ergonomic wearable glove and a laptop with rehabilitation software to enable functional training of hand, wrist and fingers. There are different models to fit both hands (left and right) and different sizes. The system allows the realization of an intensive and repetitive training but, at the same time, is flexible and adaptable to different motor abilities of patients after suffering a neurological, traumatological or rheumatological injury. The software allows the therapist to obtain different types of measures and to customize treatments for different patients, adapting the exercises to their physical and cognitive impairments. The HandTutor® provides augmented feedback and allows the participation of the user in different games that require practising their motor skills to achieve the game objective. Game objectives are highly challenging for patients and promote the improvement of deteriorated skills.

3.3. Study protocol

A randomized clinical trial (RCT) has been conducted with an experimental group and a control group. Participants in the experimental group have been treated with HandTutor® technological device, combined with conventional occupational therapy (set of functional tasks aimed at the mobility of the upper limb in ADLs). The control group only received conventional occupational therapy. All participants in the experimental group attend two weekly sessions with HandTutor®. Both groups received a weekly session of conventional therapy. It is a longitudinal study with pre-post intervention assessment, in which each subject is his control.

This chapter describes the first phase of the RCT, consisting of a pilot study (PS) to test the acceptance, usability and adaptability of the device by patients. For the PS, 18 patients of the global group were selected. Each subject completed four sessions using HandTutor® in both hands and a weekly session of COT. Each session includes quantitative and qualitative evaluation. The former one includes pre-intervention, and post-intervention assessment evaluating passive and active joint range of fingers and wrist, the latter include patients’ interviews and therapist’s observations. During the session, participants receive immediate visual and sensory feedback about their performance during exercises.

Each session includes a pre-intervention assessment and a back, wrist and hand. At the beginning of the session, the therapist evaluated the passive and active joint range of all fingers and wrist (flexion and extension). After the session, patient and therapist reviewed the increased joint range achieved during therapy on the joints involved. The software allows analysing and comparing the minimum and maximum levels in each of the movements required by the exercise. Each session lasts 45 minutes and consists of two exercises that focus their activity in flexion and extension of wrist and fingers independently, reaction speed and accuracy of the selected motion to move some elements included in the exercise.

First exercise of the session consisted in score as many balls as possible in the basket situated at the left of the patient. Every ball came to the patient from his right side. The goal of the second exercise of the session was destroying cylindrical rocks that were going from the right side to a planet situated in the left side. In both exercises, none of the elements appeared at the same height. That is why the patient had to adjust the degrees of flexion and extension of wrist, fingers or both. The occupational therapist could modify the speed, number of balls and minimum and maximum of degrees to achieve the accomplishment.

In addition to the quantitative variables described above, the therapist evaluated with qualitative methodology through interviews and observation, the condition of the skin (redness in the contact area with the glove), increased muscle tone, pain, motivation and difficulty understanding the instructions, level of usability, applicability and functionality of the patient. During the intervention, the therapist verbally corrected offsets trunk and lower limbs, annotating associated reactions in the facial muscles.

4. Results and discussion

All the participants of the experimental group completed the pilot study (n = 18). Table 1 shows the passive and active range of motion (ROM) of the preseason evaluation in fingers and wrist, divided by diagnostic (stroke vs. traumatic brain injury). Every data about ROM is shown in millimetres (average score). In the evaluation, it is noted that the hand of the participants with traumatic brain injury showed lower passive and active joints in all of the fingers (active: V: 9, IV: 10, III: 9, II: 8 and I: 10; passive: V and IV: 14, III: 11, II: 17 and I: 16), except in the wrist (stroke: active 8; passive 23 vs. traumatic brain injury: active 18; passive 20).

Stroke (average in mm) Traumatic brain injury (average in mm)
Range of motion (flexo-extension)
Wrist
Little
Ring
Middle
Index
Thumb
Active

8
11
14.3
11
10
8.3
Passive

23
20.3
22.6
22.6
22.6
20.6
Active

18
9
10
9
8
10
Passive

20
14
14
11
17
16
Active flexion deficit
Wrist
Little
Ring
Middle
Index
Thumb

9
5.6
5
4.3
5.6
9

2
0
0
2
0
1
Active extension deficit
Wrist
Little
Ring
Middle
Index
Thumb

6
3.3
3.3
8.4
7
3.3

0
5
4
0
9
5
Treatments sessions log
Reaction speed
Accuracy
Time in seconds (half)
Number of objects
Primary ranger

10
Full
240
1
Full

10
Full
240
1
Full

Table 1.

Hand ROM evaluation pre-session and treatments sessions log.

Participants with stroke show higher deficits in the flexion active of the first, second and fifth fingers (9, 5.6 and 5.6, respectively), while the extension appears more weakened in the second and third fingers (7 and 8.4, respectively). However, the participants with traumatic brain injury show higher deficit of flexion in the third finger and the extension in the second, fourth and fifth fingers.

In every session, exercises were configured with the same reaction speed and the same number of objects, to allow the participants to achieve the maximum number of hits. Some of them showed deficit of attention, which means that the speed and the increase of stimulations could decrease the final scores and the motivation of the intervention. In the case of the participants who show spasticity, this speed allows them to autorelax and control the hand between the stimulations. The length of exercises were modified according to the muscular and attentional fatigue of the participant, starting with 5 minutes and decreasing, in some cases, up to 3 minutes. All the participants reached the accuracy of movement calculated by the system, according to the preseason ROM evaluation. Also, all of them were allowed to work all of the primary movement range calculated in the evaluation.

At the beginning of the session, the occupational therapist explained the exercise to the participant and conducted a 1-minute test to check understanding. Only was necessary to provide additional verbal instruction to improve comprehension in the 11% of the cases.

Figures 1 and 2 show the ROM evaluation of the hand. In Figure 1, the active evaluation of flexion of wrist and extension of fingers is observed. Figure 2 includes the graphic representation of the millimetres of active movements (in red colour) versus the passive ones (in blue colour) of two hands with left hemiplegia (1 and 2) and two hands of participants with traumatic brain injury (tetraparesis and predominance of affectation in the right hemibody).

media/F1.png

Figure 1.

Hand ROM evaluation (active).

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Figure 2.

Hand ROM evaluation HandTutor® (passive and active).

Figures 3 and 4 display the functioning of the HandTutor® during the intervention. Figure 3 shows the glove with the hand in flexo-extension, while Figure 4 shows the assisted movement of the occupational therapist to obtain the higher ranges of flexion in a participant who shows rigidity and attentional issues. Besides, in the contralateral hand, it can be seen the associated reactions in the top member, which is not forming a part of the intervention. The hand replicates the movement that the occupational therapist is trying to get in the most affected member.

media/F3.png

Figure 3.

Flexo-extension hand with HandTutor®.

media/F4.png

Figure 4.

Example of assisted movement with HandTutor®.

Figures 5 and 6 show maximum and minimum scores for diagnostic. In them, it can be observed the heterogeneity of the flexion and extension movement of the participants in the study. Regarding the wrist, it is not observed huge differences by diagnostic, except in the minimum flexo-extension of the stroke group, especially in the extension. Nevertheless, the articular ranges of the fingers differ until they reach a difference of 20 millimetres in the third finger in the case of the group diagnosed with stroke, coinciding with the group diagnosed with traumatic brain injury.

media/F5.png

Figure 5.

Flexo-extension maximum and minimum of fingers in treatments sessions log.

media/F6.png

Figure 6.

Flexo-extension maximum and minimum of wrist in treatments session logs.

Participants referred increasing satisfaction with this new therapy. During the intervention, the software provided quantitative measures and immediate feedback of variations in patient mobility showing that HandTutor® sensors are highly sensitive to small variations in patient movement. In post-intervention interviews, patients reported that the glove decreases muscle tone of the hand and wrist, allowing ending the session with increased mobility.

All sessions evaluated qualitatively, through an interview, the following parameters: skin condition, motivation, difficulty in the understanding of instructions, level of HandTutor® utility, clinic applicability and satisfaction.

During the sessions, no side effects were observed related to the skin or post-intervention pain related with the hand use. Every participant ended the sessions without any visible injury in the skin (absence of redness, marks or changes in the coloration) and without any kind of pain. This was evaluated both at the end of the session and at the beginning of the next. To be able to contrast the information in relation with the skin condition and the pain, the data were triangulated by asking the participant and his/her primary caregiver the following day of every intervention. In both cases, they confirmed our data.

All participants referred high level of motivation and satisfaction at the end of the intervention due to the perceived higher performance of limb segments and joins involved in the exercises in their activities of daily life (ADLs). The subjective perception of the patient was checked by comparing the ROM (active vs. passive) pre-post measurement session. All participants showed and transmitted a great motivation and satisfaction with the HandTutor® intervention, except for one user. This one presents acoustic, visual and tactile hypersensitivity. After the pilot study, this participant transmitted that the glove, the sound and the images of the system induced in him/her nervousness and rejection. This information was contrasted with caregivers and professionals of the centre.

Some difficulties were found at the following of the exercise instructions, the motivation and interest maintenance during the 11% of the cases, as a consequence of the presence of attention and/or memory impairments.

All participants shared the sensation of decreasing the muscular tone, immediately at the end of every session and transmitted that this feeling stayed all day long, allowing them a higher mobility and independence at the ADLs.

During the study, some problems were observed associated with the difficulty in putting on the HandTutor® glove, especially in hands with high degrees of spasticity, mainly in diagnosed cases of traumatic brain injury (27.8%; Figure 7). Participants with lower ROM valued positively that the exercise was adapted to their possibilities, so they can reach and move objects even with their limited mobility. The 20% of the users valued negatively the weight of the system placed in the forearm, especially those with weak musculature. The occupational therapists reduced the gravity effect including a cradle to facility the placement of the forearm.

media/F7.png

Figure 7.

Spastic hand with HandTutor®.

In those patients that showed sweating, there were placed vinyl or latex gloves on their hands to avoid direct contact with the glove.

Therefore, it seems that the HandTutor® is a device with high degrees of acceptance and usability among patients with CBD.

5. Conclusions

This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD. On one hand, in the theoretical part of the study, we have found in the literature strong evidence confirming the effectiveness of glove-like devices in hand rehabilitation after brain injury, but no so solid evidence of VRs effectiveness over traditional treatment. On the other hand, the practical pilot study to test HandTutor points in the expected direction confirming participants’ satisfaction about effectiveness and ergonomics of glove-like devices, but according to Ref. [12], there are still some issues to be solved in the usability of these devices for patients with spasticity.

The grade of usability of the HandTutor® device with chronic patients with CBD is high; we only find difficulties in those who show attention disorders and/or memory issues or sensorial hypersensibility. The degree of spasticity should also be taken into account in the design of the experience, because difficulties may arise in the placement of the device when the degree of spasticity is high or there is rigidity or other associated reactions.

Most of the studies performed with active gloves similar to HandTutor® device have been performed in patients in the acute or subacute phase of brain damage. It is important to emphasize that in this study, unlike the previous ones, the rehabilitation has been done with patients with more than 24 months of evolution since the diagnosis of the damage and therefore with a very high degree of chronicity in the neurological sequelae. This is one of the main contributions of the presented work since the more time has passed since the diagnosis of brain damage; the more difficult it is to achieve significant improvements with rehabilitation.

In our study, the HandTutor® device has performed effectively for the spasticity treatment in patients with CBD, producing improvements in the performance of the ADLs and elevating the motivation and satisfaction grades with his use in rehabilitation processes. However, this trial does not provide significant statistical evidence about HandTutor® effectiveness, and it would be recommendable to replicate the study with more participants to confirm our findings.

6. Acknowledgements

Work partially funded by SYMBHYO-ITC [MCINN PTQ-15-0705], RESET [MCINN TIN2014-53199-C3-1-R], eMadrid [CAM S2013/ICE-2715] and PhyMEL [UC3M 2015/00402/001] projects. Authors would like to thank Maria Pulido for their feedback in VR devices, and we also want to express our gratitude to the patients involved in the pilot study.

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Source: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study | InTechOpen

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