Chronic Stroke Rehabilitation Research Articles

Investigating Combined Balance Training and Transcranial Direct Current Stimulation for the Recovery of Postural Control Following Chronic Stroke: A Study Protocol

Background: Stroke is one of the most debilitating diseases among the adults around the world which leads to persistent rehabilitation needs even at chronic stage. Achievement of good postural control is a critical requirement for daily activities which enhances quality of life in patients with stroke. There is increasing evidence that transcranial direct current stimulation (tDCS) may be considered as a promising adjunct technique to improve motor recovery after stroke. Evidence of augmented neuroplasticity after tDCS suggests that a paired rehabilitation followed by consecutive use of tDCS may optimize recovery outcomes. Although a few RCTs have been conducted on upper limbs rehabilitation in chronic stroke using tDCS, however no study focused on balance training in chronic stroke patients. This randomized, sham-controlled, double-blinded clinical study aims to address brain stimulation targeting postural control using tDCS in chronic stroke. Methods: The study participants will be chronic ischemic stroke individuals with postural control impairments who meet no exclusion criteria. Active or sham anodal tDCS will delivered to lesioned leg motor cortex combined with balance training. Experimental group receive active anodal tDCS stimulation (2mA) for 20 min, daily for 5 days paired with balance training. Linear and nonlinear approaches will be used to analyse postural sway changes pre and post-intervention. Postural sway fluctuation, Functional balance assessment using Berg balance scale, Timed Up-and-Go Test will be compared in active and sham groups. Conclusions: This trial could have significant implications for balance rehabilitation after stroke in the ambulatory setting. If found to be effective, this novel approach may improve rehabilitation protocol in this population.

Brain oscillations in reflecting motor status and recovery induced by action observation-driven robotic hand intervention in chronic stroke.

Hand rehabilitation in chronic stroke remains challenging, and finding markers that could reflect motor function would help to understand and evaluate the therapy and recovery. The present study explored whether brain oscillations in different electroencephalogram (EEG) bands could indicate the motor status and recovery induced by action observation-driven brain-computer interface (AO-BCI) robotic therapy in chronic stroke. The neurophysiological data of 16 chronic stroke patients who received 20-session BCI hand training is the basis of the study presented here. Resting-state EEG was recorded during the observation of non-biological movements, while task-stage EEG was recorded during the observation of biological movements in training. The motor performance was evaluated using the Action Research Arm Test (ARAT) and upper extremity Fugl-Meyer Assessment (FMA), and significant improvements (p < 0.05) on both scales were found in patients after the intervention. Averaged EEG band power in the affected hemisphere presented negative correlations with scales pre-training; however, no significant correlations (p > 0.01) were found both in the pre-training and post-training stages. After comparing the variation of oscillations over training, we found patients with good and poor recovery presented different trends in delta, low-beta, and high-beta variations, and only patients with good recovery presented significant changes in EEG band power after training (delta band, p < 0.01). Importantly, motor improvements in ARAT correlate significantly with task EEG power changes (low-beta, c.c = 0.71, p = 0.005; high-beta, c.c = 0.71, p = 0.004) and task/rest EEG power ratio changes (delta, c.c = -0.738, p = 0.003; low-beta, c.c = 0.67, p = 0.009; high-beta, c.c = 0.839, p = 0.000). These results suggest that, in chronic stroke, EEG band power may not be a good indicator of motor status. However, ipsilesional oscillation changes in the delta and beta bands provide potential biomarkers related to the therapeutic-induced improvement of motor function in effective BCI intervention, which may be useful in understanding the brain plasticity changes and contribute to evaluating therapy and recovery in chronic-stage motor rehabilitation.

The role of ventral tegmental area in chronic stroke rehabilitation: an exploratory study.

The acknowledged role of external rewards in chronic stroke rehabilitation, offering positive reinforcement and motivation, has significantly contributed to patient engagement and perseverance. However, the exploration of self-reward's importance in this context remains limited. This study aims to investigate the functional connectivity of the ventral tegmental area (VTA), a key node in the brain's reward circuitry, during motor task-based rehabilitation and its correlation with the recovery process. Twelve right-handed healthy volunteers (4 men, 8 women, aged 57.4 ± 11.3 years) and twelve chronic stroke patients (5 men, 7 women, aged 48.1 ± 11.1 years) with clinically significant right-sided motor impairment (mean FM-UE score of 27.6 ± 8.7) participated. The analysis employed the CONN toolbox to assess the association between motor tasks and VTA connectivity using psychophysiological interaction (PPI). PPI analysis revealed motor-dependent changes in VTA connectivity, particularly with regions within the motor circuitry, cerebellum, and prefrontal cortex. Notably, stronger connectivity between the ipsilesional VTA and cerebellum was observed in healthy controls compared to chronic stroke patients, highlighting the importance of VTA-cerebellum interactions in motor function. Stroke patients' motor performance was associated with VTA modulation in areas related to both motor tasks and reward processing, emphasizing the role of self-reward processes in rehabilitation. Changes in VTA influence on motor circuitry were linked to improvements in motor performance resulting from rehabilitation. Our findings underscore the potential of neuroimaging techniques in quantifying and predicting rehabilitation outcomes by examining self-reward processes. The observed associations between VTA connectivity and motor performance in both healthy and stroke-affected individuals emphasize the role of psychological factors, particularly self-reward, in the rehabilitation process. This study contributes valuable insights into the intricate interplay between reward circuits and motor function, highlighting the importance of addressing psychological dimensions in neurorehabilitation strategies.

Long-term forecasting of a motor outcome following rehabilitation in chronic stroke via a hierarchical bayesian dynamic model

BackgroundGiven the heterogeneity of stroke, it is important to determine the best course of motor therapy for each patient, i.e., to personalize rehabilitation based on predictions of long-term outcomes. Here, we propose a hierarchical Bayesian dynamic (i.e., state-space) model (HBDM) to forecast long-term changes in a motor outcome due to rehabilitation in the chronic phase post-stroke.MethodsThe model incorporates the effects of clinician-supervised training, self-training, and forgetting. In addition, to improve forecasting early in rehabilitation, when data are sparse or unavailable, we use the Bayesian hierarchical modeling technique to incorporate prior information from similar patients. We use HBDM to re-analyze the Motor Activity Log (MAL) data of participants with chronic stroke included in two clinical trials: (1) the DOSE trial, in which participants were assigned to a 0, 15, 30, or 60-h dose condition (data of 40 participants analyzed), and (2) the EXCITE trial, in which participants were assigned a 60-h dose, in either an immediate or a delayed condition (95 participants analyzed).ResultsFor both datasets, HBDM accounts well for individual dynamics in the MAL during and outside of training: mean RMSE = 0.28 for all 40 DOSE participants (participant-level RMSE 0.26 ± 0.19—95% CI) and mean RMSE = 0.325 for all 95 EXCITE participants (participant-level RMSE 0.32 ± 0.31), which are small compared to the 0-5 range of the MAL. Bayesian leave-one-out cross-validation shows that the model has better predictive accuracy than static regression models and simpler dynamic models that do not account for the effect of supervised training, self-training, or forgetting. We then showcase model’s ability to forecast the MAL of “new” participants up to 8 months ahead. The mean RMSE at 6 months post-training was 1.36 using only the baseline MAL and then decreased to 0.91, 0.79, and 0.69 (respectively) with the MAL following the 1st, 2nd, and 3rd bouts of training. In addition, hierarchical modeling improves prediction for a patient early in training. Finally, we verify that this model, despite its simplicity, can reproduce previous findings of the DOSE trial on the efficiency, efficacy, and retention of motor therapy.ConclusionsIn future work, such forecasting models can be used to simulate different stages of recovery, dosages, and training schedules to optimize rehabilitation for each person.Trial registration This study contains a re-analysis of data from the DOSE clinical trial ID NCT01749358 and the EXCITE clinical trial ID NCT00057018

A Meta-Analysis on Dual Protocols for Chronic Stroke Motor Recovery: Robotic Training and tDCS

Two popular chronic stroke rehabilitation protocols are robotic-assisted movements and transcranial direct current stimulation (tDCS). Separately, both protocols have produced encouraging motor recovery improvements. An intriguing question remains: what happens to motor recovery when both protocols are administered together? Do the two protocols together produce additive dual effects? This systematic review and meta-analysis investigated the dual effect of combining robotic training and tDCS. We investigated the potential effects of tDCS protocols in addition to robotic-training programs on motor recovery of the upper and lower extremities post-stroke. A systematic literature search identified 20 qualified studies that used robotic training combined with tDCS protocols for upper limb (i.e., 15 studies) and lower limb (i.e., 5 studies) post-stroke rehabilitation. Individuals in the subacute and chronic stages of recovery were investigated. The 20 included studies compared additive effects of the combined protocols with robotic training sham control groups. Further, we estimated short-term and long-term treatment effects of the combined protocols. The random-effects model meta-analyses failed to find any significant short-term and long-term motor improvements in the upper extremities after the combined treatments. However, robotic-assisted movements combined with tDCS protocols revealed significant moderate transient and sustained improvements in functions of the lower limbs post-stroke. These meta-analytic findings suggest clinical implications concerning coupled top-down and bottom-up training protocols (i.e., robotic training and tDCS combined), which will allow us to make progress toward post-stroke motor recovery.

Abstract 150: Vagus Nerve Stimulation (VNS) Paired With Upper Extremity Rehabilitation In Chronic Stroke: Improvements In Wrist And Hand Impairment And Function

Introduction: In the VNS-REHAB trial, vagus nerve stimulation (VNS) paired with task-specific arm and hand rehabilitation (Paired VNS) led to clinically meaningful improvements in both impairment and function of the upper extremity in people with chronic ischemic stroke. In this post hoc analysis of trial data, we assessed whether improvements were driven by proximal (shoulder and elbow) and/or distal (wrist and hand) components of the Upper Extremity Fugl-Meyer Assessment (FMA-UE). We also wanted to determine whether FMA-UE improvements correlated with improvements in functional outcome. Methods: Chronic stroke participants (n=108) with moderate-severe UE impairment (FMA-UE 35.1±8) were implanted with the VNS device and randomized to Paired VNS (n=53) or Controls (n=55). Participants underwent 6 weeks of in-clinic therapy followed by 90 days of a home exercise program. Outcomes, including the FMA-UE and Wolf Motor Function Test (WMFT), were collected after in-clinic therapy (Post-1) and 90 days of home therapy (Post-90). Results: Distal FMA-UE change was significantly greater after Paired VNS compared to Controls, both at Post-1 (2.43±2.52 vs. 0.64±2.33; 95% CI 0.87-2.72, p&lt;0.001, Cohen’s d=0.74) and Post-90 (2.58±2.88 vs. 0.93±3.16; 95% CI 0.5-2.81, p=0.005, Cohen’s d=0.55). Proximal FMA-UE change was also greater after Paired VNS compared to Controls but did not reach statistical significance at either timepoint. At Post-90, both proximal (r=0.50, p&lt;0.0001) and distal (r=0.42, p=0.001) FMA-UE change significantly correlated with WMFT change after Paired VNS, but not in Controls (proximal: r=0.24, p=0.06; distal: r=0.14, p=0.24). Conclusions: The data suggest that Paired VNS leads to greater improvement in the distal upper extremity compared to rehabilitation alone and that improvements in FMA-UE scores are correlated with improvements in function. These findings suggest that the improvements seen with Paired VNS are of functional importance. A greater understanding of region-specific arm and hand recovery after Paired VNS therapy will facilitate planning and implementation of a personalized neurorehabilitation approach based on patient-specific impairments.

Spatially selective stimulation of the pig vagus nerve to modulate target effect versus side effect

Electrical stimulation of the cervical vagus nerve using implanted electrodes (VNS) is FDA-approved for the treatment of drug-resistant epilepsy, treatment-resistant depression, and most recently, chronic ischemic stroke rehabilitation. However, VNS is critically limited by the unwanted stimulation of nearby neck muscles—a result of non-specific stimulation activating motor nerve fibers within the vagus. Prior studies suggested that precise placement of small epineural electrodes can modify VNS therapeutic effects, such as cardiac responses. However, it remains unclear if placement can alter the balance between intended effect and limiting side effect. We used an FDA investigational device exemption approved six-contact epineural cuff to deliver VNS in pigs and quantified how epineural electrode location impacts on- and off-target VNS activation. Detailed post-mortem histology was conducted to understand how the underlying neuroanatomy impacts observed functional responses. Here we report the discovery and characterization of clear neuroanatomy-dependent differences in threshold and saturation for responses related to both effect (change in heart rate) and side effect (neck muscle contractions). The histological and electrophysiological data were used to develop and validate subject-specific computation models of VNS, creating a well-grounded quantitative framework to optimize electrode location-specific activation of nerve fibers governing intended effect versus unwanted side effect.

A rehabilitative approach beyond the acute stroke event: a scoping review about functional recovery perspectives in the chronic hemiplegic patient.

Stroke is a main cause of disability worldwide and its neuro-rehabilitative management is not limited to the acute phase but requires continuity in the rehabilitation approach especially in the chronic phase. The aim of this scoping review was to highlight the different treatment opportunities available in neurorehabilitation, effective for patients with chronic stroke sequelae, not only in terms of maintaining motor function but also improving it. The literature search was conducted using the following databases: MEDLINE (PubMed), PEDro, Scopus, Web of Science (WOS), Cochrane from 2012 to February 2023. We selected Randomized Clinical Trials in English dealing with neurorehabilitation strategies in chronic hemiplegic patients after stroke focusing on motor function, muscular strength, gait, postural balance, spasticity, and quality of life. According to the inclusion criteria, 47 articles were selected for our review. All of them were analyzed following the primary outcome and the rehabilitation technique used. Despite the different protocols used within the same technique and despite the chronicity of the disease, all studies report an improvement after the rehabilitation treatment of motor function and quality of life. The literature analyzed invites us to reflect respect to neurorehabilitation approach to the patient with chronic stroke sequelae often considered to have as its objective the maintenance of the present motor function and contain disability: instead, the review reports how, even in chronicity, the patient always reports margins of statistically and clinically significant improvement. The chronic stroke rehabilitation over 6 months has been proved effective in obtaining recovery in different settings.

Music-based intervention drives paretic limb acceleration into intentional movement frequencies in chronic stroke rehabilitation.

This study presented a novel kinematic assessment of paretic limb function “online” during the actual therapeutic exercisers rooted within the acceleration domain. Twenty-eight patients at chronic stroke stages participated in an auditory-motor intervention mapping reaching movements of the paretic arm unto surfaces of large digital musical instruments and sound tablets that provided rhythmic entrainment cues and augmented auditory feedback. Patients also wore a tri-axial accelerometer on the paretic limb during the nine-session intervention. The resulting acceleration profiles were extracted and quantified within the frequency domain. Measures of peak power and peak width were leveraged to estimate volitional control and temporal consistency of paretic limb movements, respectively. Clinical assessments included the Wolf Motor Function Test and Fugl-Meyer – Upper Extremity subtest. The results showed that peak power increased significantly from Session 1 to Session 9 within oscillatory frequency ranges associated with intentional movement execution (i.e., 4.5 Hz). Decreases in peak width over time provided additional evidence for improved paretic arm control from a temporal perspective. In addition, Peak width values obtained in Session 1 was significantly correlated with pre-test Fugl-Meyer – Upper Extremity scores. These results highlighted improvements in paretic limb acceleration as an underlying mechanism in stroke motor recovery and shed further light on the utility of accelerometry-based measures of paretic limb control in stroke rehabilitation.The data reported here was obtained from a larger clinical trial: https://clinicaltrials.gov/ct2/show/NCT03246217 ClinicalTrials.gov Identifier: NCT03246217.

Virtual Reality-Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial.

BackgroundA growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)–based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function.ObjectiveThe primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants’ homes.MethodsA total of 51 chronic stroke participants were randomized to treatment (n=26, 51%; Jintronix system) or standard care (n=25, 49%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group.ResultsNo statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78%) of them having baseline low or moderate arm function, compared with 3 (33%) participants in the standard care group. Furthermore, 56% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0% (0/10) less-active participants.ConclusionsThese findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services.Trial RegistrationClinicalTrials.gov NCT02491203; https://clinicaltrials.gov/ct2/show/NCT02491203International Registered Report Identifier (IRRID)RR2-10.1016/j.cct.2015.12.006

Oscillatory beta/alpha band modulations: A potential biomarker of functional language and motor recovery in chronic stroke?

Stroke remains one of the leading causes of various disabilities, including debilitating motor and language impairments. Though various treatments exist, post-stroke impairments frequently become chronic, dramatically reducing daily life quality, and requiring specific rehabilitation. A critical goal of chronic stroke rehabilitation is to induce, usually through behavioral training, experience-dependent plasticity processes in order to promote functional recovery. However, the efficiency of such interventions is typically modest, and very little is known regarding the neural dynamics underpinning recovery processes and possible biomarkers of their efficiency. Some studies have emphasized specific alterations of excitatory–inhibitory balance within distributed neural networks as an important recovery correlate. Neural processes sensitive to these alterations, such as task-dependent oscillatory activity in beta as well as alpha bands, may be candidate biomarkers of chronic stroke functional recovery. In this review, we discuss the results of studies on motor and language recovery with a focus on oscillatory processes centered around the beta band and their modulations during functional recovery in chronic stroke. The discussion is based on a framework where task-dependent modulations of beta and alpha oscillatory activity, generated by the deep cortical excitatory–inhibitory microcircuits, serve as a neural mechanism of domain-general top-down control processes. We discuss the findings, their limitations, and possible directions for future research.

Proprioceptive Neuromuscular Facilitation-Based Physical Therapy on the Improvement of Balance and Gait in Patients with Chronic Stroke: A Systematic Review and Meta-Analysis.

The present study aims to determine the potential benefits of PNF on balance and gait function in patients with chronic stroke by using a systematic review and meta-analysis. Systematic review in the following databases: MEDLINE/PubMed, Physiotherapy Evidence Database (PEDro), Cochrane Library and Google Scholar. Studies up to September 2020 are included. A systematic database search was conducted for randomized control trials (RCTs) that investigated the effects of PNF intervention in patients with chronic stroke using balance and gait parameters as outcome measures. The primary outcomes of interest were Berg Balance Scale (BBS), Functional Reach Test (FRT), Timed Up and Go Test (TUG) and 10-Meter Walking Test (10MWT). Nineteen studies with 532 participants were included, of which twelve studies with 327 participants were included for meta-analysis. When the data were pooled, PNF made statistically significant improvements in balance with BBS, FRT and TUG (p < 0.05) or gait velocity with 10MWT (p < 0.001) when compared to the control. This review indicates that PNF is a potential treatment strategy in chronic stroke rehabilitation on balance and gait speed. Further high-quality research is required for concluding a consensus of intervention and research on PNF.

Is There a Time-Sensitive Window in Patients With Stroke to Enhance Arm Recovery With Higher Intensity Motor Therapy?

Is There a Time-Sensitive Window in Patients With Stroke to Enhance Arm Recovery With Higher Intensity Motor Therapy?

Use of virtual reality-based therapy in the field of chronic stroke rehabilitation to improve hand function: asystematic review

A stroke is neurological damage that results in the need for medical and physical therapy management. From this perspective, virtual reality (VR) is a promising rehabilitation technology that reproduces real-life scenarios through computer-generated environments. VR can be a complementary strategy to conventional rehabilitation approaches by potentially improving hand motor function and activities of daily living (ADLs). This study aimed to evaluate the effectiveness of VR-based therapy in improving hand function for people suffering from chronic stroke. For this systematic review, we searched PubMed, Cochrane, Physiotherapy Evidence Database(PEDro) and registers on International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov including all eligible articles. In the end, 8 articles were included. Three reviewers independently searched for randomized controlled trials (RCT) of VR intervention in patients with chronic stroke, including only studies where hand function rehabilitation was specifically targeted. In conclusion, VR used in rehabilitation for patients with chronic stroke improves several outcomes of hand function and may be considered as an addition to rehabilitation in routine use. Seven out of eight included studies had a high-quality score on PEDro scale. Future studies should focus on how the advantages of VR therapy for hand function can be sustained over a longer period.

Bimanual Movements and Chronic Stroke Rehabilitation: Looking Back and Looking Forward

Executing voluntary motor actions in the upper extremities after a stroke is frequently challenging and frustrating. Although spontaneous motor recovery can occur, reorganizing the activation of the primary motor cortex and supplementary motor area takes a considerable amount of time involving effective rehabilitation interventions. Based on motor control theory and experience-dependent neural plasticity, stroke protocols centered on bimanual movement coordination are generating considerable evidence in overcoming dysfunctional movements. Looking backward and forward in this comprehensive review, we discuss noteworthy upper extremity improvements reported in bimanual movement coordination studies including force generation. Importantly, the effectiveness of chronic stroke rehabilitation approaches that involve voluntary interlimb coordination principles look promising.

Changes in brain morphometry after motor rehabilitation in chronic stroke

Purpose Recent studies have revealed structural changes after motor rehabilitation, but its morphological changes related to upper limb motor behaviours have not been studied exhaustively. Therefore, we aimed to map the grey matter (GM) changes associated with motor rehabilitation after stroke using voxel-based morphometry (VBM), deformation-based morphometry (DBM), and surface-based morphometry (SBM). Methods Forty-one patients with chronic stroke received twelve sessions of low-frequency repetitive transcranial magnetic stimulation plus intensive occupational therapy. MRI data were obtained before and after the intervention. Fugl-Meyer Assessment and Wolf Motor Function Test-Functional Ability Scale were assessed at the two-time points. We performed VBM, DBM, and SBM analyses using T1-weighted images. A correlation analysis was performed between cortical thickness in motor areas and clinical outcomes. Results Clinical outcomes significantly improved after the intervention. VBM showed significant GM volume changes in ipsilesional and contralesional primary motor regions. DBM results demonstrated GM changes contralesionally and ipsilesionally after the intervention. SBM results showed significant cortical thickness changes in posterior visuomotor coordination, precentral, postcentral gyri of the ipsilesional hemisphere and contralesional visuomotor area after the intervention. A combination of threshold p < .05, False Discovery Rate and p < .001 (uncorrected) were considered significant. In addition, cortical thickness changes of the ipsilesional motor areas were significantly correlated with the clinical outcome changes. Conclusions We found GM structural changes in areas involved in motor, visuomotor and somatosensory functions after the intervention. Furthermore, our findings suggest that structural plasticity changes in chronic stroke could occur in the ipsilesional and contralesional hemispheres after motor rehabilitation.

Predicting Clinically Significant Improvement After Robot-Assisted Upper Limb Rehabilitation in Subacute and Chronic Stroke.

Prior studies examining predictors of favorable clinical outcomes after upper limb robot-assisted therapy (RT) have many shortcomings. Therefore, the aim of this study was to identify meaningful predictors and a prediction model for clinically significant motor improvement in upper limb impairment after RT for each stroke phase. This retrospective, single-center study enrolled patients with stroke who received RT using InMotion2 along with conventional therapy (CT) from January 2015 to September 2019. Demographic characteristics, clinical measures, and robotic kinematic measures were evaluated. The primary outcome measure was the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and we classified patients with improvement more than the minimal clinically important difference as responders for each stroke phase. Univariable and multivariable logistic regression analyses were performed to assess the relationship between potential predictors and RT responders and determine meaningful predictors. Subsequently, meaningful predictors were included in the final prediction model. One hundred forty-four patients were enrolled. The Hand Movement Scale and time since onset were significant predictors of clinically significant improvement in upper limb impairment (P = 0.045 and 0.043, respectively), as represented by the FMA-UE score after RT along with CT, in patients with subacute stroke. These variables were also meaningful predictors with borderline statistical significance in patients with chronic stroke (P = 0.076 and 0.066, respectively). Better hand movement and a shorter time since onset can be used as realistic predictors of clinically significant motor improvement in upper limb impairment after RT with InMotion2 alongside CT in patients with subacute and chronic stroke. This information may help healthcare professionals discern optimal patients for RT and accurately inform patients and caregivers about outcomes of RT.

Development of a Low-Cost, Modular Muscle-Computer Interface for At-Home Telerehabilitation for Chronic Stroke.

Stroke is a leading cause of long-term disability in the United States. Recent studies have shown that high doses of repeated task-specific practice can be effective at improving upper-limb function at the chronic stage. Providing at-home telerehabilitation services with therapist supervision may allow higher dose interventions targeted to this population. Additionally, muscle biofeedback to train patients to avoid unwanted simultaneous activation of antagonist muscles (co-contractions) may be incorporated into telerehabilitation technologies to improve motor control. Here, we present the development and feasibility of a low-cost, portable, telerehabilitation biofeedback system called Tele-REINVENT. We describe our modular electromyography acquisition, processing, and feedback algorithms to train differentiated muscle control during at-home therapist-guided sessions. Additionally, we evaluated the performance of low-cost sensors for our training task with two healthy individuals. Finally, we present the results of a case study with a stroke survivor who used the system for 40 sessions over 10 weeks of training. In line with our previous research, our results suggest that using low-cost sensors provides similar results to those using research-grade sensors for low forces during an isometric task. Our preliminary case study data with one patient with stroke also suggest that our system is feasible, safe, and enjoyable to use during 10 weeks of biofeedback training, and that improvements in differentiated muscle activity during volitional movement attempt may be induced during a 10-week period. Our data provide support for using low-cost technology for individuated muscle training to reduce unintended coactivation during supervised and unsupervised home-based telerehabilitation for clinical populations, and suggest this approach is safe and feasible. Future work with larger study populations may expand on the development of meaningful and personalized chronic stroke rehabilitation.

Wearable vibrotactile stimulation for upper extremity rehabilitation in chronic stroke: clinical feasibility trial using the VTS Glove

ObjectiveEvaluate the feasibility and potential impacts on hand function using a wearable stimulation device (the VTS Glove) which provides mechanical, vibratory input to the affected limb of chronic stroke survivors.MethodsA double-blind, randomized, controlled feasibility study including sixteen chronic stroke survivors (mean age: 54; 1-13 years post-stroke) with diminished movement and tactile perception in their affected hand. Participants were given a wearable device to take home and asked to wear it for three hours daily over eight weeks. The device intervention was either (1) the VTS Glove, which provided vibrotactile stimulation to the hand, or (2) an identical glove with vibration disabled. Participants were randomly assigned to each condition. Hand and arm function were measured weekly at home and in local physical therapy clinics.ResultsParticipants using the VTS Glove showed significantly improved Semmes-Weinstein monofilament exam results, reduction in Modified Ashworth measures in the fingers, and some increased voluntary finger flexion, elbow and shoulder range of motion.ConclusionsVibrotactile stimulation applied to the disabled limb may impact tactile perception, tone and spasticity, and voluntary range of motion. Wearable devices allow extended application and study of stimulation methods outside of a clinical setting.

Commercial head-mounted display virtual reality for upper extremity rehabilitation in chronic stroke: a single-case design study

BackgroundRehabilitation is crucial for maximizing recovery after stroke. Rehabilitation activities that are fun and rewarding by themselves can be more effective than those who are not. Gamification with virtual reality (VR) exploits this principle. This single-case design study probes the potential for using commercial off-the-shelf, room-scale head-mounted virtual reality for upper extremity rehabilitation in individuals with chronic stroke, the insights of which can inform further research.MethodsA heterogeneous volunteer sample of seven participants living with stroke were recruited through advertisement. A single-case design was employed with a 5-week baseline (A), followed by a 10-week intervention (B) and a 6-month follow-up. Upper extremity motor function was assessed with validated kinematic analysis of drinking task. Activity capacity was assessed with Action Research Arm Test, Box and Block Test and ABILHAND questionnaire. Assessments were done weekly and at follow-up. Playing games on a VR-system with head-mounted display (HTC Vive) was used as rehabilitation intervention. Approximately 300 games were screened and 6 tested. Visual analysis and Tau-U statistics were used to interpret the results.ResultsVisual analysis of trend, level shift and overlap as well as Tau-U statistics indicated improvement of Action Research Arm Test in six participants. Four of these had at least a moderate Tau-U score (0.50–0.92), in at least half of the assessed outcomes. These four participants trained a total of 361 to 935 min. Two out of four participants who were able to perform the drinking task, had the highest training dose (> 900 min) and showed also improvements in kinematics. The predominant game played was Beat Saber. No serious adverse effects related to the study were observed, one participant interrupted the intervention phase due to a fall at home.ConclusionsThis first study of combining commercial games, a commercial head-mounted VR, and commercial haptic hand controls, showed promising results for upper extremity rehabilitation in individuals with chronic stroke. By being affordable yet having high production values, as well as being an easily accessible off-the-shelf product, this variant of VR technology might facilitate widespread adaption. Insights garnered in this study can facilitate the execution of future studies.Trial registration The study was registered at researchweb.org (project number 262331, registered 2019-01-30, https://www.researchweb.org/is/vgr/project/262331) prior to participant enrolment.