Motor Rehabilitation Of Stroke Patients Research Articles

Challenges of neural interfaces for stroke motor rehabilitation.

More than 85% of stroke survivors suffer from different degrees of disability for the rest of their lives. They will require support that can vary from occasional to full time assistance. These conditions are also associated to an enormous economic impact for their families and health care systems. Current rehabilitation treatments have limited efficacy and their long-term effect is controversial. Here we review different challenges related to the design and development of neural interfaces for rehabilitative purposes. We analyze current bibliographic evidence of the effect of neuro-feedback in functional motor rehabilitation of stroke patients. We highlight the potential of these systems to reconnect brain and muscles. We also describe all aspects that should be taken into account to restore motor control. Our aim with this work is to help researchers designing interfaces that demonstrate and validate neuromodulation strategies to enforce a contingent and functional neural linkage between the central and the peripheral nervous system. We thus give clues to design systems that can improve or/and re-activate neuroplastic mechanisms and open a new recovery window for stroke patients.

A novel immersive virtual reality environment for the motor rehabilitation of stroke patients: A feasibility study.

We designed and implemented an immersive virtual reality (VR) environment for upper limb rehabilitation, which possesses several notable features. First, by exploiting modern computer graphics its can present a variety of scenarios that make the rehabilitation routines challenging yet enjoyable for patients, thus enhancing their adherence to the therapy. Second, immersion in a virtual 3D space allows the patients to execute tasks that are closely related to everyday gestures, thus enhancing the transfer of the acquired motor skills to real-life routines. Third, in addition to the VR environment, we also developed a client app running on a PC that allows to monitor in real-time and remotely the patients’ routines thus paving the way for telerehabilitation scenarios. Here, we report the results of a feasibility study in a cohort of 16 stroke patients. All our patients showed a high degree of comfort in our immersive VR system and they reported very high scores of ownership and agency in embodiment and satisfaction questionnaires. Furthermore, and notably, we found that behavioral performances in our VR tasks correlated with the patients’ clinical scores (Fugl-Meyer scale) and they could thus be used to assess improvements during the rehabilitation program. While further studies are needed, our results clearly support the feasibility and effectiveness of VR-based motor rehabilitation processes.

Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery.

Stroke, including hemorrhagic and ischemic stroke, refers to the blood supply disorder in the local brain tissue for various reasons (aneurysm, occlusion, etc.). It leads to regional brain circulation imbalance, neurological complications, limb motor dysfunction, aphasia, and depression. As the second-leading cause of death worldwide, stroke poses a significant threat to human life characterized by high mortality, disability, and recurrence. Therefore, the clinician has to care about the symptoms of stroke patients in the acute stage and formulate an effective postoperative rehabilitation plan to facilitate the recovery in patients. We summarize a novel application and update of the rehabilitation therapy in limb motor rehabilitation of stroke patients to provide a potential future stroke rehabilitation strategy.

Medidas de erros durante jogos de dardos virtual e real em pacientes com Acidente Vascular Cerebral: implicações para reabilitação neurológica

Objetivo: Realizar uma análise comparativa de medidas de erros após o treino com jogos de dardos virtual e real. Metodologia: Participaram do estudo 15 pacientes com Acidente Vascular Cerebral (AVC) (10 homens) e 12 indivíduos saudáveis (7 homens). O jogo virtual utilizado foi o Kinect Sports do Xbox 360 Kinect®. Os participantes realizaram 15 tentativas em cada jogo. Foram calculados os erros absoluto (EA), constante (EC) e variável (EV). Os dados foram analisados pela ANOVA. Resultados: Quanto ao EA observou-se diferença significativa entre os pacientes e saudáveis no jogo virtual (p=0,003) e no jogo real (p= 0,0001). Também houve diferença do EA entre os jogos virtual e real para os pacientes (p= 0,0001). No EC não foi encontrada diferença significativa entre pacientes e saudáveis no jogo virtual (p=0,355) e no jogo real (p= 0,544). Também não houve diferença do EC entre os jogos virtual e real para os pacientes (p= 0,452). Pela análise do EV não foi verificada diferença significativa entre pacientes e saudáveis no jogo virtual (p=0,406), mas houve no jogo real (p= 0,0001). Não houve diferença significativa do EV entre os jogos virtual e real para os pacientes (p= 0,579). Conclusão: Os resultados encontrados indicaram que os pacientes tiveram menor precisão, maior consistência de erros e menor variabilidade do desempenho. O jogo virtual proporcionou melhores resultados para os pacientes em comparação ao jogo real, o que pode ser de significativa importância para o planejamento da reabilitação motora dos pacientes com AVC.

Effects induced by motor cortex anodal transcranial direct current stimulation on wrist muscles in stroke patients

Transcranial direct current stimulation is used to modify noninvasively cortical brain excitability in humans. It consists in delivering a weak current trough two electrodes: one applied over the motor cortex and a second in supra-orbital position. Recently we showed in healthy subjects that anodal tDCS applied over the motor cortex can be used to modify descending inputs relayed by corticospinal tract on reciprocal inhibition pathways innervating wrist muscles [1] . We found that effects induced by anodal tDCS in wrist extensors and in wrist flexors are opposite: tDCS increases reciprocal inhibition in extensors but decreases reciprocal inhibition in flexors. It appears that modulations induced by anodal tDCS on reciprocal inhibition pathways favor the contraction in wrist extensors. Motor deficit in wrist extensors is usual in hemiplegic patients and the aim of this study is to combine spinal cord MRI and electrophysiological methods to explore effects of tDCS at wrist level in patients with impaired wrist motor control. Anodal tDCS is applied over the non-lesional hemisphere (ipsilateral motor cortex). Its effects at spinal level are explored using electrophysiological techniques based on EMG recordings and percutaneous stimulations of peripheral nerves to elicit reciprocal inhibition at wrist level. MRI study relies on diffusion tensor imaging (DTI) and magnetization transfer (MT) [2] . Preliminary results in hemiplegic patients suggest an increase of reciprocal inhibition contrary to the results found in healthy subjects. They also show a relationship between motor impairment and MRI metrics. It opens new vista for motor rehabilitation of stroke patients.

A hybrid brain-machine interface based on EEG and EMG activity for the motor rehabilitation of stroke patients.

Including supplementary information from the brain or other body parts in the control of brain-machine interfaces (BMIs) has been recently proposed and investigated. Such enriched interfaces are referred to as hybrid BMIs (hBMIs) and have been proven to be more robust and accurate than regular BMIs for assistive and rehabilitative applications. Electromyographic (EMG) activity is one of the most widely utilized biosignals in hBMIs, as it provides a quite direct measurement of the motion intention of the user. Whereas most of the existing non-invasive EEG-EMG-hBMIs have only been subjected to offline testings or are limited to one degree of freedom (DoF), we present an EEG-EMG-hBMI that allows the simultaneous control of 7-DoFs of the upper limb with a robotic exoskeleton. Moreover, it establishes a biologically-inspired hierarchical control flow, requiring the active participation of central and peripheral structures of the nervous system. Contingent visual and proprioceptive feedback about the user's EEG and EMG activity is provided in the form of velocity modulation during functional task training. We believe that training with this closed-loop system may facilitate functional neuroplastic processes and eventually elicit a joint brain and muscle motor rehabilitation. Its usability is validated during a real-time operation session in a healthy participant and a chronic stroke patient, showing encouraging results for its application to a clinical rehabilitation scenario.

Rhythmic Auditory Cueing in Motor Rehabilitation for Stroke Patients: Systematic Review and Meta-Analysis.

Given the increasing evidence demonstrating the effects of rhythmic auditory cueing for motor rehabilitation of stroke patients, this synthesized analysis is needed in order to improve rehabilitative practice and maximize clinical effectiveness. This study aimed to systematically analyze the literature on rhythmic auditory cueing for motor rehabilitation of stroke patients by highlighting the outcome variables, type of cueing, and stage of stroke. A systematic review with meta-analysis of randomized controlled or clinically controlled trials was conducted. Electronic databases and music therapy journals were searched for studies including stroke, the use of rhythmic auditory cueing, and motor outcomes, such as gait and upper-extremity function. A total of 10 studies (RCT or CCT) with 356 individuals were included for meta-analysis. There were large effect sizes (Hedges's g = 0.984 for walking velocity; Hedges's g = 0.840 for cadence; Hedges's g = 0.760 for stride length; and Hedges's g = 0.456 for Fugl-Meyer test scores) in the use of rhythmic auditory cueing. Additional subgroup analysis demonstrated that although the type of rhythmic cueing and stage of stroke did not lead to statistically substantial group differences, the effect sizes and heterogeneity values in each subgroup implied possible differences in treatment effect. This study corroborates the beneficial effects of rhythmic auditory cueing, supporting its expanded application to broadened areas of rehabilitation for stroke patients. Also, it suggests the future investigation of the differential outcomes depending on how rhythmic auditory cueing is provided in terms of type and intensity implemented.

Use of inertial sensors as devices for upper limb motor monitoring exercises for motor rehabilitation

This paper presents the development of a system that uses inertial sensors, wireless transceivers and virtual models to monitor the exercises of motor rehabilitation of the upper limbs based on Kabat’s method. This method involves performing rehabilitation complex exercises that cannot be easily reproduced by the patient, requiring permanent assistance of a qualified professional. However, it is very expensive to have a professional expert assisting the patient throughout the treatment. Therefore, the development of technologies to monitor this type of exercise is necessary. The Kabat’s method has several applications, e.g. in motor rehabilitation of stroke patients. Stroke is considered the second most common cardiovascular disorder and affects about 9.6 million people in Europe alone, and an estimated 6 million people worldwide die from this disorder. Also, the natural aging process increases the number of strokes, and the demand for healthcare and motor rehabilitation services. To minimize this problem, we propose an experimental system consisting of inertial sensors, wireless transceivers and virtual models according to the models of Denavit & Hartenberg and Euler Angles & Tait Bryan. Through inertial sensors, this system can characterize the movement performed by the patient, compare it with a predefined motion and then indicate if the motor system performed the correct movement. The patients monitor their own movements and the movement pattern (correct movement). All movements are stored in a database allowing continuous checking by a qualified professional. Several experimental tests have shown that the average system error was 0.97°, which is suitable to the proposed system.

Music-supported therapy (MST) in improving post-stroke patients' upper-limb motor function: a randomised controlled pilot study

Objective:Music-supported therapy (MST) is a new approach for motor rehabilitation of stroke patients. Recently, many studies have demonstrated that MST improved the motor functions of post-stroke patients. However, the underlying mechanism for this effect is still unclear. It may result from repeated practice or repeated practice combined with musical stimulation. Currently, few studies have been designed to clarify this discrepancy. In this study, the application of “mute” musical instruments allowed for the study of music as an independent factor.Methods:Thirty-three post-stroke patients with no substantial previous musical training were included. Participants were assigned to either audible music group (MG) or mute music group (CG), permitting observation of music's independent effect. All subjects received the conventional rehabilitation treatments. Patients in MG (n = 15) received 20 extra sessions of audible musical instrument training over 4 weeks. Patients in CG (n = 18) received “mute” musical instrument training of the same protocol as that of MG. Wolf motor function test (WMFT) and Fugl—Meyer assessment (FMA) for upper limbs were utilised to evaluate motor functions of patients in both groups before and after the treatment. Three patients in CG dropped out.Results:All participants in both groups showed significant improvements in motor functions of upper limbs after 4 weeks' treatment. However, significant differences in the WMFT were found between the two groups (WMFT-quality: P = 0.025; WMFT-time: P = 0.037), but not in the FMA (P = 0.448). In short, all participants showed significant improvement after 4 weeks' treatment, but subjects in MG demonstrated greater improvement than those in CG.Discussion:This study supports that MST, when combined with conventional treatment, is effective for the recovery of motor skills in post-stroke patients. Additionally, it suggests that apart from the repetitive practices of MST, music may play a unique role in improving upper-limb motor function for post-stroke patients.

An approach to improve the performance of subject-independent BCIs-based on motor imagery allocating subjects by gender.

BackgroundOne of the difficulties for the implementation of Brain-Computer Interface (BCI) systems for motor impaired patients is the time consumed in the system design process, since patients do not have the adequate physical nor psychological conditions to complete the process. For this reason most of BCIs are designed in a subject-dependent approach using data of healthy subjects. The developing of subject-independent systems is an option to decrease the required training sessions to design a BCI with patient functionality. This paper presents a proof-of-concept study to evaluate subject-independent system based on hand motor imagery taking gender into account.MethodsSubject-Independent BCIs are proposed using Common Spatial Patterns and log variance features of two groups of healthy subjects; one of the groups was composed by people of male gender and the other one by people of female gender. The performance of the developed gender-specific BCI designs was evaluated with respect to a subject-independent BCI designed without taking gender into account, and afterwards its performance was evaluated with data of two healthy subjects that were not included in the initial sample. As an additional test to probe the potential use for subcortical stroke patients we applied the methodology to two patients with right hand weakness. T-test was employed to determine the significance of the difference between traditional approach and the proposed gender-specific approach.ResultsFor most of the tested conditions, the gender-specific BCIs have a statistically significant better performance than those that did not take gender into account. It was also observed that with a BCI designed with log-variance features in the alpha and beta band of healthy subjects’ data, it was possible to classify hand motor imagery of subcortical stroke patients above the practical level of chance.ConclusionsA larger subjects’ sample test may be necessary to improve the performances of the gender-specific BCIs and to further test this methodology on different patients. The reduction of complexity in the implementation of BCI systems could bring these systems closer to applications such as controlling devices for the motor rehabilitation of stroke patients, and therefore, contribute to a more effective neurological rehabilitation.

Upper-limb robot-assisted therapy in rehabilitation of acute stroke patients: Focused review and results of new randomized controlled trial

The successful motor rehabilitation of stroke patients requires early intensive and task-specific therapy. A recent Cochrane Review, although based on a limited number of randomized controlled trials (RCTs), showed that early robotic training of the upper limb (i.e., during acute or subacute phase) can enhance motor learning and improve functional abilities more than chronic-phase training. In this article, a new subacute-phase RCT with the Neuro-Rehabilitation-roBot (NeReBot) is presented. While in our first study we used the NeReBot in addition to conventional therapy, in this new trial we used the same device in substitution of standard proximal upper-limb rehabilitation. With this protocol, robot patients achieved similar reductions in motor impairment and enhancements in paretic upper-limb function to those gained by patients in a control group. By analyzing these results and those of previous studies, we hypothesize a new robotic protocol for acute and subacute stroke patients based on both treatment modalities (in addition and in substitution).

Amplifier design for EMG recording from stimulation electrodes during functional electrical stimulation leg cycling ergometry

Functional electrical stimulation leg cycle ergometry (FES-LCE), which is often used as exercise for people with spinal cord injury (SCI), has recently been applied in the motor rehabilitation of stroke patients. Recently completed studies show controversial results, but with a tendency to positive training effects. Current technology is identical to that used in FES-LCE for SCI, whereas the pathology of stroke differs strongly. Most stroke patients with hemiparesis are able to drive an ergometer independently. Depending on the degree of spasticity, the paretic leg will partially support or hinder movements. Electrical stimulation increases muscle force and endurance and both are prerequisites for restoring gait. However, the effect of FES-LCE on improving impaired motor coordination is unclear. To measure motor coordination during FES-LCE, an EMG-amplifier design has been investigated which suppresses stimulation artifacts and allows detection of volitional or reflex induced muscle activity. Direct measurement of EMG from stimulation electrodes between stimulation pulses is an important asset of this amplifier. Photo-MOS switches in front of the preamplifier are utilized to achieve this. The technology presented here can be used to monitor the effects of FES-LCE to adapt the stimulation strategy or to realize EMG-biofeedback training.

A benchmarked automated progress measurement system for haptic motor rehabilitation

As Haptic devices become more affordable and economical, research in Haptic-based virtual rehabilitation systems is gaining more interest. In addition to the benefits provided by virtual rehabilitation, Haptics offer force and tactile feedback which can be crucial for much upper and lower extremity rehabilitation. In this paper, we present such a system that provides a rich media environment for motor rehabilitation of stroke patients. The system can be used by Occupational Therapists (OTs) to measure and monitor the progress of rehab patients. This is an expanded version of a paper presented at the 3rd IEEE International Workshop on Medical Measurements and Applications, 9 10 May 2008, Ottawa, ON, Canada.

Robot-aided intensive training in post-stroke recovery

The successful motor rehabilitation of stroke patients requires an intensive and task-specific therapy approach. The plasticity of the adult human brain provides opportunities to enhance traditional rehabilitation programs for these individuals. Intensive robot-aided sensorimotor training may have a positive effect on reducing impairment and disability and increasing reorganization of the adult brain. This approach may therefore efficaciously complement standard post-stroke multidisciplinary programs as shown by recent experimental trials.

Motor Rehabilitation of Stroke Patients

Weiterbildungsziele In diesem Beitrag sollen folgende Weiterbildungsziele vermittelt werden: Neurophysiologische Grundlagen motorischer Rehabilitation Evidenzbasierte therapeutische Interventionen Kerninhalte übender Verfahren Einsatz zusätzlicher Therapieoptionen (technische Geräte, Medikamente)