[ARTICLE] Audio-visual stimulation in conjunction with functional electrical stimulation to address upper limb and lower limb movement disorder – Full Text PDF

Abstract

Neurological disorders often manifest themselves in the form of movement deficit on the part of the patient. Conventional rehabilitation often used to address these deficits, though powerful are often monotonous in nature. Adequate audio-visual stimulation can prove to be motivational. In the research presented here we indicate the applicability of audio-visual stimulation to rehabilitation exercises to address at least some of the movement deficits for upper and lower limbs. Added to the audio-visual stimulation, we also use Functional Electrical Stimulation (FES). In our presented research we also show the applicability of FES in conjunction with audio-visual stimulation delivered through VR-based platform for grasping skills of patients with movement disorder.

Introduction

Every individual uses his/her upper and lower limbs to perform activities of daily living. However, if an individual suffers from limb movement disorders as a result of disability, then that individual becomes dependent on caregivers. Also, consequently, his participation in community life gets adversely affected. Disability is often a consequence of neurological disorders, e.g., stroke. In fact, stroke is the second leading cause of death and the third leading cause of disability-adjusted life-years (DALYs) worldwide.1 In the past two decades, the number of stroke cases and the overall global burden of stroke have been increasing.2 Rehabilitation offers stroke patients an avenue for practicing skills that can lead to enhancement of functional ability and subsequent realization of greater participation in community life. Therefore, many researchers are working on developing efficient skill training platforms for post-stoke rehabilitation. Following stroke, patients often need to re-learn how to perform motor activities. Learning requires practice, and feedback is important for practice to be effective.3 During rehabilitation, delivery of extrinsic audio-visual feedback either in the form of knowledge of results or knowledge of progress of performance can motivate the participant for continuing the repeated rehabilitation therapy. In conventional rehabilitation practices, the therapists prescribe the dosage of therapy required based on the capabilities of the patients in an individualized manner. Additionally, since the repetitive exercises often turn out to be monotonous to the patients during the rehabilitation the therapists often deliver encouraging feedback in an audible manner so as to motivate the patients to do the tasks. However, in developing countries like India, restricted access to specialized health clinics and expert clinicians often causes huge hindrance to availing specialized post-stroke care. Thus, researchers are exploring different technology-assisted techniques that can provide individualized exercise platforms and are also motivating for use by the patients through feedback delivered in the form imagery and audio stimulus. Out of the available technology- assisted mechanisms we chose Virtual Reality (VR). The VR platform allows the designer to create synthetic environments with precise control over a large number of task parameters that influence one’s behavior in an individualized manner. In fact, VR provides an option for effortlessly manipulating the number, speed or order of stimulus presentation while maintaining an objective means of data collection on relevant target responses.4 The inherent flexibility of VR-based system allows incremental variations in task difficulty thereby scaffolding the development in the Audio-visual stimulation and FES for movement disorders Eur J Transl Myol 26 (2): xx-xy – 2 – participant’s skill in a precise, objective and quantitative manner. Additionally, VR-based platform is capable of providing audio-visual feedback in an individualized manner which often serves to be motivational. In our research, we have applied VR-based platforms for rehabilitation of upper limb and lower limb disorders. Also the flexibility of VR to interface it with different hardware peripherals has enabled us to augment the VRbased rehabilitation platform with Wii Balance Boards (BB), Functional Electrical Stimulation (FES), etc. The rest of the paper is organized as follows: In Material and Methods we present our system design and methodology. Results, discussion and future work follow.

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[ARTICLE] Safety and efficacy of abobotulinumtoxinA for hemiparesis in adults with upper limb spasticity after stroke or traumatic brain injury: a double-blind randomised controlled trial

Summary

Background

Resistance from antagonistic muscle groups might be a crucial factor reducing function in chronic hemiparesis. The resistance due to spastic co-contraction might be reduced by botulinum toxin injections. We assessed the effects of abobotulinumtoxinA injection in the upper limb muscles on muscle tone, spasticity, active movement, and function.

Methods

In this randomised, placebo-controlled, double-blind study, we enrolled adults (aged 18–80 years) at least 6 months after stroke or brain trauma from 34 neurology or rehabilitation clinics in Europe and the USA. Eligible participants were randomly allocated in a 1:1:1 ratio with a computer-generated list to receive a single injection session of abobotulinumtoxinA 500 U or 1000 U or placebo into the most hypertonic muscle group among the elbow, wrist, or finger flexors (primary target muscle group [PTMG]), and into at least two additional muscle groups from the elbow, wrist, or finger flexors or shoulder extensors. Patients and investigators were masked to treatment allocation. The primary endpoint was the change in muscle tone (Modified Ashworth Scale [MAS]) in the PTMG from baseline to 4 weeks. Secondary endpoints were Physician Global Assessment (PGA) at week 4 and change from baseline to 4 weeks in the perceived function (Disability Assessment Scale [DAS]) in the principal target of treatment, selected by the patient together with physician from four functional domains (dressing, hygiene, limb position, and pain). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01313299.

Findings

243 patients were randomly allocated to placebo (n=81), abobotulinumtoxinA 500 U (n=81), or abobotulinumtoxinA 1000 U (n=81). Mean change in MAS score from baseline at week 4 in the PTMG was −0·3 (SD 0·6) in the placebo group (n=79), −1·2 (1·0) in the abobotulinumtoxinA 500 U group (n=80; difference −0·9, 95% CI −1·2 to −0·6; p<0·0001 vs placebo), and −1·4 (1·1) in the abobotulinumtoxinA 1000 U group (n=79; −1·1, −1·4 to −0·8; p<0·0001 vs placebo). Mean PGA score at week 4 was 0·6 (SD 1·0) in the placebo group (n=78), 1·4 (1·1) in the abobotulinumtoxinA 500 U group (n=80; p=0·0003 vs placebo), and 1·8 (1·1) in the abobotulinumtoxinA 1000 U group (n=78; p<0·0001 vs placebo). Mean change from baseline at week 4 in DAS score for the principal target of treatment was −0·5 (0·7) in the placebo group (n=79), −0·7 (0·8) in the abobotulinumtoxinA 500 U group (n=80; p=0·2560 vs placebo), and −0·7 (0·7) in the abobotulinumtoxinA 1000 U group (n=78; p=0·0772 vs placebo). Three serious adverse events occurred in each group and none were treatment related; two resulted in death (from pulmonary oedema in the placebo group and a pre-existing unspecified cardiovascular disorder in the abobotulinumtoxinA 500 U group). Adverse events that were thought to be treatment related occurred in two (2%), six (7%), and seven (9%) patients in the placebo, abobotulinumtoxinA 500 U, and abobotulinumtoxinA 1000 U groups, respectively. The most common treatment-related adverse event was mild muscle weakness. All adverse events were mild or moderate.

Interpretation

AbobotulinumtoxinA at doses of 500 U or 1000 U injected into upper limb muscles provided tone reduction and clinical benefit in hemiparesis. Future research into the treatment of spastic paresis with botulinum toxin should use active movement and function as primary outcome measures.

http://www.sciencedirect.com/science/article/pii/S1474442215002161