Posts Tagged upper limb

[WEB PAGE] Results from MyoRegulator for Spasticity Trial Published

myoregulator

Results from a clinical trial testing the MyoRegulator device for the non-invasive treatment of spasticity, published recently in Bioelectronic Medicine, suggest evidence for using MyoRegulator to treat upper extremity spasticity in subjects with chronic stroke, PathMaker Neurosystems Inc announces.

PathMaker Neurosystems Inc is a clinical-stage bioelectronic medicine company that develops non-invasive systems for the treatment of patients with spasticity and paralysis. The MyoRegulator is an investigational medical device and is limited by US Federal law to investigational use only.

The device is based on PathMaker’s proprietary DoubleStim technology (combining anodal trans-spinal direct current stimulation (tsDCS) and peripheral nerve direct current stimulation (pDCS)), which provides simultaneous non-invasive stimulation intended to suppress hyperexcitable spinal neurons involved with spasticity, the company explains in a media release.

“Current pharmacological approaches to managing spasticity have, at best, short-term efficacy, are confounded by adverse effects, and are often unpleasant for the patient,” said co-author Zaghloul Ahmed, PhD, professor and chairman, Department of Physical Therapy and Professor, Center for Developmental Neuroscience, CUNY and Scientific Founder of PathMaker Neurosystems.

“The initial study results demonstrate the potential of a novel, non-invasive treatment to reduce spasticity and improve functional recovery in patients with upper motor neuron syndrome after stroke.”

The single-blind, sham-controlled, crossover design study, authored by researchers at Feinstein Institute for Medical Research at Northwell Health (and led by Bruce Volpe, MD, included patients with upper limb hemiparesis and wrist spasticity at least 6 months after their initial stroke to test whether MyoRegulator treatment reduces chronic upper-extremity spasticity.

Twenty subjects received five consecutive 20-minute daily treatments with sham stimulation followed by a 1-week washout period, then five consecutive 20-minute daily treatments with active stimulation. Subjects were told that the order of active or sham stimulation would be randomized.

Clinical and objective measures of spasticity and motor function were collected before the first session of each condition (baseline), immediately following the last session of each condition, and weekly for 5 weeks after the completion of active treatments.

The results demonstrated significant group mean reductions from baseline in both Modified Tardieu Scale scores (summed across the upper limb, P<0.05), and in objectively measured muscle resistance at the wrist flexor (P<0.05) following active treatment as compared to following sham treatment.

Motor function also improved significantly (measured by the Fugl-Meyer and Wolf Motor Function Test; P<0.05 for both tests) after active treatment, even without additional prescribed activity or training. The effect of the active MyoRegulator treatment was durable for the 5-week follow-up period, the release continues.

“We are highly encouraged by these clinical results which demonstrate the potential of MyoRegulator to improve outcomes for patients suffering from spasticity, without the need for surgery or drugs,” says Nader Yaghoubi, MD, PhD, president and chief executive officer of PathMaker.

“Building on these results and our ongoing clinical trial in Europe, we expect to initiate a US multi-center, pivotal, double-blind clinical trial supported by the National Institute of Neurological Disorders and Stroke (NINDS) in early 2020.”

[Source: PathMaker Neurosystems Inc]

 

via Results from MyoRegulator for Spasticity Trial Published – Rehab Managment

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[ARTICLE] What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes – Full Text

Abstract

Background

Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.

Methods

Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge’s g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/FunctionActivity, and Participation levels of the International Classification of Functioning.

Results

Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33–0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28–0.55; p < 0.01) and Activity outcomes (g = 0.47; 95% CI: 0.34–0.60, p < 0.01), while Participation outcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28–0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.

Conclusion

VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.

Background

Stroke is one of the leading global causes of disability [], with over 17 million individuals worldwide sustaining a stroke each year []. Although stroke mortality is decreasing with improvements in medical technology [], the neurological trauma resulting from stroke can be devastating, and the majority of stroke survivors have substantial motor [], cognitive [] and functional rehabilitation needs [], and much reduced quality of life []. Targeted rehabilitation can help address some of these post-stroke deficits, however, historically, many individuals, in particular patients with cognitive impairment, have difficulty engaging in standard therapies [] at a level that will produce meaningful and lasting improvements []. Enriched and interactive rehabilitation programs are clearly needed to minimize functional disability [], increase participation in age-appropriate roles and activities [], lead to greater motivation and treatment compliance [], and reduce the long-term expense of care in stroke survivors [].

Virtual reality

Virtual reality refers to simulated interactions with environments and events that are presented to the performer with the aid of technology. These so-called virtual environments may mirror aspects of the real world or represent spaces that are far removed from it, while allowing various forms of user interaction through movement and/or speech []. Virtual reality based rehabilitation, or Virtual Rehabilitation (VR), shows considerable promise as a safe, engaging, interactive, patient-centered and relatively inexpensive medium for rehabilitation training []. VR has the potential to target a wide range of motor, functional, and cognitive issues [], affords methods that automatically record and track patient performance [], and offers a high level of flexibility and control over therapeutic tasks []. This scalability allows patients to train at the highest intensity that would be possible for their individual ability [], while keeping the experience of interaction with therapeutic tasks enjoyable and compelling []. At the same time, VR may enable patients with a neurodisability (like stroke) to practice without excessive physical fatigue [] which otherwise may deter continued effort and engagement in therapy [].

Currently, there are two main types of VR: purpose-designed Virtual Environments (VE) and Commercial Gaming (CG) systems. Both types of systems can provide augmented feedback, additional forms of sensory feedback about the patient’s movement over and above the feedback that is provided as a natural consequence of the movement itself []. VE systems are often designed by rehabilitation scientists (and others) to enhance the delivery of augmented feedback in order to develop the patient’s sense of position in space [], to reinforce different movement parameters (like trajectory and endpoint) and reduce extraneous movements (e.g. excessive trunk displacement) [].

VE systems are also more likely to involve specially designed tangible user interfaces used in mixed reality rehabilitation systems [] or training of daily functional activities []. By comparison, CG rehabilitation systems are typically “off-the-shelf” devices such as Wii (Nintendo), Xbox (Microsoft) and PlayStation (Sony), which have the advantage of being readily available and relatively inexpensive when compared with VE systems []. On the other hand, CG systems are typically designed for able-bodied participants and may not consider the physiological, motor, and cognitive aspects of recovery in rehabilitation, and may lack the scalability of purpose-designed VE systems [].

Systematic reviews comparing VE and CG systems

There is conflicting evidence about the relative effectiveness of VE- and CG-based VR systems. In a recent Cochrane review of VR following stroke [], VE systems demonstrated a significant treatment effect on upper-limb function when compared to controls (d = 0.42; 95%CI: 0.07–0.76), while the effect for CG systems failed to reach significance (d = 0.50; 95%CI: -0.04-1.04); a caveat, however, was that only two of nine studies (22%) in these comparisons were CG-based. In contrast, a meta-analysis by Lohse and colleagues of VR following stroke [] found no significant difference between VE (g = 0.43, based on 13 studies) and CG interventions (g = 0.76, based on three studies) on Body Structure/Function level outcomes. For Activity level outcomes, CG interventions showed a large but non-significant effect (g = 0.76, p = 0.14), but was based on only four of 26 studies (15%); VE interventions, however, showed a significant treatment effect (g = 0.54, p < .001). Taken together, these two reviews suggest benefits of VE systems, while previous analyses of CG treatment effects have been underpowered and inconclusive.

Cognition and VR

Cognitive impairments, including difficulties in attention, language, visuospatial skills, memory, and executive function are common and persistent sequelae of stroke [] and exert considerable influence on rehabilitation outcomes []. Cognitive dysfunction may reduce the ability to (re-)acquire motor [] and functional skills [], and decrease engagement and participation in rehabilitation program []. While the important role of cognition in both conventional and VR-based rehabilitation is increasingly recognized [] the impact of VR on cognitive function has not yet been formally evaluated in a quantitative review.

Analysis of individual domains of functioning

The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF-WHO []) is currently one of the most widely used classification systems. It is a foundation for understanding outcome effects in clinical practice [] and the preferred means for translating clinical findings in a patient-centered manner []. Under the ICF-WHO, disability and functioning are seen to arise by the interaction of the health condition, the environment, and personal factors, and can be measured at three main levels: (i) Body Structure/Function, (ii) Activity (or skill), and (iii) Participation. The ICF-WHO has been used to classify outcome measures in studies of VR (for example []) and in recent systematic reviews []. A brief critique of these reviews reveals a number of important conclusions, but also some significant gaps in the research.

An early systematic review by Crosbie and colleagues [] examined the efficacy of VR for stroke upon motor and cognitive outcomes. Of the 11 studies reviewed (up to 2005), only five addressed upper-limb function and two addressed cognitive outcomes. Overall, the review reported significant benefits of VR, but only three studies were RCTs and no effect size estimates were reported. At around the same time, a systematic review by Henderson and colleagues [] showed that there was very good evidence that immersive VR was more beneficial than no therapy for upper-limb rehabilitation in adult stroke, but insufficient evidence for non-immersive VR. Comparisons with traditional physical therapy were less impressive, however.

A 2016 systematic review by Vinas-Diz and colleagues [] included both controlled clinical trials and randomized controlled trials (RCTs) in stroke, and spanned 2009–2014. The review included 25 papers: four systematic reviews [] and 21 original trials. Evidence for treatment efficacy on upper-limb function was strong on a mix of measures like the Fugl-Meyer Test, Wolf Motor Function Test, and Motricity Index. However, a quantitative analysis of the effects was not undertaken, and important aspects of treatment implementation like dose and session scheduling were not formally examined.

A recent systematic review by Santos-Palma and colleagues [] examined the efficacy of VR on motor outcomes for stroke using the ICF-WHO framework, covering work published up to June 2015. Of the studies deemed high quality, 20 examined outcomes at the Body Structure/Function level, 17 at the Activity level, and eight examined Participation. Intriguingly, positive outcomes were evident only at the Body Structure/Function level, while results for Activity and Participation were not conclusive. Unfortunately, only three studies addressed manual ability at the Activity level, which severely limited any evaluation of skill-specific effects.

In a combined systematic review and meta-analysis of 37 RCTs published between 2004 and 2013, Laver and colleagues [] present a more comprehensive examination of the effects of VR on upper-limb function. As well, they classified outcomes broadly into upper-limb function, Activities of Daily Living (ADLs) and other aspects of motor function. In general, study quality was low, and the risk of bias high, in roughly one-half of the studies. Outcomes were significant for upper-limb function (d = 0.28) and ADLs (d = 0.43), but somewhat smaller than those reported by Lohse and colleagues []. Results for other aspects of motor function, including several at what may be considered the Body Structure/Function level, were non-significant. Dose varied considerably between studies, ranging from less than 5 h to more than 21 h in total. In general, studies that used higher doses (> 15 h of therapy) were reported as more effective. Unfortunately, results could not be pooled for cognitive outcomes, and the importance of additional treatment implementation parameters like training frequency and duration, and the impact of specific study design factors including the recovery stage of participants and type of control group (i.e. active vs passive) were not determined.

An updated systematic review by Laver and colleagues [], included an additional 35 studies that reported outcomes for upper limb function and activity. A subset of only 22 studies that compared VR with conventional therapy showed no significant effect of VR on upper-limb function (d = 0.07). As well, there was no significant difference between higher (> 15 h of therapy), and lower levels of dose. However, when VR was used in addition to usual care (10 studies; 210 participants), there was a significant effect on upper-limb outcomes (d = 0.49). As before, no significant difference was shown between high and low dose studies. Unfortunately, analysis of cognitive outcomes, and moderator analyses including study quality, and implementation parameters (e.g., daily intensity, weekly intensity, treatment frequency, and total number of sessions) were not included in the updated review. As well, the assessment of study quality was limited to the 5-item GRADE system, the ICF classification system was not given full consideration, and no distinction was drawn between treatment as usual (TAU) and active control groups (TAU + some form of additional therapy).

Taken together, recent reviews on the use of VR for adult stroke show encouraging evidence of efficacy at the level of Body Structure/Function, but mixed results for Activity and ADLs, and a paucity of evidence bearing on Participation. The impact and effectiveness of VR on cognitive outcomes also remains poorly understood, despite the important role of cognitive dysfunction in learning and rehabilitation [], and increased evidence of interconnection between cognitive function and motor deficits at the Body Structure/Function, Activity and Participation levels of the ICF []. VE-based platforms have been suggested to be superior to CG approaches [] in promoting motor function, but until recently there have been few CG studies available for analysis. As well, other design factors that may moderate treatment effects (like stage of recovery, control group type) have either not been explored or are too few in number to draw firm conclusions. There has been considerable variation in the total dose of VR therapy [], and no analysis has yet tested the dose-response relationship in moderator analyses. Finally, the bulk of conclusions have relied on qualitative synthesis, and there is a paucity of quantitative analysis of empirical data to inform opinion.

In view of limitations in past reviews and continued acceleration in VR the aim of our review was to conduct a systematic literature review and meta-analysis to re-evaluate the strength of evidence bearing on VR of upper-limb function and cognition in stroke. This review is critical given evidence that stroke rehabilitation needs to better optimize intervention techniques during the recovery windows that exist in the acute phase [] and beyond. Focusing only on RCTs, we consider outcomes across levels of the ICF-WHO, and analyze the moderating effect of design factors and dose-related parameters.

Methods

The current review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [], it should be noted that the protocol was not registered.

Data sources and search strategy

Scopus, Cochrane Database, CINAHL, The Allied and Complementary Medicine Database, Web of Science, MEDLINE, Pre-Medline, PsycEXTRA, and PsycINFO databases were systematically searched from inception until 28 June 2017. Boolean search terms included the following: “strokecerebrovascular disease, or cerebrovascular attack” and “Virtual realityAugmentrealityvirtual gam*” (see Appendix for an example of the full MEDLINE search strategy).

Inclusion and exclusion criteria

RCT studies published in English in peer-reviewed journals, utilizing a VR intervention to address either motor (upper-limb), cognitive, or activities of daily living in stroke patients were included in the current review (see Fig. 1). VR was defined as a type of user-computer interface that involves real-time simulation of an activity/environment, enabling the user to interact with the environment using motor actions and sensory systems. Comparison groups included “usual care”, “standard care” or “conventional therapy”, involving physical therapy and/or occupational therapy. Studies were excluded that applied a “hybrid” approach combining virtual reality with exogenous stimulation or robotics, targeted lower limb function, recruited a mixed study cohort including non-stroke participants, or did not utilize motor, cognitive, or participation outcome measures.

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Fig. 1
Population, Intervention, Comparison, Outcome (PICO) Question and the main variables included in the systematic literature review and meta-analysis

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Continue —-> What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes

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[Abstract] Comparison between Transcranial Direct Current Stimulation and Acupuncture on Upper Extremity Rehabilitation in Stroke: A Single-Blind Randomized Controlled Trial

Abstract

Objective: To compare the effects of transcranial direct current stimulation (TDCS) with traditional Chinese acupuncture on upper-extremity (UE) function among patients with stroke.

Materials and Methods: Participants with subacute to chronic stroke who had moderate to severe UE functional impairment were randomly allocated to the TDCS or electro-acupuncture group, then underwent three weeks of physical therapy and occupational therapy, with 20 minutes of a-TDCS (2 mA) or electro-acupuncture applied during training once weekly. Primary outcome was determined using the Fugl-Meyer Assessment of motor recovery at 1-month follow-up.

Results: The 18 participants were allocated into two groups. Fugl-Meyer Assessment increased in both the TDCS and electroacupuncture groups (5.00±3.08, p=0.001 and 7.4±4.9, p=0.002, respectively). However, no difference was found between groups, and no significant difference was observed in grip strength and task specific performance in both groups.

Conclusion: The application of TDCS might provide benefits in recovering hand motor function among patients with subacute to chronic stroke but does not go beyond those of electro-acupuncture.

via Comparison between Transcranial Direct Current Stimulation and Acupuncture on Upper Extremity Rehabilitation in Stroke: A Single-Blind Randomized Controlled Trial | Hathaiareerug | JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND

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[WEB SITE] Researchers building glove to treat symptoms of stroke

Researchers building glove to treat symptoms of stroke

Enter a captionA new glove being developed by Georgia Tech and Stanford researchers aims to treat symptoms of stroke through vibration. Credit: Caitlyn Seim

Strokes often have a devastating impact on hands function. Now, Stanford researchers are collaborating on a vibrating glove that could improve hand function after a stroke.

The most obvious sign someone has survived a  is usually some trouble speaking or walking. But another challenge may have an even greater impact on someone’s daily life: Often, stroke survivors lose sensation and muscle control in one arm and hand, making it difficult to dress and feed themselves or handle everyday objects such as a toothbrush or door handle.

Now, researchers at Stanford are working on a novel therapy that could help more stroke survivors regain the ability to control their arms and hands—a vibrating glove that gently stimulates the wearer’s hand for several hours a day.

Caitlyn Seim, Ph.D., a postdoctoral scholar at Stanford, began the project as a  in human-centered computing at Georgia Tech in the hope that the glove’s stimulation could have some of the same impact as more traditional exercise programs. After developing a prototype, she approached Stanford colleagues Maarten Lansberg, MD, Ph.D., an associate professor of neurology, and Allison Okamura, Ph.D., a professor of mechanical engineering, in order to expand her efforts. With help from a Neuroscience:Translate grant from the Wu Tsai Neurosciences Institute at Stanford, the trio are working to improve on their prototype glove and bring the device closer to clinical testing.

“The concept behind it is that users wear the glove for a few hours each day during normal —going to the supermarket or reading a book at home,” Seim said. “We are hoping that we can discover something that really helps stroke survivors.”

Reaching for new stroke treatments

Seim, Lansberg and Okamura’s goal is a tall order. Despite some individual success stories, the reality is that most stroke patients struggle to regain the ability to speak, move around and take good care of themselves.

“Stroke can affect patients in many ways, including causing problems with arm function, gait, vision, speech and cognition,” Lansberg said. Yet despite decades of research, “there are essentially no treatments that have been proven to help stroke patients recover these functions,” he added.

It was in that context that the three researchers independently started thinking about what they could do to improve the lives of people who have survived strokes. As the  in the bunch, Lansberg had already been treating stroke patients for years and has helped lead the Stanford Stroke Collaborative Action Network, or SCAN, another project of the Wu Tsai Neurosciences Institute. Okamura, meanwhile, has focused much of her research on haptic, or touch-based, devices, and in the last few years her lab has spent more and more time thinking about how to use those devices to help stroke survivors.

“Rehabilitation engineering provides a unique opportunity for me to work directly with the patients who are affected by our research,” Okamura said. “The potential to translate the kind of technology relatively quickly to a commercial product that can reach a large number of  in need of therapy is also very exciting.”

For her part, Seim’s interest in stroke stems from an interest in wearable computing devices. Yet rather than build more virtual-reality goggles and smartwatches, Seim said she wants to apply wearable computing to the areas of health and accessibility—”areas which have some of the most compelling problems to me.”

Growing a new idea

With that ambition in mind, Seim built a vibrating glove prototype that she hoped would stimulate nerves and improve both sensation and function in stroke survivors’ hands and arms. After collecting some promising initial data, Seim reached out to the Stanford team.

“Stanford has SCAN and StrokeNet, along with a community of interdisciplinary engineering and computing research, so I reached out to Maarten, and he was very supportive,” Seim said.

Now, Seim, Lansberg and Okamura are revising the glove’s design to improve its function and to add elements for comfort and accessibility. Then, they’ll begin a new round of clinical tests at Stanford.

Long term, the hope is to build something that helps stroke survivors recover some of the functions they have lost in their hands and arms. And if initial tests work out, Lansberg said, it’s possible the same basic idea could be applied to treat other complications associated with stroke.

“The glove is an innovative idea that has shown some promise in pilot studies,” Lansberg said. “If proven beneficial for patients with impaired arm function, it is conceivable that variations of this type of therapy could be developed to treat, for example, patients with impaired gait.”

 

via Researchers building glove to treat symptoms of stroke

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[WEB SITE] Medical Device as Post-Stroke Spasticity Reducer Shows Promise

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An investigational, non-invasive medical device shows promise as a possible treatment for spasticity in patients who have experienced a stroke, Feinstein Institutes for Medical Research scientists report.

Their study, published in Springer Nature’s Bioelectronic Medicine, suggests that trans-spinal direct current stimulation and peripheral nerve direct current stimulation significantly reduced upper limb spasticity in participants who experienced a stroke.

Spasticity is a residual inability of the brain to control muscle tone. It increases muscle stiffness, which inhibits movement of the hands, arms, and legs; can affect the face and throat; and sometimes causes pain.

Efforts to treat upper limb spasticity have focused on intensive, repetitive, activity-dependent learning; however, it is common to experience residual spasticity despite aggressive therapy. When spasticity continues to worsen and causes pain, the standard-of-care is botox (botulinum toxin) injection, according to a media release from Feinstein Institutes for Medical Research.

“Spasticity is a persistent and common inhibitor of movement in patients with chronic stroke, and it has been a great hurdle as we continue to use intensive training to assist motor recovery,” says Bruce T. Volpe, MD, professor at the Feinstein Institutes and lead author of the paper, in the release.

“The surprise in these clinical results were the improved motor functions that apparently occurred with the focused treatment only of spasticity. We are eager to start a trial that couples motor training and anti-spasticity treatment.”

The treatment involves passing a direct electrical current across the spinal cord with a skin surface electrode, known as trans-spinal direct current stimulation (tsDCS), and adding a peripheral direct current stimulation (pDCS) in the paralyzed upper limb. There are additional benefits to patients when tsDCS is combined with pDCS.

Volpe, along with a team that includes Johanna Chang, MS, Alexandra Paget-Blanc, BS, and Maira Saul, MD, employed this device in patients with chronic stroke and hemiparesis to test whether treatment would decrease upper limb spasticity. The trial was a single-blind cross-over design study.

Twenty six participants were treated with five consecutive days of 20 minutes of active, paired tsDCS+pDCS. The participants received both active and sham stimulation conditions, but were not told the order of stimulation.

The device used in the trial was PathMaker Neurosystems Inc’s MyoRegulator, a non-invasive device designed to provide simultaneous, non-invasive stimulation intended to suppress hyperexcitable spinal neurons involved with spasticity.

The results demonstrated that the active treatment condition significantly reduced upper limb spasticity for up to five weeks and these patient responders saw significant improvements in motor function, the release explains.

[Source(s): Feinstein Institutes for Medical Research, PR Newswire]

 

via Medical Device as Post-Stroke Spasticity Reducer Shows Promise – Rehab Managment

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[Abstract] Unilateral vs. Bilateral Hybrid Approaches for Upper Limb Rehabilitation in Chronic Stroke: A Randomized Controlled Trial

Abstract

Objective

To investigate the effects of unilateral hybrid therapy (UHT) and bilateral hybrid therapy (BHT) compared with robot-assisted therapy (RT) alone in patients with chronic stroke.

Design

A single-blind, randomized controlled trial

Setting

Four hospitals

Participants

Forty-four outpatients with chronic stroke and mild to moderate motor impairment.

Intervention

UHT combined unilateral RT (URT) and modified constraint-induced therapy. BHT combined bilateral RT (BRT) and bilateral arm training. The RT group received URT and the BRT. The intervention frequency for the 3 groups was 90 min/day, 3 days/week, for 6 weeks.

Outcome measures

Fugl-Meyer Assessment (FMA, divided into the proximal and distal subscale) and Stroke Impact Scale (SIS) version 3.0 scores before, immediately after, and 3 months after treatment, and Wolf Motor Function Test (WMFT) and Nottingham Extended Activities of Daily Living (NEADL) scale scores before and immediately after treatment.

Results

The results favored BHT over UHT on the FMA total score and distal score at the posttest (p = .03 and .04) and follow-up (p = .01 and .047) assessment, and BHT over RT on the follow-up FMA distal scores (p = .03). At the posttest assessment, the WMFT and SIS scores of the 3 groups improved significantly without between-group differences, and the RT group showed significantly greater improvement in the mobility domain of NEADL, as compared to the BHT group (p<.01).

Conclusions

BHT was more effective for improving upper extremity motor function, particularly distal motor function at follow-up, and individuals in the RT group demonstrated improved functional ambulation post intervention.

via Unilateral vs. Bilateral Hybrid Approaches for Upper Limb Rehabilitation in Chronic Stroke: A Randomized Controlled Trial – Archives of Physical Medicine and Rehabilitation

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[Abstract] Bilateral Contralaterally Controlled Functional Electrical Stimulation Reveals New Insights Into the Interhemispheric Competition Model in Chronic Stroke

Background. Upper-limb chronic stroke hemiplegia was once thought to persist because of disproportionate amounts of inhibition imposed from the contralesional on the ipsilesional hemisphere. Thus, one rehabilitation strategy involves discouraging engagement of the contralesional hemisphere by only engaging the impaired upper limb with intensive unilateral activities. However, this premise has recently been debated and has been shown to be task specific and/or apply only to a subset of the stroke population. Bilateral rehabilitation, conversely, engages both hemispheres and has been shown to benefit motor recovery. To determine what neurophysiological strategies bilateral therapies may engage, we compared the effects of a bilateral and unilateral based therapy using transcranial magnetic stimulation.

Methods. We adopted a peripheral electrical stimulation paradigm where participants received 1 session of bilateral contralaterally controlled functional electrical stimulation (CCFES) and 1 session of unilateral cyclic neuromuscular electrical stimulation (cNMES) in a repeated-measures design. In all, 15 chronic stroke participants with a wide range of motor impairments (upper extremity Fugl-Meyer score: 15 [severe] to 63 [mild]) underwent single 1-hour sessions of CCFES and cNMES. We measured whether CCFES and cNMES produced different effects on interhemispheric inhibition (IHI) to the ipsilesional hemisphere, ipsilesional corticospinal output, and ipsilateral corticospinal output originating from the contralesional hemisphere.

Results. CCFES reduced IHI and maintained ipsilesional output when compared with cNMES. We found no effect on ipsilateral output for either condition. Finally, the less-impaired participants demonstrated a greater increase in ipsilesional output following CCFES.

Conclusions. Our results suggest that bilateral therapies are capable of alleviating inhibition on the ipsilesional hemisphere and enhancing output to the paretic limb.

 

via Bilateral Contralaterally Controlled Functional Electrical Stimulation Reveals New Insights Into the Interhemispheric Competition Model in Chronic Stroke – David A. Cunningham, Jayme S. Knutson, Vishwanath Sankarasubramanian, Kelsey A. Potter-Baker, Andre G. Machado, Ela B. Plow, 2019

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[Abstract] Forced, Not Voluntary, Aerobic Exercise Enhances Motor Recovery in Persons With Chronic Stroke

Background. The recovery of motor function following stroke is largely dependent on motor learning–related neuroplasticity. It has been hypothesized that intensive aerobic exercise (AE) training as an antecedent to motor task practice may prime the central nervous system to optimize motor recovery poststroke.

Objective. The objective of this study was to determine the differential effects of forced or voluntary AE combined with upper-extremity repetitive task practice (RTP) on the recovery of motor function in adults with stroke.

Methods. A combined analysis of 2 preliminary randomized clinical trials was conducted in which participants (n = 40) were randomized into 1 of 3 groups: (1) forced exercise and RTP (FE+RTP), (2) voluntary exercise and RTP (VE+RTP), or (3) time-matched stroke-related education and RTP (Edu+RTP). Participants completed 24 training sessions over 8 weeks.

Results. A significant interaction effect was found indicating that improvements in the Fugl-Meyer Assessment (FMA) were greatest for the FE+RTP group (P = .001). All 3 groups improved significantly on the FMA by a mean of 11, 6, and 9 points for the FE+RTP, VE+RTP, and Edu+RTP groups, respectively. No evidence of a treatment-by-time interaction was observed for Wolf Motor Function Test outcomes; however, those in the FE+RTP group did exhibit significant improvement on the total, gross motor, and fine-motor performance times (P ≤ .01 for all observations).

Conclusions. Results indicate that FE administered prior to RTP enhanced motor skill acquisition greater than VE or stroke-related education. AE, FE in particular, should be considered as an effective antecedent to enhance motor recovery poststroke.

via Forced, Not Voluntary, Aerobic Exercise Enhances Motor Recovery in Persons With Chronic Stroke – Susan M. Linder, Anson B. Rosenfeldt, Sara Davidson, Nicole Zimmerman, Amanda Penko, John Lee, Cynthia Clark, Jay L. Alberts, 2019

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[WEB SITE] Telerehab vs In-Clinic for Post-Stroke Arm Weakness: Which One Wins?

Old woman training at home

Telerehabilitation was not inferior to in-clinic rehabilitation therapy in helping to improve arm function after stroke but could substantially increase access to therapy for those who are unable to access a rehabilitation clinic, researchers opine.

“Few patients fully recover from arm weakness after a stroke. The remainder demonstrate persistent arm impairments that are directly linked to activity limitations, participation restrictions, reduced quality of life, and decreased well-being,” Steven C. Cramer, MD, from the department of neurology at the University of California, Irvine, and colleagues write, in a study published in JAMA Neurology.

“Some rehabilitation therapies can improve these deficits, with higher doses associated with better outcomes. However, many patients do not receive high doses of rehabilitation therapy, for reasons that include cost, difficulty traveling to the location where therapy is provided, shortage of regional rehabilitation care, and poor adherence with assignments,” they continue, in a media release from Healio.

Cramer and colleagues conducted a randomized, assessor-blinded, noninferiority clinical trial to compare telerehabilitation and in-clinic rehabilitation therapy outcomes for patients who had a stroke that resulted in arm motor deficit.

Patients were enrolled in the study at 4 to 36 weeks after experiencing an ischemic stroke or intracerebral hemorrhage that resulted in arm weakness. After enrollment, participants were randomly assigned to receive intensive arm motor therapy in a rehabilitation clinic or in their home using telerehabilitation delivery services with a computer connected to the internet. Scores on the Fugl-Myer arm motor scale were measured at the baseline and after treatment to determine changes in arm motor function.

All patients received 36 treatment sessions (70 minutes) in a 6- to 8-week period, which included 18 supervised and 18 unsupervised sessions. The content of therapy was carefully matched, with each group using the same exercises and standard exercise equipment.

A total of 124 participants were included in the study. Participants had a mean age of 61 years, a mean baseline Fugl-Meyer score of 43 points and were enrolled for a mean 18.7 weeks following stroke, the release explains.

Patients in the in-clinic group were adherent to 33.6 of 36 therapy sessions (93.3%), and those who received telerehabilitation at home were adherent to 35.4 of 36 therapy sessions (98.3%).

Both groups experienced significant changes in Fugl-Meyer scores from the baseline period to 30 days after treatment, with a mean change of 8.36 points in patients who received in-clinic therapy and 7.86 points in those who received telerehabilitation therapy.

The noninferiority margin was 2.47 and fell outside the 95% confidence interval, suggesting that telerehabilitation was not inferior to in-clinic therapy.

“Our study found that a 6-week course of daily home-based [telerehabilitation] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic,” Cramer and colleagues conclude, in the release.

[Source: Healio Primary Care]

 

via Telerehab vs In-Clinic for Post-Stroke Arm Weakness: Which One Wins? – Physical Therapy Products

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[Abstract + References] Design and Development of a Robotic Platform Based on Virtual Reality Scenarios and Wearable Sensors for Upper Limb Rehabilitation and Visuomotor Coordination – Conference paper

Abstract

The work reintegration following shoulder biomechanical overload illness is a multidimensional process, especially for those tasks requiring strength, movement control and arm dexterity. Currently different robotic devices used for upper limb rehabilitation are available on the market, but these devices are not based on activities focused on the work reintegration. Furthermore, the rehabilitation programmes aimed to the work reintegration are insufficiently focused on the recovery of the necessary skills for the re-employment.

In this study the details of the design of an innovative robotic platform integrated with wearable sensors and virtual reality scenarios for upper limbs motor rehabilitation and visuomotor coordination is presented. The design of control strategy will also be introduced. The robotic platform is based on a robotic arm characterized by seven degrees of freedom and by an adaptive control, wearable sensorized insoles, virtual reality (VR) scenarios and the Leap Motion device to track the hand gestures during the rehabilitation training. Future works will address the application of deep learning techniques for the analysis of the acquired big amount of data in order to automatically adapt both the difficulty level of the VR serious games and amount of motor assistance provided by the robot.

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