[Abstract] Upper Limb Motor Improvement after Traumatic Brain Injury: Systematic Review of Interventions

Abstract

Background

Traumatic brain injury (TBI) is a leading cause of adult morbidity and mortality. Individuals with TBI have impairments in both cognitive and motor domains. Motor improvements post-TBI are attributable to adaptive neuroplasticity and motor learning. Majority of the studies focus on remediation of balance and mobility issues. There is limited understanding on the use of interventions for upper limb (UL) motor improvements in this population.

Objective

We examined the evidence regarding the effectiveness of different interventions to augment UL motor improvement after a TBI.

Methods

We systematically examined the evidence published in English from 1990–2020. The modified Downs and Black checklist helped assess study quality (total score: 28). Studies were classified as excellent: 24–28, good: 19–23, fair: 14–18, and poor: ≤13 in quality. Effect sizes helped quantify intervention effectiveness.

Results

Twenty-three studies were retrieved. Study quality was excellent (n = 1), good (n = 5) or fair (n = 17). Interventions used included strategies to decrease muscle tone (n = 6), constraint induced movement therapy (n = 4), virtual reality gaming (n = 5), non-invasive stimulation (n = 3), arm motor ability training (n = 1), stem cell transplant (n = 1), task-oriented training (n = 2), and feedback provision (n = 1). Motor impairment outcomes included Fugl-Meyer Assessment, Modified Ashworth Scale, and kinematic outcomes (error and movement straightness). Activity limitation outcomes included Wolf Motor Function Test and Motor Activity Log (MAL). Effect sizes for majority of the interventions ranged from medium (.5-.79) to large (≥.8). Only ten studies included retention testing.

Conclusion

There is preliminary evidence that using some interventions may enhance UL motor improvement after a TBI. Answers to emergent questions can help select the most appropriate interventions in this population.

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[Abstract] Design of a hand rehabilitation gaming platform using IoT technologies – IEEE Conference Publication

Abstract

Nowadays, elements of the game can be met more often in regular processes. Education, business, marketing and many other spheres are being included with gaming elements, since games, according to conducted studies, positively affect people and make them happier. Also, games reduce stress and help to be focused on specific tasks. Today’s technologies such as virtual reality tools provide huge opportunities for developers to create projects that can be used as a key element that improves the efficiency and results of certain processes.This article presents a gaming platform for hand rehabilitation, which includes the use of a Leap Motion controller in conjunction with an Arduino-based robotic arm. The main idea of gamification of hand rehabilitation is to help improve the accuracy of gestures, coordination, and also restore the functionality of the hands using the capabilities of Leap Motion and Arduino.

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[ARTICLE] Reward During Arm Training Improves Impairment and Activity After Stroke: A Randomized Controlled Trial – Full Text

Abstract

Background

Learning and learning-related neuroplasticity in motor cortex are potential mechanisms mediating recovery of movement abilities after stroke. These mechanisms depend on dopaminergic projections from midbrain that may encode reward information. Likewise, therapist experience confirms the role of feedback/reward for training efficacy after stroke.

Objective

To test the hypothesis that rehabilitative training can be enhanced by adding performance feedback and monetary rewards.

Methods

This multicentric, assessor-blinded, randomized controlled trial used the ArmeoSenso virtual reality rehabilitation system to train 37 first-ever subacute stroke patients in arm-reaching to moving targets. The rewarded group (n = 19) trained with performance feedback (gameplay) and contingent monetary reward. The control group (n = 18) used the same system without monetary reward and with graphically minimized performance feedback. Primary outcome was the change in the two-dimensional reaching space until the end of the intervention period. Secondary clinical assessments were performed at baseline, after 3 weeks of training (15 1-hour sessions), and at 3 month follow-up. Duration and intensity of the interventions as well as concomitant therapy were comparable between groups.

Results

The two-dimensional reaching space showed an overall improvement but no difference between groups. The rewarded group, however, showed significantly greater improvements from baseline in secondary outcomes assessing arm activity (Box and Block Test at post-training: 6.03±2.95, P = .046 and 3 months: 9.66±3.11, P = .003; Wolf Motor Function Test [Score] at 3 months: .63±.22, P = .007) and arm impairment (Fugl-Meyer Upper Extremity at 3 months: 8.22±3.11, P = .011).

Conclusions

Although neutral in its primary outcome, the trial signals a potential facilitating effect of reward on training-mediated improvement of arm paresis.

Introduction

After stroke, 50% of survivors are left with upper extremity impairments,^1,2 a disability that lowers their health-related quality of life.³ Therapies to cure or ameliorate arm impairment are limited in their population efficacy, although some patients respond to therapy or recover spontaneously. Apart from training dose (ie, time spent training), it is unknown what makes training effective and in whom. When training dose is matched, most randomized controlled trials introducing new interventions (eg, robot-assisted therapy)⁴ showed no difference to control being routine care or conventional physical/occupational therapy. Assuming that currently available therapies do not fully exploit the biological recovery potential,⁵ there is urgent need for improvement.

Improvement may be achieved by identifying effective elements of therapy and boosting them. Reward during training may be one such element. In the rat, dopaminergic projections from the midbrain’s ventral tegmental area (VTA) to primary motor cortex (M1) are necessary for successful motor skill learning.⁶ Dopamine in M1 modulates excitability⁷ and enables long-term potentiation of cortico-cortical connections.⁸ Populations of dopaminergic VTA neurons respond to food rewards as well as to the combination of reward and training.⁹ In humans, reward enhances procedural¹⁰ and motor skill learning^11,12 and has a positive effect on motor adaptation.¹³ This is mainly the result of improved retention or consolidation.^11–13 In a functional magnetic resonance imaging study, we demonstrated that adding monetary rewards after good performance leads to better consolidation and higher ventral striatum activation than knowledge of performance alone,¹² the striatum being a key area of reward processing.^14,15

While motor skill learning is not the only mechanism mediating movement recovery after stroke, it certainly is an important factor.^16,17 It therefore seems likely that reward will also affect recovery, as it does skill learning. We thus hypothesized that augmenting reward improves recovery in response to training. Using the ArmeoSenso, a standardized virtual reality-based training system, allowed for delivery of intensive repetitive training of the upper limb¹⁸ while rewarding features like game scores (linked to a monetary reward), visual and sound special effects of the applied therapy game could be easily manipulated. Here we report a proof-of-concept, assessor-blinded, multicenter randomized controlled trial comparing the effect of enhanced feedback and reward vs unrewarded training matched in time and movement repetitions on arm activity and impairment.

Materials and Methods

Study Design

ArmeoSenso-Reward was a Swiss national, multicentric, assessor-blinded, parallel-group randomized controlled trial testing the hypothesis that rehabilitative training could be enhanced by reward incentives. Eligible patients were randomized 1:1 to either rewarded or control group using permuted block randomization (blocks of 4) stratified by study center (5 sites).¹⁹ The randomization procedure was planned and set up by an independent contract research organization (Appletree CI Group, Winterthur, Switzerland). The study protocol including a detailed description of the randomization procedure has been described in a previous publication (see Widmer et al¹⁹). The study was conducted according to national and international guidelines²⁰ and followed the Consolidated Standards of Reporting Trials (CONSORT) statement on randomized trials of non-pharmacological treatment²¹ (see Figure 1 and checklist in Supplementary File 1) and Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT; see Supplementary File 2) guidance for protocol reporting.²² Assessors were trained in performing the assessments, blinded to treatment allocation, and patients were unaware of the training characteristics of the other study group. The ArmeoSenso-Reward trial was registered at clinicaltrials.gov (ID: NCT02257125).

Figure 1. Participant flow through the study. Consolidated Standards of Reporting Trials (CONSORT) flow chart.

Study Population

This study included subacute ischemic stroke patients (max. 100 days after stroke) that met the following criteria: Minimum age of 18 years, hemiparesis of the arm, ability to lift the paretic arm against gravity with a minimal arm workspace of 20 cm × 20 cm in the horizontal plane (as visually assessed by a member of the study team), ability and willingness to participate, as well as the absence of severe aphasia (ie, patients that were not able to follow 2 stage commands), documented severe depression (medical records), dementia, and hemianopia. Patients were recruited from 5 Swiss stroke rehabilitation centers.

Interventions

The ArmeoSenso arm rehabilitation system combines motion capturing via wearable inertial measurement units (IMUs)²³ and a therapy game consisting of fast 3-dimensional target reaching movements (Figure 2(A)).^18,24 Three wireless IMUs (MotionPod 3, Movea SA, Grenoble, France) are fixed to the functionally impaired lower and upper arm as well as the trunk. Note that what we refer to as “ArmeoSenso” in this work is a research prototype of the Armeo®Senso product (Hocoma AG, Volketswil, Switzerland), using different hardware and custom-developed software for therapy and assessments.

Figure 2. ArmeoSenso-Reward: Device and interventions. (A) Healthy subject using the ArmeoSenso training system. (B) Arm workspace assessment: Gray cubic voxels arranged in the transverse plane reflecting 10 cm × 10 cm active workspace relative to the patient’s trunk. (C) Rewarded training using the METEORS game: The hand of the virtual arm was used to catch the falling meteors before they crash onto the planet. If caught, the meteor exploded (visual and auditory feedback), and a score appeared (visual feedback). The earlier the meteor was caught, the higher was the produced score. If missed, the planet got damaged (note the impact crater (visual and auditory feedback)). Monetary rewards were given for each completed level. Patients could win up to 1 Swiss Franc (CHF), if they succeeded, but .1 CHF was deducted for every missed meteor. As a new level could be started approximately every 3 minutes, a maximum of 20 CHF (approx. 20 US-Dollars) could be won per training session in case of an uninterrupted winning streak. Summary statistics and monetary rewards were displayed visually after successfully completing a level. (D) Control game. The virtual hand was a green decagon that could be used to touch the pill-shaped, single-colored targets dropping in from the top of the screen, which then disappeared with a delay of 1 s without producing visual or sound effects and without producing a score. For more details, see Widmer et al.¹⁹

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[Abstract] Effects of virtual reality-based motor rehabilitation: a systematic review of fMRI studies

Abstract

Background: The use of virtual reality (VR) as a rehabilitation tool has been shown to induce motor and cognitive improvements in different populations. Functional magnetic resonance imaging (fMRI) has been used to investigate neuroplasticity resulting from these treatments. We hypothesize that VR rehabilitation induces functional improvement and brain changes that can be detected by fMRI.

Objective: To systematically review the effects of VR intervention on the cortical reorganization measured by fMRI and associated with functional improvement.

Methods: We performed a systematic review of studies published between 2005 and 2021. Papers were retrieved from six databases using the following keywords: “motor rehabilitation”, “fMRI” and “virtual reality”. Case studies, pre-post studies, cross-sectional studies, and randomized controlled trials published were included. Manuscripts were assessed by The NIH Study Quality Assessment Tools to determine their quality.

Results: Twenty-three articles met our eligibility criteria: 18 about VR rehabilitation in stroke and five on other clinical conditions (older adults, cerebral palsy, and Parkinson’s disease). Changes in neural patterns of activation and reorganization were revealed in both the ipsilesional and the contralesional hemispheres. Results were located mainly in the primary motor cortex, sensorimotor cortex and supplementary motor area in post-stroke patients in the acute, subacute, and chronic rehabilitation phases, and were associated with functional improvement after VR intervention. Similar effects were observed in older adults and in patients with other neurological diseases with improved performance.

Conclusion: Most stroke-related studies showed either restoration to normal or increase of activation patterns or relateralization at/to the ipsilesional hemisphere, with some also reporting a decrease in activity or extent of activation after VR therapy. In general, VR intervention demonstrated evidence of efficacy both in neurological rehabilitation and in performance improvement of older adults, accompanied by fMRI evidence of brain reorganization.

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[ARTICLE] Effects of Virtual Reality-Based Intervention on Cognition, Motor Function, Mood, and Activities of Daily Living in Patients With Chronic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials – Full Text

Introduction

Stroke is one of the global leading causes of death and may cause long-term disability for many stroke survivors (Mendis, 2013; Andrew et al., 2014). Up to three-quarters of patients with poststroke experienced ongoing cognitive impairment (Pasi et al., 2012; Jokinen et al., 2015; Renjen et al., 2015). Cognitive impairment and functional disability are often associated with the following stroke. Furthermore, the depressive mode worsens the difficulties for patients with stroke to maintain their social and personal relationships. Clinical depression is characterized by behavioral, cognitive, and emotional features (Merriman et al., 2019). Cognitive performance is always associated with symptoms of depression (Nakling et al., 2017), and early cognitive deficits in patients after stroke may predict long-term depressive symptoms (Nys et al., 2006). Furthermore, poststroke cognitive impairment is associated with early and enduring activity limitations and participation restrictions (Stolwyk et al., 2021). These disorders might lead to a poor quality of life (QoL) for individuals with stroke and their families.

In recent years, interventions for poststroke motor and cognitive impairment, depression, and reduced functional independence have become the focus of international stroke rehabilitation research, and novel clinical rehabilitation therapies [e.g., virtual reality (VR), repetitive transcranial magnetic stimulation (rTMS), and robotic assistive therapies] have shown great potential in future practice (Langhorne et al., 2011; Winstein et al., 2016a; Gittler and Davis, 2018). VR-based training is defined by using computer hardware and software-generated user-computer interface for users to interact with virtual environments that relate to the real world to facilitate task-oriented training and provide multimodal feedback to augment functional recovery (Laver et al., 2017; Hao et al., 2021). Basic neuroscience behind VR-based treatment was the finding of mirror neurons (MNs) in the primary motor cortex (M1), dorsal premotor cortex, supplementary motor area (SMA), and M1 from animal studies (Gentilucci et al., 1988; Rizzolatti et al., 1996; Rizzolatti and Sinigaglia, 2016; Mekbib et al., 2020). The evidence from human neuroimaging suggested that the neural mechanisms of VR on neural plasticity and motor reorganization in humans might be to stimulate the internal sensorimotor system through activating MNs in the cortical and subcortical motor control-related areas, particularly M1, SMA, and cerebellum (August et al., 2006(Prochnow et al., 2013; Mekbib et al., 2020, 2021; Hao et al., 2021).

Recently, many clinical studies favored VR-based intervention for motor function, balance, gait, and activities of daily living (ADL) in patients with stroke. Although multiple systematic reviews and meta-analyses have indicated that VR-based training was useful for upper limb motor function, lower limb motor function, balance, gait, and activities of daily living (ADL) in stroke (Henderson et al., 2007; Laver et al., 2011; Saposnik et al., 2011; Lohse et al., 2014; Laver et al., 2015; de Rooij et al., 2016; Li et al., 2016; Silver, 2016; Yates et al., 2016; Laver et al., 2017; Aminov et al., 2018; Al-Whaibi et al., 2021; Fang et al., 2021; Peng et al., 2021; Zhang et al., 2021), two recent articles published in The Lancet Neurology by Saposnik et al. (2016) and Silver (2016) argued that the methodological issues that existed in some of the studies (Broeren et al., 2008; Kwon et al., 2012) were the comparison of VR combined with conventional rehabilitation vs. conventional rehabilitation alone without active control. Such study design (Saposnik et al., 2011; Lohse et al., 2014; Laver et al., 2015) might create an imbalance in the total rehabilitation time, and the effect might be induced by any active intervention and might not be explained by VR (Saposnik et al., 2016; Silver, 2016).

Conventional paper-and-pencil exercises and computer-assisted cognitive training designed to improve specific domains of cognitive deficits are widely used for patients with stroke with cognitive impairment. However, traditional cognitive training is limited by its insufficient personalization and adaptation and suboptimal intensity (Faria et al., 2016; Maier et al., 2020). Preliminary results (Kim et al., 2011; Choi et al., 2014; Faria et al., 2016, 2020; De Luca et al., 2018; Kannan et al., 2019; Maggio et al., 2019; Oh et al., 2019; Maier et al., 2020; Manuli et al., 2020) suggested that VR-based training combined with traditional rehabilitation might be more effective for enhancing cognition, depressive mood, and QoL in stroke than traditional cognitive rehabilitation. However, there is no clear evidence concerning the effectiveness of VR for cognition, depression, and QoL in patients with stroke (Laver et al., 2011, 2015; Silver, 2016). Recently, several systematic reviews (Aminov et al., 2018; Wiley et al., 2020; Zhang et al., 2021) have evaluated the effectiveness of VR for cognitive impairment in patients with stroke. Aminov et al. (2018) included 4 studies that assess VR-based rehabilitation on cognitive outcomes and found that VR could induce significant gains on improvements in cognitive function. Zhang et al. (2021) combined 7 RCTs to evaluate the effectiveness of VR interventions for cognitive outcomes compared with control groups, but no significant difference was found. However, in the two meta-analyses (Aminov et al., 2018; Zhang et al., 2021), only global cognition examined by MMSE or MoCA test for screening cognitive impairment was included, and specific domains of cognition were not investigated. Wiley et al. (2020) performed a systematic review that included five manuscripts to evaluate VR-based intervention combined with rehabilitation exercise on global cognition and specific domains of cognition and concluded that VR therapy was not better than traditional rehabilitation interventions for enhancing cognitive function in stroke survivors. However, due to the limited number of original articles, small sample size, different types of VR devices, different VR intervention durations, and different stages after stroke onset, the results remain controversial.

To date, however, few systematic reviews and meta-analyses have investigated VR-based training for cognitive function in contrast to cognitive exercise or motor exercise on the chronic stage of stroke. Therefore, this study aimed to explore the effect of VR-based training on cognition, motor function, mood, and ADL among individuals at the chronic phase of stroke.[…]

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[Abstract] Effects of virtual reality in improving upper extremity function after stroke: A systematic review and meta-analysis of randomized controlled trials

Abstract

Objective

To investigate the effect of virtual reality on arm motor impairment, activity limitation, participation restriction, and quality of life in patients with stroke. To determine potential moderators that affect the efficacy of virtual reality.

Data sources

CINAHL, Medline, PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang Data from inception to October 23, 2021.

Review methods

Randomized controlled trials that investigated the effect of virtual reality on arm recovery in adult patients with stroke compared to conventional therapy or sham control were included. Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study.

Results

Forty studies with 2018 participants were identified. Quality of included studies was fair to high. Virtual reality exhibited better effects on overall arm function (g = 0.28, p < 0.001), motor impairment (g = 0.36, p < 0.001) and activity limitation (daily living) (g = 0.24, p < 0.001) compared with the control group. No significant improvement was observed in participation restriction and activity limitation (specific task). The result for quality of life was described qualitatively. Subgroup analyses demonstrated that immersive virtual reality produced a greater beneficial effect (g = 0.60, p < 0.001). Patients with moderate to severe arm paresis could make more progress after training (g = 0.71, p < 0.001).

Conclusion

Virtual reality is recommended for improving motor impairment and activities of daily living after stroke and is favorable to patients with moderate to severe paresis. An immersive design could produce greater improvement.

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[Abstract] Gaze-controlled Robot-assisted Painting in Virtual Reality for Upper-limb Rehabilitation

Abstract

Stroke is the leading cause of adult disability. Robot-assisted rehabilitation systems show great promise for motor recovery after a stroke. In this work, we present a gazecontrolled robotic system for upper limb rehabilitation. Subjects perform a painting task in virtual reality. We designed a novel and challenging painting task to encourage motivation and engagement, as these are critical factors in treatment efficacy. Because the robotic system can be programmed to provide varying amounts of assistance or resistance to the subject, it can be applied to a wide range of patients at different phases of recovery. We describe here the system configured in two modes: resistive control and hierarchical control. The former is designed for later stages of recovery, where the patient’s impaired limb has recovered some function. It can be configured to provide varying degrees of resistance by adjusting the properties of an admittance controller. The latter targets patients in more acute phases, where the impaired limb is less responsive. It provides a combination of assistive and corrective control. We pilot tested our system on 10 able-bodied subjects. Our results show that the system can provide varying degrees of resistive control, and that the integration of high level control modulated by gaze can improve engagement. These results suggest that the system may provide a more engaging environment for a wide range of rehabilitative therapies than currently available.

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[TEDx Talks] Can Virtual Reality Change Your Mind? – Thong Nguyen

In this talk, Thong shares insights on how VR experiences are impacting training and development, health care, and even our own self perception. Virtual reality even has the capacity to create empathy and strengthen how we understand ourselves – and each other. Thong Nguyen is an entrepreneur who is using virtual reality to help people experience, test and learn from the future. His company, Roomera, works with innovative business leaders to apply VR within the enterprise to accelerate prototyping and research, enhance learning, and aid in sales development. Before Roomera, Thong spent 15 years in the corporate sector in roles ranging from analyst to VP and CTO. Featured as a 2017 Minnesota Business young entrepreneur, Thong has a profound fascination with exploring the nuances of human behavior, and is interested in technology that creates empathy and strengthens how we understand ourselves and each other. This talk was given at a TEDx event using the TED conference format but independently organized by a local community.

Learn more at https://www.ted.com/tedx

[ARTICLE] Effects of Virtual Reality Training on Upper Limb Function and Balance in Stroke Patients: Systematic Review and Meta-Meta-Analysis – Full Text

Abstract

Background

Virtual reality (VR) training is a promising intervention strategy that has been utilized in health care fields like stroke rehabilitation and psychotherapy. Current studies suggest that VR training is effective in improving the locomotor ability of stroke patients.

Objective

This is the first meta-meta-analysis of the effects of VR on motor function in stroke patients. This study aimed to systematically summarize and quantify the present meta-analyses results of VR training and produce high-quality meta-meta-analysis results to obtain a more accurate prediction.

Methods

We searched 4 online databases (Web of Science, Scopus, PubMed, and Chinese National Knowledge Infrastructure) for meta-analysis studies. After accounting for overlap, 10 studies (accounting for almost 550 stroke patients) were obtained. Based on the meta-meta-analysis of these patients, this study quantified the impact of VR training on stroke patients’ motor performance, mainly including upper limb function, balance, and walking ability. We combined the effects under the random effect model and pooled the estimates as standardized mean differences (SMD).

Results

The results of the meta-meta-analysis showed that VR training effectively improves upper limb function (SMD 4.606, 95% CI 2.733-6.479, P<.05) and balance (SMD 2.101, 95% CI 0.202-4.000, P<.05) of stroke patients. However, the results showed considerable heterogeneity and thus, may need to be treated with caution. Due to the limited research, a meta-meta-analysis of walking ability was not performed.

Conclusions

These findings represent a comprehensive body of high-quality evidence that VR training is more effective at improving upper limb function and balance of stroke patients.

Introduction

Stroke is the most common cause of chronic physical disabilities, such as dyskinesia. Most stroke patients have dyskinesia, which causes different degrees of impediment to upper limb function, walking ability, and balance. Because of limited exercise ability, these patients cannot participate in daily activities; thus, their quality of life is reduced [1,2]. Stroke rehabilitation mainly aims to help patients return to society and work [3]. Therefore, it is important to comprehensively understand the severity of stroke; improve treatment methods; reduce the incidence, disability, and mortality of stroke; and find safe and effective treatment for stroke patients.

In the past decade, virtual reality (VR), as a means of neurological rehabilitation for stroke, has gradually become popular in the field of rehabilitation because of the continuous improvement in virtual systems and the substantial reduction in cost of virtual equipment [4]. VR technology is a system that can simulate the environment, scene, and activity in real time and allow users to interact through multiple sensory modalities. The system can be combined with a treadmill, bionic gloves, or robots to provide better feedback for users [5]. Moreover, in the virtual rehabilitation scene created by VR technology, the content, duration, and intensity of the exercise can be manipulated, and even timely feedback can be obtained so as to provide users sufficient and personalized exercise [6]. The following VR-related technologies are widely used in the treatment of stroke patients: an innovative exoskeleton, VR telerehabilitation system, IREX immersion VR systems, Xbox Kinect, keyboard with VR, VR combined with gloves, Nintendo Wii, and virtual surfaces [6]. Compared with traditional rehabilitation, the main advantage of VR training is that stroke patients can think of it as an exciting game rather than as treatment; VR training can help users focus their attention completely on the task, thus improving motivation and treatment compliance, which can be of great benefit in recovering from poststroke trauma [7].

In the last 20 years, a large number of studies have confirmed that VR training has certain advantages in improving the condition of people with dyskinesia [8,9]. Among these studies, nearly 300 experimental and more than 60 meta-analysis studies of stroke patients have been published in international journals. However, between the different meta-analysis studies, there is an inconsistency in the effect size of VR training to improve the different exercise abilities of stroke patients. The purpose of this study was to aggregate high-quality evidence from randomized trials and quantify the effects of VR training on the exercise performance of these patients. Meta-meta-analysis is the meta-analysis of meta-analyses and follows the primary outcome research. Moreover, the overlap of primary studies in a meta-analysis is also fully considered in order to clearly illustrate the effectiveness of VR training in improving motor performance. These findings are expected to be the highest quality of evidence to date. Meanwhile, the methodological quality of the included meta-analyses was evaluated to provide valuable information for future research and practice and to help clinical rehabilitation practitioners better understand the potential benefits of VR training.[…]

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[Review] Telerehabilitation – A Viable Option for the Recovery of Post-Stroke Patients – Full Text

Abstract

As the number of stroke survivors is continuously growing, with an important number suffering from consequent functional deficits, the rehabilitation field is facing more complex demands. Technological progress gives us the opportunity to remotely assist patients while they exercise at home through telerehabilitation (TR), addressing the problems of limited medical resources and staff, difficult transportation, or living a long distance from rehabilitation centers. In addition, TR is a way to provide continuity in long-term post-stroke recovery during the COVID-19 pandemic, which limits traveling and human interaction. While the implementation of TR is increasing, the biggest challenges are to raise patients’ acceptability of the new method and their motivation and engagement during the program. In this review, we aimed to find methods to address these challenges by identifying the patients who benefit the most from this therapy and efficiently organizing the space and technology used for telerehabilitation. User-friendly technologies and devices along with therapists’ constant support and feedback are some of the most important aspects that make TR an efficient intervention and an alternative to conventional therapy.

1. Introduction

Strokes are a frequent condition affecting 15 million people every year, of which 5 million survivors live with a consequent disability [1,2]. Healthcare and medical technologies have rapidly evolved in the last years, increasing the survival rate after stroke and therefore raising the number of patients with infirmities [3,4]. Post-stroke patients usually suffer from impaired motor function of one or more limbs, diminished sense of touch, cognition or swallowing alterations and speech and language difficulties [5]. Motor deficit of one of the upper limbs, present in about 80% of patients, is one of the most frequent consequences of stroke, and produces a dire need of rehabilitation therapy [6,7]. Loss of upper limb functionality severely impacts patients’ quality of life [6,8]. The average time hospitalized post-stroke patients spend training their upper limbs is insufficient for total function recovery [7,9]. As a result of short hospitalizations and limited human resources available for face-to-face rehabilitation therapy, the majority of stroke survivors are discharged with functional deficits and are in need of continuous recovery treatment [6,10]. Statistics show that an important number of patients do not take part in rehabilitation programs after the acute phase of a stroke [11]. It is considered that the best time to work with the neuroplasticity and deficit recovery ability is within the first 6 months after a stroke [10,12]. However, there is evidence that also supports an intense recovery program during the chronic phase of the disease [6,12]. Thereby, post-stroke rehabilitation has an important role when applied in any stage of the disease, with its absence having consequences such as pathological motor pattern development, non-use of the affected limb, spasticity enhancement, joint rigidity, increased pain and disability [12,13,14]. In addition, rehabilitation programs initiated in the clinic and continued at patients’ homes represent a therapeutic alternative to hepatotoxic and nephrotoxic medications administered to relieve pain and trophic effects [15,16].Rehabilitation therapy has proven its efficacy when task-oriented and applied in large doses, intensively, with many repetitions and continuously, in order to facilitate relearning [7,12,17]. The results seem to be directly proportional to the training period [7,17]. For example, improvements of arm function have been obtained after sessions summing 3 h or more per week [10]. Traditional exercises provided for patients upon discharge in order to be practiced at home have low adherence because of motivation loss, lack of pleasure while exercising and tasks that are either too hard or too easy [9]. Stroke rehabilitation represents a complex field that brings together physiotherapy, occupational therapy, speech and language therapy and neuropsychology [10]. As a result of the high costs of individual therapy sessions provided by a specialist, this is not the standard approach to chronic post-stroke patients.Teletherapy represents an alternative in the form of a variety of communication technologies, robotic devices or computer games used at home under the remote guidance of the therapist, and is a promising option that can stimulate motivation and prevent boredom [6,8]. Telerehabilitation (TR) implies access anytime and anywhere, through the Internet and technology, to qualitative rehabilitation services of any kind: physiotherapy, occupational therapy, speech and language therapy and neuropsychology [3]. It allows patients to have continuity in the rehabilitation of their acute or chronic conditions in cases of shortage of healthcare staff and medical resources, difficult transport, living in rural areas with difficult access to rehabilitation centers or mobility and interpersonal contact restrictions in the case of a pandemic [18].The purpose of this literature review was to identify in the literature the main challenges that may be faced when trying to initiate post-stroke telerehabilitation with the help of technology, and to contribute to the decision-making process in this emerging field. According to this, the secondary objectives were represented by: identifying patient categories who may benefit from telerehabilitation, the optimal organization of the patient’s domestic space, the suitable choice of TR devices taking into account the patient’s needs, the organizational needs of the therapist’s workspace, ways of increasing the patient’s motivation and adherence to treatment and innovative methods in TR.[…]

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Figure 4
TR Network setup.