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Posts Tagged Subacute
[Abstract] Evolution of upper limb kinematics four years after subacute robot-assisted rehabilitation in stroke patients
Purpose: To assess functional status and robot-based kinematic measures four years after subacute robot-assisted rehabilitation in hemiparesis.
Material and methods: Twenty-two patients with stroke-induced hemiparesis participated in a ≥3-month upper limb combined program of robot-assisted and occupational therapy from two months post-stroke, and received community-based therapy after discharge. Four years later, nineteen (86%) participated in this long-term follow-up study. Assessments two, five and 54 months post-stroke included Fugl-Meyer (FM), Modified Frenchay Scale (MFS, at Month 54) and robot-based kinematic measures of targeting tasks in three directions, north, paretic and non-paretic: distance covered, velocity, accuracy (RMS error from straight line) and smoothness (number of velocity peaks; upward changes in accuracy and smoothness measures represent worsening). Analysis was stratified by FM score at two months: ≥17 (Group 1) or < 17 (Group 2). Correlation between impairment (FM) and function (MFS) was explored at 54 months.
Results: Fugl-Meyer scores were stable from five to 54 months (+1[-2;4], median[1st;3rd quartiles], ns). Kinematic changes in the three directions pooled were: distance covered, -1[-17;2]% (ns); velocity, -8[-32;28]% (ns); accuracy, +6[-13;98]% (ns); smoothness, +44[-6;126]% (p<0.05). Group 2 showed decline vs Group 1 (p<0.001) in FM (Group 1, +3[1;5], p<0.01; Group 2, -7[-11;-1], ns) and accuracy (Group 1, -3[-27;38]%, ns; Group 2, +29[17;140]%, p<0.001). At 54 months, FM and MFS were highly correlated (Pearson’s rho = 0.89; p<0.001).
Conclusions: While impairment appeared stable four years after robot-assisted upper limb training during subacute post-stroke phase, kinematic performance deteriorated in spite of community-based therapy, especially in patients with more severe impairment.
[ARTICLE] Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients – Full Text
The purpose of this study was to critically evaluate the effects of robot-assisted gait training (RAGT) on gait-related function in patients with acute/subacute stroke. We conducted a systematic review of randomized controlled trials published between May 2012 and April 2016. This search included 334 articles (Cochrane, 51 articles; Embase, 175 articles; PubMed, 108 articles). Based on the inclusion and exclusion criteria, 7 studies were selected for this review. We performed a quality evaluation using the PEDro scale. In this review, 3 studies used an exoskeletal robot, and 4 studies used an end-effector robot as interventions. As a result, RAGT was found to be effective in improving walking ability in subacute stroke patients. Significant improvements in gait speed, functional ambulatory category, and Rivermead mobility index were found with RAGT compared with conventional physical therapy . Therefore, aggressive weight support and gait training at an early stage using a robotic device are helpful, and robotic intervention should be applied according to the patient’s functional level and onset time of stroke.
Stroke is a common disease . In most patients, disabilities remain after stroke, and long-lasting disability requires continuous management and intensive rehabilitation [1, 2]. Furthermore, the economic burden on the patient increases because of the prolonged rehabilitation period. Therefore, the application of intensive and efficient rehabilitation programs and techniques is an urgent need after stroke .
Gait impairment is one of the most important problems after stroke and is associated with activities of daily living and mobility issues . Therefore, recovery of gait function is an important goal of rehabilitation for independent living . Interventions to enhance gait function require repetitive task training with high intensity, and extensive effort by physical therapists is essential . Moreover, the most effective rehabilitation intervention, including gait training, must be performed shortly after stroke and in an intensive and task-oriented manner and should include multisensory stimulation .
Robot-assisted gait training (RAGT) for patients in the acute/subacute stage who are nonambulatory is effective at reeducating motor control function through repetitive training of a specific task ; RAGT provides intensive therapy, which reduces the burden on therapists, and enhances motor reeducation with multisensory stimulation . Several previous studies reported that gait training using robotic devices is effective at enhancing muscular activity patterns , muscle tone, joint range of motion , gait speed, functional gait capability [7, 9], gait independence, and mobility in the community [10, 11]. Moreover, patients who received RAGT and conventional physical therapy had a higher chance of regaining independent gait function than those who received only conventional gait training . However, owing to studies that suggested RAGT is ineffective , the effect on gait and gait-related function in subacute stroke remains unclear. In a previous review of effectiveness in stroke patients, the RAGT group showed significant improvement in balance and balance-related activity function, but the comparison between the groups was not significant . These results show that RAGT is effective, but whether it is more effective than other gait-related rehabilitation interventions is still unclear. In this context, the effect of RAGT is still not clearly demonstrated, and reviews that have recently demonstrated the effect of RAGT on gait-related outcome measures in patients with acute/subacute stroke are also limited.
Therefore, the aim of this systematic review was to investigate the effects of RAGT on acute/subacute stroke. The specific goals included identifying the effects of RAGT using assessment tools associated with gait and gait-related function in patients with acute/subacute stroke.[…]
Virtual reality training was as effective as, but not superior to, conventional therapy for improving arm and hand function after stroke when both were added to standard rehabilitation in the subacute phase of stroke recovery, researchers found.
In the phase III VIRTUES study, conducted at five rehabilitation hospitals in Europe, similar and significant improvements from baseline assessments of arm and hand mobility were seen at the end of the 4-week intervention and at 3-month follow-up, but there was no difference between the two groups in the results for any endpoints (P<0.001), Iris Brunner, PhD, of Aarhus University, Hammel Neurocenter in Denmark, and colleagues reported online in Neurology.
“These results suggest that either type of training could be used, depending on what the patient prefers,” Brunner said in a statement. “Virtual reality training may be a motivating alternative for people to use as a supplement to their standard therapy after a stroke.”
Improvement of upper extremity motor function performance on the Action Research Arm Test (ARAT) was similar with the virtual reality and conventional training after the 4-week intervention and at follow-up. Patients in virtual reality training improved their ARAT scores an average of 12 points (21%) from baseline to the postintervention assessment, and 17 points (30%) at 3-month follow-up, while those receiving conventional training improved 13 points (21%) at those respective assessments.
Likewise, no differences were seen between the virtual reality and conventional training groups in secondary endpoints, including the Box and Blocks Test, Functional Independence Measure, and Patient Global Impression of Change assessment.
The study involved 120 patients (average age 62) enrolled between March 2014 and April 2016 who had mild-to-severe upper extremity impairment in their wrists, hands, or upper arms as a result of suffering a stroke an average of one month before the study started.
For the add-on conventional or virtual reality therapy, participants had four to five hour-long training sessions per week for four weeks: 62 received conventional physical and occupational therapy, and 58 received virtual reality training that involved using a screen and gloves with sensors to play games that could be adapted to the person’s abilities.
Level of impairment had no differential effect on outcomes, which were similar for patients with mild/moderate impairment – defined as the ability to extend the wrist at least 20 degrees and the fingers at least 10 degrees from drop hand position – or severe impairment. On ARAT, improvements at 3-month follow-up in the mild/moderate group were 14 points (25%) with virtual reality (VR) training and 13 points (23%) with conventional therapy, while the severe group improved 23 points (40%) with VR and 23 points (40%) with conventional therapy.
While active training time was considerably increased among severely impaired participants using virtual reality training compared to those using conventional training, this was not reflected in a larger improvement in arm motor function, authors wrote. This reflects a study design limitation, they wrote: The addition of a third arm receiving only standard rehabilitation would have helped identify potential benefits of more intensive training and increased training time, as previously reported.
Danielle Levac, MD, PhD, PT, of Northeastern University in Boston, who was not involved in the study, agreed with Brunner and colleagues that future study should apply outcome measures that differentiate between recovery on an impairment level and compensation, given that training intensity within the first few months of a stroke is crucial for maximally exploiting the window of increased plasticity.
Also, neither patient engagement nor motivation — attributes through which VR systems are thought to increase adherence and potentially enhance motor learning — were “subjectively or objectively measured here, which seriously detracts from the author’s conclusions that VR constitutes ‘motivating’ training,” Levac told MedPage Today.
The numerous small studies that have demonstrated benefits of virtual reality training have used specially engineered rehab-specific systems, whereas a recent larger trial in subacute stroke patients that did not find superiority over conventional training used a commercial gaming system.
“It is the low cost and easy accessibility of off-the-shelf gaming systems that have made them so pervasive and attractive in clinical practice, despite the disadvantages for tailoring to individual patient needs noted by the authors,” Levac said.
Robert Teasell MD, of Western University in London, Ontario, and head of the Stroke Rehabilitation Writing Group for the Canadian Stroke Best Practice Recommendations, told MedPage Today that many small trials of virtual reality training have demonstrated a benefit in stroke patients.
“This study is important because it is comparatively larger, employs a multisite design, and has an active control group which gets an equal amount of ‘conventional’ therapy and not just ‘usual care,'” said Teasell, who was not involved in the study. “It demonstrates effectiveness – although not superiority – of virtual reality as a promising adjunct treatment.”
Despite advancing rehabilitation programs, stroke is the most prevalent disease to cause disablement. With the increase of the elderly population, the number of stroke patients increases as well. Although stroke patients at an early stage depend on a stroke unit in the acute hospital, their functional recovery and long-term health status are more affected by subacute rehabilitation hospital. Moreover, a stroke patient’s initial evaluation is crucial for prognosis and establishment of rehabilitation training strategies. The earlier stroke patients start their rehabilitation treatment, the better results they can attain; the recovery from stroke occurs within 3 months after the onset of stroke. Similarly, while neurological and functional recovery occurs in the acute and subacute stages, sometimes, it occurs 6 months after the onset of stroke or in the chronic stage. There are two main mechanisms of neurological recovery. The first is activity-dependent neuroplasticity in the injured cortical representation area, and second is vicariation, which is an operating mechanism as a substitute for the injured brain function in the remnant cortical area, outside of the damaged brain area. This stroke recovery is affected by many factors that influence reorganization of the damaged brain and early rehabilitation; furthermore, intensive rehabilitation and organized enriched environments also significantly affect recovery. In addition, there are substantial researches about new rehabilitation treatment, likely rTMS, tDCT, robotic therapies, mirror therapy, virtual reality, and drug augmentation; therefore, the results of these studies are expected to highlight promising rehabilitation treatments for stroke in the future.
[ARTICLE] Effect of Static versus Cyclical Stretch on Hand Motor Control in Subacute Stroke – Full Text PDF
Background and Purpose: The purpose of this study was to investigate the impact of passive static and cyclical stretching of the fingers on hand function in subacute stroke survivors.
Participants: Thirteen stroke survivors, 2-5 months post-incident, with moderate to severe hand impairment took part in the study.
Method: Each participant completed three separate sessions, separated by at least one week, consisting of 30 minutes of: static stretch of the digits, cyclical stretch, or rest. Stretching was performed by a powered glove orthosis (X-Glove). Outcome measures, comprised of three timed hand-specific tasks from the Graded Wolf Motor Function Test (GWMFT-Time), grip termination time (GTT), grip strength, and lateral pinch strength, were assessed at the beginning and end of each session. Change in outcome score during each session was used for analysis.
Results: Data suggested a trend for improvement following stretching. Reduction in mean completion time for the GWMFT-Time after the cyclic stretching was 5 times greater than for the rest condition (P = 0.010). After the static stretching, GTT was 31% faster than the mean pre-test times (P = 0.055). Improvements in grip and pinch strength were also evident following the stretching interventions, although these changes did not reach statistical significance.
Discussion and Conclusion: While more study is needed, cyclically stretching the finger muscles in the stroke hand appears to be a promising treatment for stroke survivors in the subacute phase of recovery. It may prove especially effective as an adjuvant therapy facilitating subsequent performance of active movement therapy. Future studies exploring the neural correlates of improvement are warranted.