- •The post-stroke spasticity of upper limb can cause significant functional impairment.
- •This study for spasticity was a nationwide multicenter study in South Korea.
- •The median time to develop upper limb spasticity after stroke onset was 34 days.
- •The 13% of post-stroke spasticity cases developed after 90 days from onset.
Posts Tagged UE
[Abstract] When does spasticity in the upper limb develop after a first stroke? A nationwide observational study on 861 stroke patients
This study investigated the time taken for upper extremity spasticity to develop and its regional difference after first-ever stroke onset in a nationwide multicenter study in South Korea. The retrospective observational study included 861 individuals with post-stroke spasticity in the upper limbs. Spasticity in the upper extremity joints was defined as a modified Ashworth Scale score ≥1. The median time to develop upper limb spasticity after stroke onset was 34 days. 12% of post-stroke spasticity cases developed between 2 months and 3 months and 13% developed after 3 months from onset. At the time of diagnosis of spasticity, most patients showed only a slight increase in muscle tone, which was observed most frequently in the elbow, followed by the wrist, and fingers. Younger stroke survivors were more spastic, and the severity of spasticity increased with time. Approximately half of the patients with post-stroke spasticity developed spasticity during the first month. However, post-stroke spasticity can develop more than 3 months after stroke onset. Therefore, it is important to assess spasticity, even in the chronic state.
[ARTICLE] Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study – Full Text
Virtual reality technologies show potential as effective rehabilitation tools following neuro-trauma. In particular, the Elements system, involving customized surface computing and tangible interfaces, produces strong treatment effects for upper-limb and cognitive function following traumatic brain injury. The present study evaluated the efficacy of Elements as a virtual rehabilitation approach for stroke survivors.
Twenty-one adults (42–94 years old) with sub-acute stroke were randomized to four weeks of Elements virtual rehabilitation (three weekly 30–40 min sessions) combined with treatment as usual (conventional occupational and physiotherapy) or to treatment as usual alone. Upper-limb skill (Box and Blocks Test), cognition (Montreal Cognitive Assessment and selected CogState subtests), and everyday participation (Neurobehavioral Functioning Inventory) were examined before and after inpatient training, and one-month later.
Effect sizes for the experimental group (d = 1.05–2.51) were larger compared with controls (d = 0.11–0.86), with Elements training showing statistically greater improvements in motor function of the most affected hand (p = 0.008), and general intellectual status and executive function (p ≤ 0.001). Proportional recovery was two- to three-fold greater than control participants, with superior transfer to everyday motor, cognitive, and communication behaviors. All gains were maintained at follow-up.
A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke. The magnitude of training effects, maintenance of gains at follow-up, and generalization to daily activities provide compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner.
this pilot study was not registered.
Stroke is one of the most common forms of acquired brain injury (ABI), with around 60,000 new and recurrent strokes occurring every year in Australia alone . The clinical outcome of stroke is variable but often includes persistent upper-limb motor deficits, including weakness, discoordination, and reduced speed and mobility , and cognitive impairments in information processing and executive function [3, 4]. Not surprisingly, stroke is a leading cause of disability worldwide, and the burden of stroke across all levels of the International Classification of Functioning (ICF) – body structures/function, activity, and participation – underlines the importance of interventions that can impact multiple domains of functioning [5, 6].
Recovery of functional performance following stroke remains a significant challenge for rehabilitation specialists [7, 8], but may be enhanced by innovation in the use of new technologies like virtual reality [9, 10, 11, 12]. A critical goal is to find compelling ways of engaging individuals in their therapy by creating meaningful, stimulating and intensive forms of training . The term, virtual rehabilitation (VR), is used to describe a form of training wherein patients interact with virtual or augmented environments, presented with the aid of technology [14, 15]. The technologies can be either commercial systems (e.g. Nintendo Wii, Xbox Kinect) or those customised specifically for rehabilitation. VR offers a number of advantages over traditional therapies, including the ability to engage individuals in the simulated practice of functional tasks at higher doses [16, 17], automated assessment of performance over time, flexibility in the scaling of task constraints, and a variety of reward structures to help maintain compliance .
While evaluation research is still in its infancy, recent systematic reviews and meta-analyses show that VR can enhance upper-limb motor outcomes in stroke [10, 11, 19], yielding treatment effects of medium-to-large magnitude [10, 11], and complementing conventional approaches to rehabilitation. VR has been shown to engender high levels of engagement in stroke patients undergoing physical therapy [20, 21] and training of even moderate intensity can afford functional benefits at the activity/skill level [9, 19]. In the specific case of upper-limb VR, however, there is little available evidence that these benefits transfer to participation . Furthermore, most available data is on patients in chronic stages of recovery, with less on acute stroke . Notwithstanding this, use of VR has begun to emerge in clinical practice, recommended in Australian and international stroke guidelines as a viable adjunct in therapy to improve motor and functional outcomes [22, 23, 24].
Until recently, most VR systems have been designed to improve motor functions, with cognitive outcomes often a secondary consideration in evaluation studies [9, 10, 11]. Notwithstanding this, treatments that target both motor and cognitive functions are indicated for stroke, given evidence that cognitive and motor systems overlap at a structural and functional level [25, 26], and work synergistically in a “perception-action cycle”  in stroke patients undergoing rehabilitation . Recent studies provide preliminary evidence of improved attention and memory in stroke patients following motor-oriented VR [29, 30, 31, 32], amounting to a small-to-medium effect on cognition . When designed to address aspects of cognitive control and planning, VR has the potential to enhance dual-task control, resulting in better generalization of trained skills to daily functioning .
While evaluation research is still in its infancy, several recent customized systems (like Elements, the system evaluated here) have been deliberately designed to exploit factors known to enhance training intensity and motor learning. Informed by neuroscience and learning theory [for a recent review see 12], the Elements VR system was designed to enhance neuro-plastic recovery processes via: (1) an enriched therapeutic environment affording a natural form of user interaction via tangible computing and surface displays , which engage both the cognitive attention of participants and their motivation to explore training tasks; (2) concurrent augmented feedback (AF) on performance  offering participants additional information on the outcome of their actions to assist in re-building a sense of body position in space (aka body schema) and ability to predict/plan future actions; and (3) scaling of task challenges to the current level of motor and cognitive function , ensuring dynamic scaffolding of participants’ information processing and response capabilities. The Elements system, described in detail below and in earlier publications [37, 38], consists of a large (42 in.) tabletop surface display, tangible user interfaces, and software for presenting both goal-directed and exploratory virtual environments. Previous evaluations of the system in patients with traumatic brain injury showed improvements in both motor and cognitive performance, with transfer to activities of daily living [37, 39]. However, the impact of Elements in other forms of ABI, such as stroke, has not been evaluated.
The broad aim of current study was to evaluate the efficacy of the Elements VR interactive tabletop system for rehabilitation of motor and cognitive functions in sub-acute stroke, compared with treatment as usual (TAU). We were particularly interested in motor and cognitive outcomes, their relationship, and the transfer and maintenance of treatment effects. Training-related changes at the activity/skill level on standardized measures of motor and cognitive performance were investigated, together with functional changes. By offering an engaging, principled and customized form of interaction, we predicted that the Elements system would effect (i) greater changes on both motor and cognitive outcomes than with TAU alone; (ii) sustained benefits, as assessed over a short follow-up period, and (iii) transfer to everyday functional performance (i.e. participation).[…]
Continue —> Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text
Examples of the Elements (a) goal-directed Bases task with visual augmented feedback, and (b) exploratory Squiggles task
[Abstract] An Adaptive Iterative Learning Based Impedance Control For Robot-Aided Upper-limb Passive Rehabilitation
In this paper, an anthropomorphic arm is introduced and used to the upper-limb passive rehabilitation therapy. The anthropomorphic arm is constructed via pneumatic artificial muscles so that it may assist patients suffering upper-limb diseases to achieve mild therapeutic exercises. Due to the uncertain dynamic environment, external disturbances and model uncertainties, a combined control is proposed to stabilize and to enhance the adaptivity of the system. In the combined control, an iterative learning control is used to realize accurate position tracking. Meanwhile, an adaptive iterative learning based impedance control is proposed to execute the appropriate contact force during the therapy of the upper-limb. The advantage of the combined control is that it doesn’t depend on the accurate model of systems and it may deal with highly nonlinear system which has strong coupling and redundancies. The convergence of the adaptive iterative learning based impedance control is emphasized analyzed. Numerical simulations are performed to verify the proposed control method. In addition, real experiments are executed on the Southwest anthropomorphic arm.
Published on May 8, 2019
NEOFECT has redesigned its Smart Board for Home in reply to feedback from patients recovering from stroke and other musculoskeletal conditions and neurological disorders.
The new Smart Board for Home NextGen includes a smaller surface to help patients use it at home more easily, a redesigned handle to better stabilize the user’s hand and arm, and updated gamified software.
The board size has been reduced from 42 inches to 32 inches so it can fit on most tables. To accommodate the weakened grip of many stroke patients, the redesigned handle includes more straps to better stabilize the user’s arm, ensure appropriate measurement for the post-game metrics, and provide a more secure, comfortable experience, according to the company in a media release.
“We took patient feedback and completely revamped the Smart Board for Home NextGen,” says Scott Kim, co-founder and CEO of San Francisco-based NEOFECT USA.
“This new model still has all the fun, measurable qualities patients can use at home, but now we’ve reduced even more barriers so that people of all abilities can gain back function in their hands and upper arms.”
Patients play games on the Smart Board for Home NextGen by placing their forearm in a cradle and moving their arm across the board. All movements are virtually mimicked on a Bluetooth-connected screen in real time. The gamified software also features an updated AI-powered algorithm to curate a more customized experience for each patient.
The Smart Board for Home NextGen games mimic real-world motions to rehabilitate users’ upper arms and shoulders, including new games like “Air Hawk” and “Tennis.”
Additionally, NEOFECT is developing a dual-player game for patients to use at home, which will be available in summer 2019.
[Source(s): NEOFECT, Business Wire]
[ARTICLE] Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme – Full Text
Objective Persistent difficulty in using the upper limb remains a major contributor to physical disability post-stroke. There is a nihilistic view about what clinically relevant changes are possible after the early post-stroke phase. The Queen Square Upper Limb Neurorehabilitation programme delivers high-quality, high-dose, high-intensity upper limb neurorehabilitation during a 3-week (90 hours) programme. Here, we report clinical changes made by the chronic stroke patients treated on the programme, factors that might predict responsiveness to therapy and the relationship between changes in impairment and activity.
Methods Upper limb impairment and activity were assessed on admission, discharge, 6 weeks and 6 months after treatment, with modified upper limb Fugl-Meyer (FM-UL, max-54), Action Research Arm Test (ARAT, max-57) and Chedoke Arm and Hand Activity Inventory (CAHAI, max-91). Patient-reported outcome measures were recorded with the Arm Activity Measure (ArmA) parts A (0–32) and B (0–52), where lower scores are better.
Results 224 patients (median time post-stroke 18 months) completed the 6-month programme. Median scores on admission were as follows: FM-UL = 26 (IQR 16–37), ARAT=18 (IQR 7–33), CAHAI=40 (28-55), ArmA-A=8 (IQR 4.5–12) and ArmA-B=38 (IQR 24–46). The median scores 6 months after the programme were as follows: FM-UL=37 (IQR 24–48), ARAT=27 (IQR 12–45), CAHAI=52 (IQR 35–77), ArmA-A=3 (IQR 1–6.5) and ArmA-B=19 (IQR 8.5–32). We found no predictors of treatment response beyond admission scores.
Conclusion With intensive upper limb rehabilitation, chronic stroke patients can change by clinically important differences in measures of impairment and activity. Crucially, clinical gains continued during the 6-month follow-up period.
Stroke remains common1 and persistent difficulty in using the upper limb is a major contributor to ongoing physical disability.2 The general consensus remains that most spontaneous recovery of the upper limb occurs over the first 3 months after stroke and current levels of rehabilitation result in little improvement after that, particularly at the level of impairment.3 Improving outcomes through higher dose (time in rehabilitation or number of repetitions) and intensity (dose per session) of rehabilitation is an attractive option.4 However, clinical trials of higher dose upper limb rehabilitation have generally not produced the magnitude of improvement that will change clinical practice,5 whether delivered in the early6 or chronic stages post-stroke.7–9 A common factor in these trials is that the dose (in hours) of additional therapy remained relatively low (18–36 hours). Despite scepticism that stroke patients could tolerate much higher doses,8 one study managed to deliver 300 hours of upper limb therapy to chronic stroke patients over 12 weeks and reported changes in measures of both impairment and activity that were far greater than those in lower dose studies.10 Three hundred hours represents an order of magnitude higher than any dose of rehabilitation offered in previous upper limb rehabilitation trials and deserves further consideration. However, this idea is challenging because of the logistics of setting up such a trial in healthcare settings where the ethic of high-dose, high-intensity rehabilitation is not supported. In this context, it is important to report the findings of clinical services that are able to deliver higher doses than conventionally seen. The Queen Square Upper Limb (QSUL) Neurorehabilitation programme is a single-centre clinical service that provides 90 hours of timetabled treatment focusing on the post-stroke upper limb in chronic (>6 months post-stroke) stroke patients. Here, we report (i) outcomes for patients admitted to this programme at the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust (UCLH), including 6-month follow-up data to look at whether any clinical benefits were maintained, (ii) the characteristics of the patients admitted and any predictors of response and (iii) the relationship between changes in impairment and activity.[…]
Continue —> https://jnnp.bmj.com/content/90/5/498
[Abstract] Brain-machine interface of upper limb recovery in stroke patients rehabilitation: A systematic review
Technologies such as brain-computer interfaces are able to guide mental practice, in particular motor imagery performance, to promote recovery in stroke patients, as a combined approach to conventional therapy.
The aim of this systematic review was to provide a status report regarding advances in brain-computer interface, focusing in particular in upper limb motor recovery.
The databases PubMed, Scopus, and PEDro were systematically searched for articles published between January 2010 and December 2017. The selected studies were randomized controlled trials involving brain-computer interface interventions in stroke patients, with upper limb assessment as primary outcome measures. Reviewers independently extracted data and assessed the methodological quality of the trials, using the PEDro methodologic rating scale.
From 309 titles, we included nine studies with high quality (PEDro ≥ 6). We found that the most common interface used was non-invasive electroencephalography, and the main neurofeedback, in stroke rehabilitation, was usually visual abstract or a combination with the control of an orthosis/robotic limb. Moreover, the Fugl-Meyer Assessment Scale was a major outcome measure in eight out of nine studies. In addition, the benefits of functional electric stimulation associated to an interface were found in three studies.
Neurofeedback training with brain-computer interface systems seem to promote clinical and neurophysiologic changes in stroke patients, in particular those with long-term efficacy.
[Abstract] Improvement of Upper Limb Motor Control and Function After Competitive and Noncompetitive Volleyball Exercises in Chronic Stroke Survivors: A Randomized Clinical Trial.
To investigate the effects of competitive and noncompetitive volleyball exercises on the functional performance and motor control of the upper limbs in chronic stroke survivors.
Randomized clinical trial.
Outpatient rehabilitation center.
Chronic stroke survivors (N=48).
Participants were randomly assigned to competitive (n=16) or noncompetitive (n=16) volleyball exercise groups (60min/d volleyball exercise+30min/d traditional rehabilitation, 3d/wk for 7wk) and control group (n=16).
MAIN OUTCOME MEASURES:
Reach and grasp motor control measures were evaluated through kinematic analysis. Functional outcomes were assessed via Motor Activity Log, Wolf Motor Function Test (WMFT), Box and Block Test, and Wrist Position Sense Test.
Significant improvement of functional performance was observed in both competitive (P<.0001) and noncompetitive volleyball exercise groups (P<.01), but not in the control group (P>.05), with the exception of WMFT score. Volleyball training, in general, resulted in more efficient spatiotemporal control of reach and grasp functions, as well as less dependence on feedback control as compared to the control group. Moreover, the competitive volleyball exercise group exhibited greater improvement in both functional performance and motor control levels.
Volleyball team exercises, especially in a competitive format, resulted in enhancing the efficacy of the preprogramming and execution of reach and grasp movements, as well as a shift from feedback to feedforward control of the affected upper limb in chronic stroke survivors. This may well be a potential underlying mechanism for improving functional performance.
[Abstract] Virtual Reality in Upper Extremity Rehabilitation of Stroke Patients: A Randomized Controlled Trial.
Virtual reality game system is one of novel approaches, which can improve hemiplegic extremity functions of stroke patients. We aimed to evaluate the effect of the Microsoft Xbox 360 Kinect video game system on upper limb motor functions for subacute stroke patients.
The study included 42 stroke patients of which 35 (19 Virtual reality group, 16 control group) completed the study. All patients received 60 minutes of conventional therapy for upper extremity, 5 times per-week for 4 weeks. Virtual reality group additionally received Xbox Kinect game system 30 minutes per-day. Patients were evaluated prior to the rehabilitation and at the end of 4 weeks. Box&Block Test, Functional independence measure self-care score, Brunnstorm stage and Fugl-Meyer upper extremity motor function scale were used as outcome measures.
The Brunnstrom stages and the scores on the Fugl-Meyer upper extremity, Box&Block Test and Functional independence measure improved significantly from baseline to post-treatment in both the experimental and the control groups. The Brunnstrom stage-upper extremity and Box&Block Test gain for the experimental group were significantly higher compared to the control group, while the Brunnstrom stage-hand, the Functional independence measure gain and Fugl-Meyer gain were similar between the groups.
We found evidence that kinect-based game system in addition to conventional therapy may have supplemental benefit for stroke patients. However, for virtual reality game systems to enter the routine practice of stroke rehabilitation, randomized controlled clinical trials with longer follow-up periods and larger sample sizes are needed especially to determine an optimal duration and intensity of the treatment.
[Abstract] Stroke, hand rehabilitation, motor synergy pattern correction, deep relaxation, multisensory stimulation, motor synergy rehabilitation.
Background: This study aims to determine motor synergy rehabilitation for upper limb functional recovery in stroke patients.
Methodology: A 48year old male, apparently normal till June, 2016, had an acute onset of right sided hemiparesis and slurred speech. 2 years later he reported with inability to use the upper limb and difficulty in walking independently. He was a diagnosed case of left capsule-ganglionic bleed with accelerated hypertension. His participation limitations were inability to finger feed, drink his coffee, dress and groom selfand discontinuation of his job as an automobile salesman. He received motor synergy rehabilitation for 6 weeks.
Result: At 6 weeks patient was able to perform scapular elevation and shoulder scaption up to 100° with isolated elbow and forearm movements. He re-learnt to release objects with wrist in neutral position with verbal cues. His ability to feel rough textures improved by 50% and silky texture by 40% (self-reported) throughout the limb except hand. He retrained to eat hard cut fruit, sip water from a glass with straw and comb hair with 20–25% assistance and rejoined his job once a week.
Conclusion: Muscle synergy rehabilitation can help to improve the functional use of upper limb in stroke.
[Abstract] Effectiveness of Virtual Reality Using PS4 Gaming Technology in Stroke Rehabilitation for Improving Upper Limb Function-A Pilot Study
Background: Hemiparesis resulting in functional limitation of an upper extremity and lower limb is common among stroke survivors. Virtual reality is one of the way of improving motor function in stroke, limited evidence is available on the efficacy of virtual reality for stroke rehabilitaton.
Methods: In this pilot study 2 parallel groups involving stroke patients, we compared the feasibility, safety and efficacy of virtual reality using the sony PS4 gaming technology to evaluate upper limb motor improvement. The primary feasibility outcome was the total time receiving the intervention. The… primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with wolf motor function test and Spasticity Grading at 4 weeks after intervention. OUTCOME MEASURE: WOLF Motor function test and Box and Block test.
Result: This study shows that mean values obtained from WOLF motor function test showed no statistical significance and the mean values of Box and Block test showed statistical significance.
Conclusion: This study concludes that the PS4 gaming technology is a feasible, safe, and potentially effective intervention to enhance motor function recovery in patients with a recent stroke.