Recovery of upper extremity (UE) motor function after stroke is variable from one to another due to heterogeneity of stroke pathology. Structural and biochemical magnetic resonance imaging of the primary motor cortex (M1) have been used to document reorganization of neural activity after stroke.
To assess cortical biochemical and structural causes of delayed recovery of UE motor function impairment in chronic subcortical ischemic stroke patients.
A cross-sectional study with fifty patients were enrolled: thirty patients with chronic (> 6 months) subcortical ischemic stroke suffering from persistent UE motor function impairment (not improved group) and twenty patients with chronic subcortical ischemic stroke and improved UE motor function (improved group). We recruited a group of (16) age-matched healthy subjects. Single voxel proton magnetic resonance spectroscopy (1H-MRS) was performed to measure N-acetylaspartate (NAA) and glutamate+glutamine (Glx) ratios relative to creatine (Cr) in the precentral gyrus which represent M1of hand area in both ipsilesional and contralesional hemispheres. Brain magnetic resonance imaging (MRI) to measure precentral gyral thickness is representing the M1of hand area. UE motor function assessment is using the Fugl Meyer Assessment (FMA-UE) Scale.
The current study found that ipslesional cortical thickness was significantly lower than contralesional cortical thickness among all stroke patients. Our study found that ipsilesional NAA/Cr ratio was lower than contralesional NAA/Cr among stroke patients. UE and hand motor function by FMA-UE showed highly statistically significant correlation with ipsilesional cortical thickness and ipsilesional NAA/Cr ratio, more powerful with NAA/Cr ratio.
We concluded that persistent motor impairment in individuals with chronic subcortical stroke may be at least in part related to ipsilesional structural and biochemical changes in motor areas remote from infarction in form of decreased cortical thickness and NAA/Cr ratio which had the strongest relationship with that impairment.
Motor impairment of one side of the body is a major cause of disability in activities of daily living. Recovery from strokes varies from one patient to another due to the heterogeneity of the stroke pathology and rehabilitation strategies. While most stroke patients recover spontaneously, many are left with permanent neurological impairments .
Understanding the brain pathologies associated with upper extremity (UE) impairment after stroke, the underlying mechanisms of injury, and the processes associated with recovery is important for achieving good recovery and successful rehabilitation. Advancements in neuroimaging technology have made this possible. Structural and biochemical brain imaging of primary motor cortices has been used to document the reorganization of neural activity after stroke. Ipsilesional and contralesional primary motor cortices, as well as the dorsal premotor cortex, have been identified as areas that can undergo substantial post-stroke neuroplasticity .
Single voxel proton magnetic resonance spectroscopy (1H-MRS) is a non-invasive tool to measure the levels of certain metabolites. In acute stroke, the presence of a measurable lactate peak demonstrates a shift from aerobic to anaerobic metabolism in the brain. Previous studies have shown that this is a temporary effect, and levels return to an almost undetectable state within 3 weeks .
Biochemical changes have also been observed chronically within ipsilesional normal-appearing grey matter and have been associated with morphological changes in stroke patients .
N-Acetylaspartate (NAA) is a metabolite found exclusively in neurons and their processes. It is considered a putative marker of their integrity with specific roles in the central nervous system, including myelin synthesis, neuronal energetics, neuronal osmoregulation, and axonal–glial signaling .
In individuals with chronic stroke, lower NAA and higher myo-inositol (an astrocyte marker) concentrations have been reported within ipsilesional and contralesional primary motor cortices .
A positive correlation has been drawn between NAA, glutamate (Glu: the principle excitatory neurotransmitter in the human central nervous system), and UE function in a chronic stroke population .
Structural changes in regional cortical thickness have also been observed in individuals in the subacute phase (3 months of recovery) after subcortical ischemic stroke and have been linked to functional activation changes in individuals with chronic stroke [8, 9].
The purpose of this study is to assess cortical, biochemical, and structural causes of delayed recovery of UE motor function impairment in patients with chronic, subcortical ischemic stroke.
Subjects and methods
A cross-sectional study with fifty patients were enrolled: thirty patients with chronic (> 6 months) subcortical ischemic stroke suffering from persistent upper extremity motor function impairment (not improved group) and twenty patients with chronic subcortical ischemic stroke and improved upper extremity motor function (improved group).
All patients were recruited from El Sahel Teaching Hospital outpatient clinics.
1.Eligible right handed patients aged between 50 and 70 years old.
2.Single clinically diagnosed chronic (> 6 months) subcortical ischemic stroke presented with UE motor impairment at the acute stage.
2.Patients with aphasia, cognitive impairment, UE apraxia, sensory deficit, or ataxia.
3.Patients with history of previous stroke.
4.Patients who had any contraindication for MRI or 1H-MRS.
5.Patients who underwent neuro-rehabilitation through transmagnetic brain stimulation or transcranial direct current brain stimulation.
6.Patients with uncontrolled diabetes mellitus.
7.Patients with chronic renal or hepatic failure.
We recruited right-handed age-matched (16) healthy subject group to be references for our results regarding Egyptian people.
All participants subjected to:
1.Full medical history and neurological examination.
2.Routine lab and imaging.
3.(1H-MRS) to measure NAA and Glx concentration as ratios of their peak heights to Cr peak height as a stable internal reference (NAA/Cr and Glx/Cr) in ipsilesional and contralesional precentral gyrus which represent the M1 of hand area (landmark of precentral gyrus), determined anatomically by the area that faces and forms the “middle knee” of the central sulcus, located just at the cross point between the precentral sulcus and the central sulcus, which is topographically located at the level of the distal end of the superior frontal sulcus and is therefore also visible on the cortical surface  (Fig. 1).
4.MRI brain to (a) quantify cortical thickness of the precentral gyrus representing the M1of hand area in both ipsilesional and contralesional hemispheres through Picture Archiving and Communication System (PACS), presented in millimeters (mm) and (b) assess white matter disease by fazekas scale which divides the white matter in periventricular (PVWM) and deep white matter (DWM) through fluid attenuated recovery (FLAIR) film with the higher score means more severity.
5.UE motor function assessment using the Fugl Meyer Assessment (FMA-UE) Scale .
6.Modified rankin scale (mRS) to assess disability degree in stroke patients ranging from 0 to 5 with higher score indicating more disability .
Human activity recognition (HAR) technology has been advanced with the development of wearable devices and the machine learning (ML) algorithm. Although previous researches have shown the feasibility of HAR technology for home rehabilitation, there has not been enough evidence based on clinical trial.
We intended to achieve two goals: (1) To develop a home-based rehabilitation (HBR) system, which can figure out the home rehabilitation exercise of patient based on ML algorithm and smartwatch; (2) To evaluate clinical outcomes for patients with chronic stroke using the HBR system.
We used off-the-shelf smartwatch and the convolution neural network (CNN) of ML algorithm for developing our HBR system. It was designed to be able to share the time data of home exercise of individual patient with physical therapist. To figure out the most accurate way for detecting exercise of chronic stroke patients, we compared accuracy results with dataset of personal/total data and accelerometer only/gyroscope/accelerometer combined with gyroscope data. Using the system, we conducted a preliminary study with two groups of stroke survivors (22 participants in HBR group and 10 participants in a control group). The exercise compliance was periodically checked by phone calls in both groups. To measure clinical outcomes, we assessed the Wolf motor function test (WMFT), Fugl-meyer assessment of upper extremity (FMA-UE), grip power test, Beck’s depression index and range of motion (ROM) of the shoulder joint at 0 (baseline), 6 (mid-term), 12 weeks (final) and 18 weeks(6 weeks after the final assessment without HBR system).
The ML model created by personal data(99.9%) showed greater accuracy than total data(95.8%). The movement detection accuracy was the highest in accelerometer combined with gyroscope data (99.9%) compared to gyroscope(96.0%) or accelerometer alone(98.1%). With regards to clinical outcomes, drop-out rates of control and experimental group were 4/10 (40%) and 5/22 (22%) at 12 weeks and 10/10 (100%) and 10/22 (45%) at 18 weeks, respectively. The experimental group (N=17) showed a significant improvement in WMFT score (P=.02) and ROM (P<.01). The control group (N=6) showed a significant change only in shoulder internal rotation (P=.03).
This research found that the homecare system using the commercial smartwatch and ML model can facilitate the participation of home training and improve the functional score of WMFT and shoulder ROM of flexion and internal rotation for the treatment of patients with chronic stroke. We recommend our HBR system strategy as an innovative and cost-effective homecare treatment modality. Clinical Trial: Preliminary study (Phase I)
Background. Priming results in a type of implicit memory that prepares the brain for a more plastic response, thereby changing behavior. New evidence in neurorehabilitation points to the use of priming interventions to optimize functional gains of the upper extremity in poststroke individuals. Objective. To determine the effects of priming on task-oriented training on upper extremity outcomes (body function and activity) in chronic stroke.
Methods. The PubMed, CINAHL, Web of Science, EMBASE, and PEDro databases were searched in October 2019. Outcome data were pooled into categories of measures considering the International Classification Functional (ICF) classifications of body function and activity. Means and standard deviations for each group were used to determine group effect sizes by calculating mean differences (MDs) and 95% confidence intervals via a fixed effects model. Heterogeneity among the included studies for each factor evaluated was measured using the I2 statistic.
Results. Thirty-six studies with 814 patients undergoing various types of task-oriented training were included in the analysis. Of these studies, 17 were associated with stimulation priming, 12 with sensory priming, 4 with movement priming, and 3 with action observation priming. Stimulation priming showed moderate-quality evidence of body function. Only the Wolf Motor Function Test (time) in the activity domain showed low-quality evidence. However, gains in motor function and in use of extremity members were measured by the Fugl-Meyer Assessment (UE-FMA). Regarding sensory priming, we found moderate-quality evidence and effect size for UE-FMA, corresponding to the body function domain (MD 4.77, 95% CI 3.25-6.29, Z = 6.15, P < .0001), and for the Action Research Arm Test, corresponding to the activity domain (MD 7.47, 95% CI 4.52-10.42, Z = 4.96, P < .0001). Despite the low-quality evidence, we found an effect size (MD 8.64, 95% CI 10.85-16.43, Z = 2.17, P = .003) in movement priming. Evidence for action observation priming was inconclusive.
Conclusion. Combining priming and task-oriented training for the upper extremities of chronic stroke patients can be a promising intervention strategy. Studies that identify which priming techniques combined with task-oriented training for upper extremity function in chronic stroke yield effective outcomes in each ICF domain are needed and may be beneficial for the recovery of upper extremities poststroke.
Background. In monkey, reticulospinal connections to hand and forearm muscles are spontaneously strengthened following corticospinal lesions, likely contributing to recovery of function. In healthy humans, pairing auditory clicks with electrical stimulation of a muscle induces plastic changes in motor pathways (probably including the reticulospinal tract), with features reminiscent of spike-timing dependent plasticity. In this study, we tested whether pairing clicks with muscle stimulation could improve hand function in chronic stroke survivors.
Methods. Clicks were delivered via a miniature earpiece; transcutaneous electrical stimuli at motor threshold targeted forearm extensor muscles. A wearable electronic device (WD) allowed patients to receive stimulation at home while performing normal daily activities. A total of 95 patients >6 months poststroke were randomized to 3 groups: WD with shock paired 12 ms before click; WD with clicks and shocks delivered independently; standard care. Those allocated to the device used it for at least 4 h/d, every day for 4 weeks. Upper-limb function was assessed at baseline and weeks 2, 4, and 8 using the Action Research Arm Test (ARAT), which has 4 subdomains (Grasp, Grip, Pinch, and Gross).
Results. Severity across the 3 groups was comparable at baseline. Only the paired stimulation group showed significant improvement in total ARAT (median baseline: 7.5; week 8: 11.5; P = .019) and the Grasp subscore (median baseline: 1; week 8: 4; P = .004).
Conclusion. A wearable device delivering paired clicks and shocks over 4 weeks can produce a small but significant improvement in upper-limb function in stroke survivors.
Motion capture (Mocap) systems are considered more and more interesting for the assessment of rehabilitation processes. In fact, medical personnel are increasingly demanding for technologies (possibly low-cost) to quantitatively measure and assess patients’ improvements during rehabilitation exercises. In this paper, we focus the attention on the assessment of rehabilitation process for injured shoulders. This is particularly challenging because the recognition and the measurement of compensatory movements are very difficult during visual assessment and the movements of a shoulder are complex and arduous to be captured. The proposed solution integrates a low-cost Mocap system with video processing techniques to allow a quantitative evaluation of abduction, which is one of the first post-surgery exercises required for shoulder rehabilitation. The procedure is based on a set of open-source software tools to measure abduction and evaluate the correctness of the movement by detecting and measuring compensatory movements according to the parameters commonly considered by the physicians. Finally, a preliminary results and future works are presented and discussed.
Purpose: Motor recovery of the upper limb (UL) is related to exercise intensity, defined as movement repetitions divided by minutes in active therapy, and task difficulty. However, the degree to which UL training in virtual reality (VR) applications deliver intense and challenging exercise and whether these factors are considered in different centres for people with different sensorimotor impairment levels is not evidenced. We determined if (1) a VR programme can deliver high UL exercise intensity in people with sub-acute stroke across different environments and (2) exercise intensity and difficulty differed among patients with different levels of UL sensorimotor impairment.
Methods: Participants with sub-acute stroke (<6 months) with Fugl-Meyer scores ranging from 14 to 57, completed 10 ∼ 50-min UL training sessions using three unilateral and one bilateral VR activity over 2 weeks in centres located in three countries. Training time, number of movement repetitions, and success rates were extracted from game activity logs. Exercise intensity was calculated for each participant, related to UL impairment, and compared between centres.
Results: Exercise intensity was high and was progressed similarly in all centres. Participants had most difficulty with bilateral and lateral reaching activities. Exercise intensity was not, while success rate of only one unilateral activity was related to UL severity.
Conclusion: The level of intensity attained with this VR exercise programme was higher than that reported in current stroke therapy practice. Although progression through different activity levels was similar between centres, clearer guidelines for exercise progression should be provided by the VR application.
Implications for rehabilitation
VR rehabilitation systems can be used to deliver intensive exercise programmes.
VR rehabilitation systems need to be designed with measurable progressions through difficulty levels.
To investigate the effects of an exercise program with action observation versus conventional physical therapy on upper limb functionality in chronic stroke subjects.
In this controlled clinical trial, thirty-five stroke patients were divided into two groups, experimental group, comprising eighteen patients that received an exercise program with action observation; and a control group, comprising seventeen patients that received conventional exercise program. Functional recovery was assessed with the Fugl-Meyer Scale, manual dexterity was assessed with the Box and Blocks test, and the functional use of the affected upper limb was assessed with the Reach scale. Evaluations occurred at baseline, after three and six months of intervention. Statistical analyses were performed with the Repeated Measures Analysis of Variance and the Friedman test, under a 5% significance.
Both interventions provided benefits to chronic stroke patients. Exercise program with action observation presented better results on motor recovery (p < 0.001) and functional use of the affected limb (p < 0.001) when compared with conventional therapy. Both treatments improved the manual dexterity of the participants (p = 0.002), but in a similar way (p = 0.461).
A six-month exercise program with action observation provided benefits on functional recovery and functional use of an affected upper limb in chronic stroke patients. Exercises with action observation demonstrated the potential for improving affected upper limb in chronic stroke patients.
Recovery of the affected upper limb is one of the great challenges in the rehabilitation of stroke patients. Approximately 60% of severely affected individuals do not present manual dexterity six months after the stroke1. The functional deficits of the upper limb affect the ability for self-care, contribute to low perceived quality of life and higher healthcare services costs2,3.
Exercise programs should start early, be intensive and developed with the active participation of patients to promote motor learning and minimize functional deficits4. Action observation training (AO) is an alternative treatment in which the individual observes an action and then imitates the task5.
AO stimulates the mirror neuron system, a special type of neurons activated by the execution and observation of action6. Initially studied in monkeys, the mirror neuron system is associated with the premotor cortex, supplementary motor area, primary somatosensory cortex, and inferior parietal cortex. By its connections with neurocognitive processing, exercises programs that stimulate the mirror neuron system may promote important benefits to stroke patients6,7.
During AO there is an activation of several cortical areas. An internal representation of the action can potentiate motor learning and functional recovery8,9. AO uses movements guided by external stimuli in which visual attention recruits the cerebellar-thalamic-cortical circuit10. This circuit is involved in neural integration during the initial stages of motor learning. In this matter, Wright and collegues11 showed that directed attention facilitates corticospinal excitability of the brain.
Previous studies using AO showed positive results in the recovery of the affected upper limb in stroke1213141516–17. There were improvements in functionality, on the ability to perform activities of daily living and on manual dexterity. Nevertheless, there are still few studies comparing the effects of AO versus conventional therapy (exercise without AO) aiming to see how effective AO is in relation to exercise programs already consecrated.
Thus, in the present study, we investigated the benefits of AO in comparison to conventional physical therapy on upper limb functional recovery, manual dexterity and everyday use of the affected upper limb in individuals with stroke. We hypothesized that AO would present better outcomes to patients with stroke than a conventional exercise program.[…]
Background An important reason for the difficulty in recovering sensorimotor dysfunction of the upper extremity in chronic stroke survivors, is the lack of sensory function, such as tactile and proprioception feedback. In clinical practice, single sensory training is only for the restoration of sensory function. Increasing evidence suggests that use of task-oriented training (TOT) is a useful approach to hand motor rehabilitation. However, neither approach is optimal since both methods are trained only for specific functional recovery. Our hypothesis is that multi-sensory feedback therapy (MSFT) combined with TOT has the potential to provide stimulating tasks to restore both sensory and motor functions. The objective of the trial is to investigate whether novel MSFT is more effective in improving arm sensorimotor function in chronic stroke phase than single TOT.
Methods/Design: The study will be conducted as a multicenter, randomized, double blind controlled trial. Participants (n = 90) will be randomised into three groups to compare the effect of the multi-sensory feedback therapy group against task-oriented training group and conventional group. Participants will receive treatment at the same intensity (60 min, 5 days a week, 4 weeks, 20 hours total). Primary outcome measures for assessment of sensory function are the Semmes Weinstein monofilaments examination (SWME),two-point discrimination test (2PD) test. Secondary measures are the Action Research Arm Test (ARAT)༌Nine-Hole Peg Test (NHPT), Wolf Motor Function Test (WMFT), Box and Blocks Test (BBT), Modified Barthel Index (MBI), Instrumental activities of daily living (IADL) and Generalized Anxiety Disorder 7-Item Scale (GAD-7). Outcome mearsures will be evaluated at baseline, post treatment, and two months follow-up. All assessments will be conducted by trained assessors blinded to treatment allocation.
Discussion This study will determine the acceptability and efficacy of the intervention on the hemiparetic upper limb, it may be promising tools for sensorimotor functional recovery after stroke.
Figure 2. The multi-sensory feedback therapy system used in the present study. Step 1：Patients will undergo multi-sensory training under a visual feedback device, including (A) Tactile training for patients with different materials, textures, objects; (B) Proprioceptive control of hand gestures; (C) 2-point discrimination with tools. Step 2：All sensory stimuli will be visually blocked and visually exposed in all patients. Step 3：The multi-sensory feedback therapy combined with task-oriented training will increase motivation for sensorimotor tasks.
Stroke is a major cause of serious long-term disability in chronic stroke [1, 2]. In China alone, the age-standardized prevalence, incidence, and mortality rates were approximately 1114.8/100 000 people, 246.8 and 114.8/100 000 person-years, respectively . More than two thirds of all patients experience impaired function in the upper extremity [4, 5], and many of chronic stroke patients require continued rehabilitation for hand disability from hospitals. Sensory impairments of all modalities are thought to be common during the chronic stage of stroke .
Although tactile loss is more frequent than proprioceptive dysfunction, especially in the hand. Approximately 80% of chronic stroke patients experience tactile loss, over 69% without proprioceptive discriminations . Somatosensory deficits are associated with the degree of weakness and stroke severity, and they are also related to mobility, mental health, independence in activities of daily living, and recovery . Sensory function is an important composition of widely used physiotherapy approaches such as Bobath (known as Neurodevelopment Therapy in the United States) and Brunnstrom, and it is considered a precursor to the recovery of movement and functional activities of daily living in patients with stroke . Poor motor function is associated with reduced sensory experience and processing after stroke [10, 11]. Joint position sensation of the upper extremity is closely related to motor ability due to stroke-related reduced discrimination in proprioception , it causes disturbances in the arm movement trajectory. The relation between sensory and motor dysfunction is unsurprising since biomechanics and motor control of human movement require bidirectional interaction between cortex and periphery .
Sensory disorders include light touch, temperature, joint position, two-point discrimination, object discrimination, spatial orientation . Different types of sensory disorders have different inefficiencies to perform daily activities and social participation . Thermohypesthesia is the reason leading to scalding and freezing injury . Scalding injuries often occur as the result of spilled food or beverages. They are also unable to feel pain, which means that they can’t retract arms and hands actively. In addition, bleeding often happens after touching acupuncture or sharp objects. Stroke is also a major global mental health problem. The sensory impairment has negative implications to explore environment, and lower the effect of rehabilitation outcomes. Anxiety, depressive symptoms, general psychological distress and social isolation are prevalent if chronic patients have sensory disorders . Psychosocial difficulties may impact significantly on long-term functioning and quality of life [14, 15], and it reduces the effects of rehabilitation services and bring about higher mortality rates .
The purpose of this study is to determine whether multi-sensory feedback therapy (MSFT) can promote upper limb motor function, daily life activities, social participation and help to relieve anxiety in patients with chronic stroke.[…]
Objective: To compare the clinical therapeutic effect on post-stroke spastic paralysis of the upper extremity between the combination of kinematic-acupuncture therapy and rehabilitation training and the combined treatment of the conventional acupuncture with rehabilitation training.
Methods: A total of 60 patients of post-stroke spastic paralysis of the upper extremity at the non-acute stage were randomized into an observation group (30 cases) and a control group (30 cases, 1 case dropped off). On the base of the routine western medication and rehabilitation treatment, the kinematic-acupuncture therapy was added in the observation group and the conventional acupuncture was used in the control group. Baihui (GV 20), Dazhui (GV 14), Jiaji (EX-B 2) from T1 to T8, Tianzong (SI 11), Jianzhen (SI 9), Jianyu (LI 15) and Quyuan (SI 13) were selected in both groups. The treatment was given once daily and the treatment for 14 days was as one course. The one course of treatment was required in this research. Separately, before treatment and in 7 and 14 days of treatment, the score of simplified Fugl-Meyer scale of the upper extremity (FMA-UE), the grade of the modified Ashworth scale (MAS) and the score of the modified Barthel index scale (MBI) were compared between the two groups.
Results: Compared before treatment, in 7 and 14 days of treatment, FMA-UE score was increased obviously in either group (P<0.01). In 14 days of treatment, FMA-UE score in the observation group was higher than that in the control group (P<0.05). In 7 and 14 days of treatment, MAS grades of shoulder joint, elbow joint, wrist joint and metacarpophalangeal joint were all improved markedly in the two groups (P<0.05). Compared with the grades in 7 days of treatment, MAS grades of elbow joint and metacarpophalangeal joint were improved markedly in 14 days of treatment in the two groups (P<0.05). Compared with the control group, MAS grades of elbow joint and metacarpophalangeal joint were improved more markedly in the observation group in 14 days of treatment (P<0.05). Compared with the score before treatment, MBI score was increased in 7 and 14 days of treatment respectively in the observation group (P<0.05, P<0.01). In 14 days of treatment, MBI score was increased in the control group (P<0.01).
Conclusion: For the patients with post-stroke spastic paralysis of the upper extremity at the non-acute stage, the combined treatment with kinematic-acupuncture therapy and rehabilitation training obviously improves the motor function of the upper extremity and the muscle tone of elbow joint and metacarpophalangeal joint. The therapeutic effect of this combination is better than that of the combined treatment of the conventional acupuncture with rehabilitation training. Additionally, this combined therapy improves the ability of daily life activity.
Approximately 30% of stroke survivors experience an upper limb impairment, which impacts on participation and quality of life. Gaming devices (Nintendo Wii) are being incorporated into rehabilitation to improve function. We explored the stroke survivor experience of gaming as an upper limb intervention.
Semi-structured, individual interviews with stroke survivors living within the UK were completed. Interviews were audio-recorded, transcribed verbatim and analysed using Framework methods. Transcripts were coded and summarised into thematic charts. Thematic charts were refined during analysis until the final framework emerged.
We captured experiences of 12 stroke survivors who used Nintendo Wii. Gaming devices were found to be acceptable for all ages but varying levels of enthusiasm existed. Enthusiastic players described gaming as having a positive impact on their motivation to engage in rehabilitation. For some, this became a leisure activity, encouraging self-practice. Non-enthusiastic players preferred sports to gaming.
An in-depth account of stroke survivor experiences of gaming within upper limb rehabilitation has been captured. Suitability of gaming should be assessed individually and stroke survivor abilities and preference for interventions should be taken into consideration. There was no indication that older stroke survivors or those with no previous experience of gaming were less likely to enjoy the activity.
Stroke is considered to be a major cause of serious, long-term disability in Europe.1 Within the UK, hemiparesis affects up to 80% of the estimated 1.3 million stroke survivors2 and is persistent, with 30–66% still experiencing difficulties with arm movement or function 6 months after their stroke.3 Stroke upper limb impairment is a top research priority for stroke survivors and healthcare professionals.4 Intensive, repetitive and functional movements are considered most effective in promotion of recovery5 and commercial gaming devices (e.g. Nintendo Wii) encourage high repetition of arm movements.6 Some stroke rehabilitation services have introduced commercial gaming devices to address upper limb impairment.7 However, little information is available on the stroke survivor experience of this intervention.8 In order to be able to inform future research and aid health professionals in making clinical judgements about suitability of intervention, optimising adherence and facilitating implementation, it is important to capture the perspectives of stroke survivors.
Celinder and Peoples9 interviewed nine Danish stroke survivors who played Nintendo Wii within a pilot inpatient rehabilitation programme. The study focused on physical and cognitive rehabilitation and concluded that Nintendo Wii could be used to promote engagement in leisure activities. Wingham et al.10 interviewed 18 stroke survivors who used Nintendo Wii as part of a home-based upper limb rehabilitation programme. They reported high usage rates within the home and the intervention was found to be acceptable to both stroke survivors and caregivers. Limited information was however captured on factors that influence engagement in upper limb rehabilitation. In addition, Lewis et al.11 in their literature review (three articles including participants with chronic neurological conditions) concluded that use of virtual reality offered increased enjoyment and motivation compared to traditional rehabilitation. The aim of our qualitative study was to explore whether use of commercial gaming devices for upper limb rehabilitation was acceptable to stroke survivors and to capture their experience of this intervention. A pragmatic stance was taken to this study where investigations are not necessarily aligned to a particular qualitative research method.[…]