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Beovich A, Boose J, Patel R, Wolf SL. Vagus Nerve Stimulation Paired With Rehabilitation for Chronic Stroke: Characterizing Responders. J Neurol Phys Ther 2024:01253086-990000000-00072. [PMID: 39028576 DOI: 10.1097/npt.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
BACKGROUND AND PURPOSE Implantable vagus nerve stimulation (VNS) paired with volitional upper extremity rehabilitation can improve impairment and function among moderately to severely impaired, chronic stroke survivors. This study is a retrospective analysis of the in-clinic rehabilitation phase of the blinded, placebo-controlled, randomized pivotal VNS-REHAB trial to determine whether dosing parameters during in-clinic paired VNS therapy were associated with responder status and whether covariates might impact that determination. METHODS Data were limited to 53 participants in the active VNS group who had received VNS implants prior to undergoing 6 weeks of in-clinic rehabilitation paired with VNS. Tasks were standardized across all participants. Dosing parameters included number of stimulations and task time. The primary outcome was the Fugl-Meyer Upper Extremity Assessment (FMA-UE), evaluated at the end of 6 weeks (Post-1). Participants were classified a priori as responders based on an improvement of ≥6 points on the FMA-UE from baseline to Post-1. RESULTS Dosing parameters were not associated with FMA-UE responder status at the end of 6 weeks. Covariates including age, gender, paretic hand, baseline severity, and chronicity of stroke were also not significant associations of response. DISCUSSION AND CONCLUSIONS While responders to VNS could be defined, therapy dosing and participant attributes did not provide greater specification for association of responder status. Limitations of this study include small sample size and non-linearity of the FMA-UE. Future studies will include reassessing responder categorization using more linear scales and examining stroke lesion characteristics to determine whether these measures are more sensitive to dosing parameters. VIDEO ABSTRACT AVAILABLE for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://www.w3.org/1999/xlink).
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Affiliation(s)
- Alexa Beovich
- Emory Neurologic Physical Therapy Residency Program (A.B., R.P.), Doctor of Physical Therapy Program, Department of Rehabilitation Medicine (J.B.), Emory University, Atlanta, Georgia; Division of Physical Therapy, Department of Rehabilitation Medicine (S.L.W.), Emory University, School of Medicine, Atlanta, Georgia; Departments of Cell Biology and Medicine (S.L.W.), Woodruff School of Nursing, Emory University, Atlanta, Georgia; Atlanta VA Center for Visual and Neurocognitive Rehabilitation (S.L.W.), Decatur, Georgia
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McGregor KM, Novak T, Nocera JR, Mammino K, Wolf SL, Krishnamurthy LC. Examination of acute spin exercise on GABA levels in aging and stroke: The EASE study protocol. PLoS One 2024; 19:e0297841. [PMID: 39008457 PMCID: PMC11249249 DOI: 10.1371/journal.pone.0297841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 01/08/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Changes in regional levels of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) may indicate the potential for favorable responses to the treatment of stroke affecting the upper extremity. By selectively altering GABA levels during training, we may induce long-term potentiation and adjust excitatory/inhibitory balance (E/I balance). However, the impact of this alteration may be limited by neural damage or aging. Aerobic exercise has been shown to increase GABA levels in the sensorimotor cortex and improve motor learning by widening the dynamic range of E/I balance. The cross-sectional project, Effects of Acute Exercise on Functional Magnetic Resonance Spectroscopy Measures of GABA in Aging and Chronic Stroke (EASE), is designed to assess the functional relevance of changes in GABA concentration within the sensorimotor cortex before and after an acute aerobic exercise session. METHODS/DESIGN EASE will enroll 30 participants comprised of healthy younger adults (18-35 years; n = 10), older adults (60+ years; n = 10), and persons with chronic stroke (n = 10) affecting distal upper extremity function. We will use resting magnetic resonance spectroscopy to measure all participants' GABA levels at rest before and after aerobic exercise. In addition, we will employ functional magnetic resonance spectroscopy using motor skill acquisition and recall tasks in healthy adults. We hypothesize that acute aerobic exercise will increase resting sensorimotor GABA concentration and that higher GABA resting levels will predict better motor learning performance on measures taken both inside and outside the magnet. We also hypothesize that a higher dynamic range of GABA during task-based spectroscopy in healthy adults will predict better motor skill acquisition and recall. DISCUSSION The EASE project will evaluate the effect of acute exercise on GABA levels as a biomarker of upper extremity motor skill learning with two populations (aging adults and those with chronic stroke). We predict that acute exercise, higher sensorimotor GABA levels, and broader dynamic range will be related to better motor skill acquisition.
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Affiliation(s)
- Keith M. McGregor
- Birmingham VA Geriatric Research Education and Clinical Center, Birmingham VA Health Care System, Birmingham, Alabama, United States of America
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham School of Health Professions, Birmingham, Alabama, United States of America
| | - Thomas Novak
- Rehabilitation R&D Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, Atlanta, Georgia, United States of America
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Joe R. Nocera
- Rehabilitation R&D Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, Atlanta, Georgia, United States of America
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Kevin Mammino
- Rehabilitation R&D Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, Atlanta, Georgia, United States of America
| | - Steven L. Wolf
- Rehabilitation R&D Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, Atlanta, Georgia, United States of America
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Cell Biology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Lisa C. Krishnamurthy
- Atlanta VA Health Care System, Decatur, Georgia, United States of America
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State, Georgia Tech and Emory, Atlanta, Georgia, United States of America
- Department of Physics & Astronomy, Georgia State University, Atlanta, Georgia, United States of America
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, United States of America
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Gopalakrishnan R, Cunningham DA, Hogue O, Schroedel M, Campbell BA, Baker KB, Machado AG. Electrophysiological Correlates of Dentate Nucleus Deep Brain Stimulation for Poststroke Motor Recovery. J Neurosci 2024; 44:e2149232024. [PMID: 38724284 PMCID: PMC11223455 DOI: 10.1523/jneurosci.2149-23.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 07/05/2024] Open
Abstract
While ipsilesional cortical electroencephalography has been associated with poststroke recovery mechanisms and outcomes, the role of the cerebellum and its interaction with the ipsilesional cortex is still largely unknown. We have previously shown that poststroke motor control relies on increased corticocerebellar coherence (CCC) in the low beta band to maintain motor task accuracy and to compensate for decreased excitability of the ipsilesional cortex. We now extend our work to investigate corticocerebellar network changes associated with chronic stimulation of the dentato-thalamo-cortical pathway aimed at promoting poststroke motor rehabilitation. We investigated the excitability of the ipsilesional cortex, the dentate (DN), and their interaction as a function of treatment outcome measures. Relative to baseline, 10 human participants (two women) at the end of 4-8 months of DN deep brain stimulation (DBS) showed (1) significantly improved motor control indexed by computerized motor tasks; (2) significant increase in ipsilesional premotor cortex event-related desynchronization that correlated with improvements in motor function; and (3) significant decrease in CCC, including causal interactions between the DN and ipsilesional cortex, which also correlated with motor function improvements. Furthermore, we show that the functional state of the DN in the poststroke state and its connectivity with the ipsilesional cortex were predictive of motor outcomes associated with DN-DBS. The findings suggest that as participants recovered, the ipsilesional cortex became more involved in motor control, with less demand on the cerebellum to support task planning and execution. Our data provide unique mechanistic insights into the functional state of corticocerebellar-cortical network after stroke and its modulation by DN-DBS.
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Affiliation(s)
- Raghavan Gopalakrishnan
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Cleveland FES Center, Cleveland, Ohio 44106
| | - David A Cunningham
- Cleveland FES Center, Cleveland, Ohio 44106
- Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106
- Center for Rehabilitation Research, MetroHealth Systems, Cleveland, Ohio 44109
| | - Olivia Hogue
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Madeleine Schroedel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Brett A Campbell
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Kenneth B Baker
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
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Mbalilaki JA, Lilleheie I, Rimehaug SA, Tveitan SN, Linnestad AM, Krøll P, Lundberg S, Molle M, Moore JL. Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study. J Clin Med 2024; 13:3708. [PMID: 38999274 PMCID: PMC11242475 DOI: 10.3390/jcm13133708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 07/14/2024] Open
Abstract
(1) Background: High-intensity gait training (HIT) is a recommended intervention that improves walking function (e.g., speed and distance) in individuals who are undergoing stroke rehabilitation. This study explored clinicians' perceived barriers and facilitators to implementing HIT utilizing a mixed-methods approach comprising a survey and exploratory qualitative research. (2) Methods: Clinicians (n = 13) who were implementing HIT at three facilities participated. We collected and analyzed data using the consolidated framework for implementation research. Three focus groups were recorded and transcribed, and data were coded and thematically categorized. (3) Results: Survey results identified that the facilitators with a strong impact on implementation were access to knowledge/resources and intervention knowledge/beliefs. The only agreed-upon barrier with a strong impact was lack of tension for change. The focus groups resulted in 87 quotes that were coded into 27 constructs. Frequently cited outer setting facilitators were cosmopolitanism and peer pressure, and the only barrier was related to the patient needs. Innovation characteristics that were facilitators included relative advantage and design quality and packaging, and complexity was a barrier. Inner setting facilitators included networks and communication, learning climate, leadership engagement, and readiness for implementation. However, communication, leadership engagement, and available resources were also barriers. Regarding characteristics of individuals, knowledge and beliefs were both barriers and facilitators. In the implementation process domain, common facilitators were formally appointed implementation leaders and innovation participants. Barriers in this domain were related to the patients. (4) Conclusions: Clinicians identified many barriers and facilitators to implementing HIT that often varied between facilities. Further research is warranted to deepen our understanding of clinicians' experiences with HIT implementation.
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Affiliation(s)
- Julia Aneth Mbalilaki
- Regional Rehabilitation Knowledge Center, Sunnaas Rehabilitation Hospital, 1453 Nesodden, Norway; (J.A.M.); (I.L.); (S.A.R.); (S.N.T.); (A.-M.L.)
| | - Ingvild Lilleheie
- Regional Rehabilitation Knowledge Center, Sunnaas Rehabilitation Hospital, 1453 Nesodden, Norway; (J.A.M.); (I.L.); (S.A.R.); (S.N.T.); (A.-M.L.)
- Department of Nursing and Health Sciences, University of South-Eastern Norway, 3045 Drammen, Norway
| | - Stein A. Rimehaug
- Regional Rehabilitation Knowledge Center, Sunnaas Rehabilitation Hospital, 1453 Nesodden, Norway; (J.A.M.); (I.L.); (S.A.R.); (S.N.T.); (A.-M.L.)
| | - Siri N. Tveitan
- Regional Rehabilitation Knowledge Center, Sunnaas Rehabilitation Hospital, 1453 Nesodden, Norway; (J.A.M.); (I.L.); (S.A.R.); (S.N.T.); (A.-M.L.)
| | - Anne-Margrethe Linnestad
- Regional Rehabilitation Knowledge Center, Sunnaas Rehabilitation Hospital, 1453 Nesodden, Norway; (J.A.M.); (I.L.); (S.A.R.); (S.N.T.); (A.-M.L.)
| | - Pia Krøll
- Skogli Health and Rehabilitation Center, 2614 Lillehammer, Norway;
| | - Simen Lundberg
- Division of Physical Medicine and Rehabilitation, Vestfold Hospital, 3103 Tønsberg, Norway;
| | | | - Jennifer L. Moore
- Regional Rehabilitation Knowledge Center, Sunnaas Rehabilitation Hospital, 1453 Nesodden, Norway; (J.A.M.); (I.L.); (S.A.R.); (S.N.T.); (A.-M.L.)
- Institute for Knowledge Translation, Carmel, IN 46082, USA
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Lin S, Rodriguez CO, Wolf SL. Vagus Nerve Stimulation Paired With Upper Extremity Rehabilitation for Chronic Ischemic Stroke: Contribution of Dosage Parameters. Neurorehabil Neural Repair 2024:15459683241258769. [PMID: 38836606 DOI: 10.1177/15459683241258769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) combined with rehabilitation is a Food and Drug Administration approved intervention for moderate to severe upper extremity deficits in chronic ischemic stroke patients. Previous studies demonstrated that VNS improves upper extremity motor impairments, using the Fugl Meyer Assessment of Upper Extremity (FMA-UE); however, delineating where these improvements occur, and the role of VNS dosage parameters were not reported. OBJECTIVE This study explored the relationship between dosing (time over which task repetitions were executed and number of VNS stimulations) and changes within proximal and distal components of the FMA-UE. METHODS Participants underwent VNS implantation, with 1 group receiving VNS paired with rehabilitation (Active VNS) and the other group receiving rehabilitation with sham stimulation (Controls). Both groups received 6 weeks of in-clinic therapy followed by a 90-day at-home, self-rehabilitation program. Participants who completed at least 12 of 18 in-clinic sessions were included in the analyses (n = l06). Pearson correlations and analysis of covariance were used to investigate the relationship between dosing and FMA-UE outcome change along with the effect of covariates including baseline severity, time since stroke, age, and paretic side. RESULTS Compared to Controls, active VNS favorably influenced distal function with sustained improvement after the home program. Significant improvements were observed in only distal components (FMdist) at both post day-1 (1.80 points, 95% Cl [0.85, 2.73], P < .001) and post-day 90 (1.62 points, 95% CI [0.45, 2.80], P < .007). CONCLUSIONS VNS paired with rehabilitation resulted in significant improvements in wrist and hand impairment compared to Controls, despite similar in-clinic dosing across both groups.NCT03131960.
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Affiliation(s)
- Shiyu Lin
- Department of Rehabilitation Medicine, Division of Physical Therapy, Center for Movement Science and Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA
| | - Chelsea O Rodriguez
- Department of Rehabilitation Medicine, Division of Physical Therapy, Center for Movement Science and Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven L Wolf
- Department of Rehabilitation Medicine, Division of Physical Therapy, Center for Movement Science and Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Cell Biology, Emory University School of Medicine, Atlanta, GA, USA
- Senior Research Scientist, Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care Center, Decatur, GA, USA
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Vora I, Gochyyev P, Engineer N, Wolf SL, Kimberley TJ. Distal Versus Proximal Arm Improvement After Paired Vagus Nerve Stimulation Therapy After Chronic Stroke. Arch Phys Med Rehabil 2024:S0003-9993(24)01014-1. [PMID: 38815953 DOI: 10.1016/j.apmr.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To evaluate differences in upper-extremity (UE) segment-specific (proximal or distal segment) recovery after vagus nerve stimulation (VNS) paired with UE rehabilitation (Paired-VNS) compared with rehabilitation with sham-VNS (Control). We also assessed whether gains in specific UE segments predicted clinically meaningful improvement. DESIGN This study reports on a secondary analysis of Vagus nerve stimulation paired with rehabilitation for UE motor function after chronic ischemic stroke (VNS-REHAB), a randomized, triple-blinded, sham-controlled pivotal trial. A Rasch latent regression was used to determine differences between Paired-VNS and Controls for distal and proximal UE changes after in-clinic therapy and 3 months later. Subsequently, we ran a random forest model to assess candidate predictors of meaningful improvement. Each item of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Wolf Motor Function Test (WMFT) was evaluated as a predictor of response to treatment. SETTING Nineteen stroke rehabilitation centers in the USA and UK. PARTICIPANTS Dataset included 108 participants (N=108) with chronic ischemic stroke and moderate-to-severe UE impairments. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FMA-UE and WMFT. RESULTS Distal UE improvement was significantly greater in the Paired-VNS group than in Controls immediately after therapy (95% confidence interval, 0.27-0.73; P≤.001) and after 3 months (95% confidence interval, 0.16-0.75; P=.003). Both groups showed similar improvement in proximal UE at both time points. A subset of both distal and proximal items from the FMA-UE and WMFT were predictors of meaningful improvement. CONCLUSIONS Paired-VNS improved distal UE impairment in chronic stroke to a greater degree than intensive rehabilitation alone. Proximal improvements were equally responsive to either treatment. Given that meaningful UE recovery is predicted by improvements across both proximal and distal segments, Paired-VNS may facilitate improvement that is otherwise elusive.
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Affiliation(s)
- Isha Vora
- Department of Rehabilitation Science, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA
| | - Perman Gochyyev
- Department of Rehabilitation Science, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA; Berkeley Evaluation and Assessment Research Center, University of California, Berkeley, Berkeley, CA
| | | | - Steven L Wolf
- Division of Physical Therapy, Center for Physical Therapy and Movement Science, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA
| | - Teresa J Kimberley
- Department of Rehabilitation Science, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA; Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA.
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Langerak AJ, Regterschot GRH, Selles RW, Meskers CGM, Evers M, Ribbers GM, van Beijnum BJF, Bussmann JBJ. Requirements for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients: a user-centred approach. Disabil Rehabil Assist Technol 2024; 19:1392-1404. [PMID: 36905631 PMCID: PMC11073044 DOI: 10.1080/17483107.2023.2183993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/17/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE Telerehabilitation systems have the potential to enable therapists to monitor and assist stroke patients in achieving high-intensity upper extremity exercise in the home environment. We adopted an iterative user-centred approach, including multiple data sources and meetings with end-users and stakeholders to define the user requirements for home-based upper extremity rehabilitation using wearable motion sensors for subacute stroke patients. METHODS We performed a requirement analysis consisting of the following steps: 1) context & groundwork; 2) eliciting requirements; 3) modelling & analysis; 4) agreeing requirements. During these steps, a pragmatic literature search, interviews and focus groups with stroke patients, physiotherapists and occupational therapists were performed. The results were systematically analysed and prioritised into "must-haves", "should-haves", and "could-haves". RESULTS We formulated 33 functional requirements: eighteen must-have requirements related to blended care (2), exercise principles (7), exercise delivery (3), exercise evaluation (4), and usability (2); ten should-haves; and five could-haves. Six movement components, including twelve exercises and five combination exercises, are required. For each exercise, appropriate exercise measures were defined. CONCLUSION This study provides an overview of functional requirements, required exercises, and required exercise measures for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients, which can be used to develop home-based upper extremity rehabilitation interventions. Moreover, the comprehensive and systematic requirement analysis used in this study can be applied by other researchers and developers when extracting requirements for designing a system or intervention in a medical context.
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Affiliation(s)
- A. J. Langerak
- Department of Rehabilitation Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - G. R. H. Regterschot
- Department of Rehabilitation Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands
| | - R. W. Selles
- Department of Rehabilitation Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Plastic and Reconstructive Surgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C. G. M. Meskers
- Department of Rehabilitation Medicine, Amsterdam Neuroscience and Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - M. Evers
- Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - G. M. Ribbers
- Department of Rehabilitation Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - B. J. F. van Beijnum
- Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands
| | - J. B. J. Bussmann
- Department of Rehabilitation Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
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Teasell R, Fleet JL, Harnett A. Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy. Phys Med Rehabil Clin N Am 2024; 35:339-351. [PMID: 38514222 DOI: 10.1016/j.pmr.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.
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Affiliation(s)
- Robert Teasell
- Parkwood Institute Research, Parkwood Institute, D4-101A, 550 Wellington Road, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, D4-101A, 550 Wellington Road, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Amber Harnett
- Parkwood Institute Research, Parkwood Institute, B3-123, 550 Wellington Road, London, Ontario N6C 0A7, Canada
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Reinecke S, Mijic M, Gerhard J, Jung A, Ernst K, Dreher C, Lohmann M, Koch M, Jahjah A, Fichtemüller A, Balzer J. Evidence-based practice - implementation level and attitude among physical, occupational, and speech and language therapists in Germany: status quo. JBI Evid Implement 2024; 22:205-217. [PMID: 38639217 DOI: 10.1097/xeb.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Evidence-based practice (EBP) is an important component of clinical practice in public health. Its implementation involves interpreting scientific studies and then applying this knowledge to clinical decision-making. In Germany, the therapy professions are often trained in non-academic medical schools, and only a small number of therapists are university graduates. AIMS This study assessed the current status of EBP among physiotherapists, occupational therapists, and speech and language therapists and to determine whether academization influences the implementation of EBP in Germany. METHODS To assess the EBP implementation level and therapists' attitudes toward EBP, a cross-sectional study was conducted using the German version of the Evidence-Based Practice Inventory (EBPI), which consists of five dimensions: attitude; subjective norm; perceived behavioral control; decision-making; and intention and behavior. The structural validity and internal consistency of the EBPI survey were also tested. RESULTS Of the 2,412 responses, only 557 were eligible. There were statistically significant differences between academically educated vs. non-academically educated therapists in four of the five EBPI dimensions. Furthermore, four of the five dimensions had sufficient unidimensionality and internal consistency. CONCLUSION There are differences between academically educated and non-academically educated therapists regarding EBP knowledge, attitudes, and implementation. Academically educated therapists are more likely to use EBP than non-academically educated therapists. There are still barriers to clinical application that need to be addressed. SPANISH ABSTRACT http://links.lww.com/IJEBH/A195.
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Affiliation(s)
- Sarah Reinecke
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
| | - Marko Mijic
- Ludwig-Maximilians-Universität München, Friedrich-Baur-Institut/Neurologische Klinik und Poliklinik, LMU Klinikum, Munich, Germany
| | - Janina Gerhard
- Institute of Public Health, Medical Decision Making and Health Technology Assessment; UMIT TIROL - University for Health Sciences and Technology, Tirol, Austria
| | - Andrés Jung
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck, Universität zu Lübeck, Lübeck, Germany
| | - Kathrin Ernst
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
| | - Christian Dreher
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
| | - Marieke Lohmann
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
| | - Maren Koch
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
| | | | - Andrea Fichtemüller
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
| | - Julia Balzer
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
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Abstract
Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and thereby address this unmet need. A specific example is reviewed in detail, focused on a telerehabilitation system that targets upper extremity motor deficits after stroke. Strengths of this system include provision of daily therapy associated with very high patient compliance, safety and feasibility in the inpatient or home setting, comparable efficacy to dose-matched therapy provided in-clinic, and a holistic approach that includes assessment, education, prevention, and activity-based therapy.
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Affiliation(s)
- Steven C Cramer
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA.
| | - Brittany M Young
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Anne Schwarz
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Tracy Y Chang
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Michael Su
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
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Gooch HJ, Jarvis KA, Stockley RC. Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review. J Med Internet Res 2024; 26:e48725. [PMID: 38656777 PMCID: PMC11079774 DOI: 10.2196/48725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/14/2023] [Accepted: 12/26/2023] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions. OBJECTIVE This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT. METHODS Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1). RESULTS From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality. CONCLUSIONS Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.
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Affiliation(s)
- Helen J Gooch
- Stroke Research Team, School of Nursing and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Kathryn A Jarvis
- Stroke Research Team, School of Nursing and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Rachel C Stockley
- Stroke Research Team, School of Nursing and Midwifery, University of Central Lancashire, Preston, United Kingdom
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12
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Plawecki A, Henderson CE, Lotter JK, Shoger LH, Inks E, Scofield M, Voigtmann CJ, Katta-Charles S, Hornby TG. Comparative Efficacy of High-Intensity Training Versus Conventional Training in Individuals With Chronic Traumatic Brain Injury: A Pilot Randomized Controlled Study. J Neurotrauma 2024; 41:807-817. [PMID: 38204184 DOI: 10.1089/neu.2023.0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Numerous studies have evaluated the efficacy of interventions to improve locomotion after acute-onset brain injury, although most focus on patients with stroke, with less attention toward traumatic brain injury (TBI). For example, a number of studies in patients post-stroke have evaluated the effects of high-intensity training (HIT) attempting to maximize stepping practice, while no studies have attempted this intervention in patients with TBI. The purpose of this blinded-assessor randomized trial was to evaluate the effects of HIT focused on stepping practice versus conventional training on walking and secondary outcomes in individuals with TBI. Using a crossover design, ambulatory participants with TBI >6-months duration performed HIT focused on stepping in variable contexts (overground, treadmill, stairs) or conventional training for up to 15 sessions over five weeks, with interventions alternated >4 weeks later. HIT focused on maximizing stepping practice while trying to achieve higher cardiovascular intensities (>70% heart rate reserve), while conventional training focused on impairment-based and functional exercises with no restrictions on intensities achieved. Greater increases in 6-min walk test and peak treadmill speed during graded exercise testing were observed after HIT versus conventional training, with moderate associations between differences in stepping practice and outcomes. Greater gains were also observed in estimates of aerobic capacity and efficiency after HIT, with additional improvements in selected cognitive assessments. The present study suggests that the amount and intensity of stepping practice may be important determinants of improved locomotor outcomes in patients with chronic TBI, with possible secondary benefits on aerobic capacity/efficiency and cognition. Clinical Trial Registration-URL: https://clinicaltrials.gov/; Unique Identifier: NCT04503473.
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Affiliation(s)
- Abbey Plawecki
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Christopher E Henderson
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Erin Inks
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Molly Scofield
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | | | - Sheryl Katta-Charles
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - T George Hornby
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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13
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Neibling B, Hayward KS, Smith M, Chapman P, Barker RN. Perseverance with home-based upper limb practice after stroke: perspectives of stroke survivors and their significant others. Disabil Rehabil 2024; 46:1103-1111. [PMID: 37144251 DOI: 10.1080/09638288.2023.2191011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 03/09/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE The aim of this study was to explore factors that influence stroke survivors' ability to persevere with home-based upper limb practice. METHODS A qualitative descriptive study embedded within a theoretical framework was conducted. Data were collected through semi-structured focus group, dyadic, and individual interviews. The Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour (COM-B) model guided data collection and directed content analysis. FINDINGS Participants were 31 adult stroke survivors with upper limb impairment, with 13 significant other/s, who were living at home in Queensland, Australia. Three central tenants aligned with the COM-B and six themes were identified. Stroke survivors' capability to persevere was influenced by being physically able to practice and being able to understand, monitor and modify practice, their opportunity to persevere was influenced by accessing therapy and equipment required for practice and fitting practice into everyday life, and their motivation to persevere was influenced by having goals and experiencing meaningful outcomes and having support and being accountable. CONCLUSION Persevering with practice is multifaceted for stroke survivors. All facets need to be addressed in the design of strategies to enhance stroke survivors' ability to persevere and in turn, enhance their potential for continued upper limb recovery.IMPLICATIONS FOR REHABILITATIONMany stroke survivors do not persevere with long-term home-based upper limb practice despite the belief that high dose practice will promote continued recovery.Therapists need to support stroke survivors to setup individualised goal-based home programs that they can complete independently, or with support, within their everyday life.Stroke survivors need coaching to monitor and modify their practice and map their progress, so that they can recognise and experience meaningful recovery.To optimise upper limb recovery after stroke, strategies to enhance stroke survivors' capability, opportunity, and motivation to persevere across the continuum of recovery, need to be co-designed by stroke survivors, therapists and researchers.
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Affiliation(s)
- Bridee Neibling
- College of Healthcare Sciences, James Cook University, Townsville, Australia
| | - Kathryn S Hayward
- College of Healthcare Sciences, James Cook University, Townsville, Australia
- Departments of Physiotherapy, Medicine and Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Moira Smith
- College of Healthcare Sciences, James Cook University, Townsville, Australia
| | - Paul Chapman
- Rehabilitation Unit, Townsville University Hospital, Townsville, Australia
| | - Ruth N Barker
- College of Healthcare Sciences, James Cook University, Cairns, Australia
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14
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Lin DJ, Backus D, Chakraborty S, Liew SL, Valero-Cuevas FJ, Patten C, Cotton RJ. Transforming modeling in neurorehabilitation: clinical insights for personalized rehabilitation. J Neuroeng Rehabil 2024; 21:18. [PMID: 38311729 PMCID: PMC10840185 DOI: 10.1186/s12984-024-01309-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/24/2024] [Indexed: 02/06/2024] Open
Abstract
Practicing clinicians in neurorehabilitation continue to lack a systematic evidence base to personalize rehabilitation therapies to individual patients and thereby maximize outcomes. Computational modeling- collecting, analyzing, and modeling neurorehabilitation data- holds great promise. A key question is how can computational modeling contribute to the evidence base for personalized rehabilitation? As representatives of the clinicians and clinician-scientists who attended the 2023 NSF DARE conference at USC, here we offer our perspectives and discussion on this topic. Our overarching thesis is that clinical insight should inform all steps of modeling, from construction to output, in neurorehabilitation and that this process requires close collaboration between researchers and the clinical community. We start with two clinical case examples focused on motor rehabilitation after stroke which provide context to the heterogeneity of neurologic injury, the complexity of post-acute neurologic care, the neuroscience of recovery, and the current state of outcome assessment in rehabilitation clinical care. Do we provide different therapies to these two different patients to maximize outcomes? Asking this question leads to a corollary: how do we build the evidence base to support the use of different therapies for individual patients? We discuss seven points critical to clinical translation of computational modeling research in neurorehabilitation- (i) clinical endpoints, (ii) hypothesis- versus data-driven models, (iii) biological processes, (iv) contextualizing outcome measures, (v) clinical collaboration for device translation, (vi) modeling in the real world and (vii) clinical touchpoints across all stages of research. We conclude with our views on key avenues for future investment (clinical-research collaboration, new educational pathways, interdisciplinary engagement) to enable maximal translational value of computational modeling research in neurorehabilitation.
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Affiliation(s)
- David J Lin
- Department of Neurology, Division of Neurocritical Care and Stroke Service, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Veterans Affairs, Rehabilitation Research and Development Service, Center for Neurorestoration and Neurotechnology, Providence, RI, USA.
| | - Deborah Backus
- Crawford Research Institute, Shepherd Center, Atlanta, GA, USA
| | - Stuti Chakraborty
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Sook-Lei Liew
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Francisco J Valero-Cuevas
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Carolynn Patten
- Department of Physical Medicine and Rehabilitation, UC Davis School of Medicine, Sacramento, CA, USA
- Department of Veterans Affairs, Northern California Health Care System, Martinez, CA, USA
| | - R James Cotton
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
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15
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Bessler-Etten J, Schaake L, Buurke JH, Prange-Lasonder GB. Investigating change of discomfort during repetitive force exertion though an exoskeleton cuff. APPLIED ERGONOMICS 2024; 115:104055. [PMID: 37984083 DOI: 10.1016/j.apergo.2023.104055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 11/22/2023]
Abstract
This article investigates discomfort development for forces exerted repetitively and for extended durations through a rigid cuff. Three force patterns, chosen to mimic exoskeleton use, were applied to the thigh of 15 healthy participants for 30 min. Changes in perceived comfort and skin effects were recorded. Discomfort was detected at normal forces ranging from 40 to >230 N. Repetitive force application triggered discomfort after a median of 4.1 min (normal force only) and 5.4 min (normal and shear force) respectively. Discomfort increased over time but the repetitive force applications did generally not result in pain and there were no significant differences between repetitive loading patterns. Exoskeleton design and use should be informed by comfort thresholds specific to prolonged repetitive loading. Large interindividual differences in perception of discomfort limit the possibilities for generally applicable comfort thresholds. Further research is needed to investigate how patient groups perceive such repetitive loading.
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Affiliation(s)
- Jule Bessler-Etten
- Roessingh Research and Development, Enschede, the Netherlands; Department of Biomedical Signals and Systems, University of Twente, Enschede, the Netherlands.
| | | | - Jaap H Buurke
- Roessingh Research and Development, Enschede, the Netherlands; Department of Biomedical Signals and Systems, University of Twente, Enschede, the Netherlands
| | - Gerdienke B Prange-Lasonder
- Roessingh Research and Development, Enschede, the Netherlands; Department of Biomechanical Engineering, University of Twente, Enschede, the Netherlands
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16
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Urbin MA, Lafe CW, Bautista ME, Wittenberg GF, Simpson TW. Effects of noninvasive neuromodulation targeting the spinal cord on early learning of force control by the digits. CNS Neurosci Ther 2024; 30:e14561. [PMID: 38421127 PMCID: PMC10851178 DOI: 10.1111/cns.14561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 03/02/2024] Open
Abstract
AIMS Control of finger forces underlies our capacity for skilled hand movements acquired during development and reacquired after neurological injury. Learning force control by the digits, therefore, predicates our functional independence. Noninvasive neuromodulation targeting synapses that link corticospinal neurons onto the final common pathway via spike-timing-dependent mechanisms can alter distal limb motor output on a transient basis, yet these effects appear subject to individual differences. Here, we investigated how this form of noninvasive neuromodulation interacts with task repetition to influence early learning of force control during precision grip. METHODS The unique effects of neuromodulation, task repetition, and neuromodulation coinciding with task repetition were tested in three separate conditions using a within-subject, cross-over design (n = 23). RESULTS We found that synchronizing depolarization events within milliseconds of stabilizing precision grip accelerated learning but only after accounting for individual differences through inclusion of subjects who showed upregulated corticospinal excitability at 2 of 3 time points following conditioning stimulation (n = 19). CONCLUSIONS Our findings provide insights into how the state of the corticospinal system can be leveraged to drive early motor skill learning, further emphasizing individual differences in the response to noninvasive neuromodulation. We interpret these findings in the context of biological mechanisms underlying the observed effects and implications for emerging therapeutic applications.
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Affiliation(s)
- Michael A. Urbin
- Human Engineering Research Laboratories, VA RR&D Center of ExcellenceVA Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Charley W. Lafe
- Human Engineering Research Laboratories, VA RR&D Center of ExcellenceVA Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Manuel E. Bautista
- Human Engineering Research Laboratories, VA RR&D Center of ExcellenceVA Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - George F. Wittenberg
- Human Engineering Research Laboratories, VA RR&D Center of ExcellenceVA Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
- Department of NeurologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Rehabilitation Neural Engineering Laboratories, Department of Physical Medicine & RehabilitationUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Tyler W. Simpson
- Rehabilitation Neural Engineering Laboratories, Department of Physical Medicine & RehabilitationUniversity of PittsburghPittsburghPennsylvaniaUSA
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17
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Bernal-Jiménez JJ, Polonio-López B, Sanz-García A, Martín-Conty JL, Lerín-Calvo A, Segura-Fragoso A, Martín-Rodríguez F, Cantero-Garlito PA, Corregidor-Sánchez AI, Mordillo-Mateos L. Is the Combination of Robot-Assisted Therapy and Transcranial Direct Current Stimulation Useful for Upper Limb Motor Recovery? A Systematic Review with Meta-Analysis. Healthcare (Basel) 2024; 12:337. [PMID: 38338223 PMCID: PMC10855329 DOI: 10.3390/healthcare12030337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/18/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Stroke is the third leading cause of disability in the world, and effective rehabilitation is needed to improve lost functionality post-stroke. In this regard, robot-assisted therapy (RAT) and transcranial direct current stimulation (tDCS) are promising rehabilitative approaches that have been shown to be effective in motor recovery. In the past decade, they have been combined to study whether their combination produces adjuvant and greater effects on stroke recovery. The aim of this study was to estimate the effectiveness of the combined use of RATs and tDCS in the motor recovery of the upper extremities after stroke. After reviewing 227 studies, we included nine randomised clinical trials (RCTs) in this study. We analysed the methodological quality of all nine RCTs in the meta-analysis. The analysed outcomes were deficit severity, hand dexterity, spasticity, and activity. The addition of tDCS to RAT produced a negligible additional benefit on the effects of upper limb function (SMD -0.09, 95% CI -0.31 to 0.12), hand dexterity (SMD 0.12, 95% CI -0.22 to 0.46), spasticity (SMD 0.04, 95% CI -0.24 to 0.32), and activity (SMD 0.66, 95% CI -1.82 to 3.14). There is no evidence of an additional effect when adding tDCS to RAT for upper limb recovery after stroke. Combining tDCS with RAT does not improve upper limb motor function, spasticity, and/or hand dexterity. Future research should focus on the use of RAT protocols in which the patient is given an active role, focusing on the intensity and dosage, and determining how certain variables influence the success of RAT.
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Affiliation(s)
- Juan J. Bernal-Jiménez
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - Begoña Polonio-López
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - Ancor Sanz-García
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - José L. Martín-Conty
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - Alfredo Lerín-Calvo
- Neruon Neurobotic S.L., 28015 Madrid, Spain;
- Department of Physiotherapy, Faculty of Health Sciences, University La Salle, 28023 Madrid, Spain
| | - Antonio Segura-Fragoso
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, University of Valladolid, 47005 Valladolid, Spain;
- Advanced Life Support, Emergency Medical Services (SACYL), 47007 Valladolid, Spain
| | - Pablo A. Cantero-Garlito
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - Ana-Isabel Corregidor-Sánchez
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
| | - Laura Mordillo-Mateos
- Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; (J.J.B.-J.); (A.S.-G.); (J.L.M.-C.); (A.S.-F.); (P.A.C.-G.); (A.-I.C.-S.); (L.M.-M.)
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of de Castilla-La Mancha, 45600 Talavera de la Reina, Spain
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Proietti T, Nuckols K, Grupper J, Schwerz de Lucena D, Inirio B, Porazinski K, Wagner D, Cole T, Glover C, Mendelowitz S, Herman M, Breen J, Lin D, Walsh C. Combining soft robotics and telerehabilitation for improving motor function after stroke. WEARABLE TECHNOLOGIES 2024; 5:e1. [PMID: 38510985 PMCID: PMC10952055 DOI: 10.1017/wtc.2023.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/07/2023] [Accepted: 12/02/2023] [Indexed: 03/22/2024]
Abstract
Telerehabilitation and robotics, either traditional rigid or soft, have been extensively studied and used to improve hand functionality after a stroke. However, a limited number of devices combined these two technologies to such a level of maturity that was possible to use them at the patients' home, unsupervised. Here we present a novel investigation that demonstrates the feasibility of a system that integrates a soft inflatable robotic glove, a cloud-connected software interface, and a telerehabilitation therapy. Ten chronic moderate-to-severe stroke survivors independently used the system at their home for 4 weeks, following a software-led therapy and being in touch with occupational therapists. Data from the therapy, including automatic assessments by the robot, were available to the occupational therapists in real-time, thanks to the cloud-connected capability of the system. The participants used the system intensively (about five times more movements per session than the standard care) for a total of more than 8 hr of therapy on average. We were able to observe improvements in standard clinical metrics (FMA +3.9 ± 4.0, p < .05, COPM-P + 2.5 ± 1.3, p < .05, COPM-S + 2.6 ± 1.9, p < .05, MAL-AOU +6.6 ± 6.5, p < .05) and range of motion (+88%) at the end of the intervention. Despite being small, these improvements sustained at follow-up, 2 weeks after the end of the therapy. These promising results pave the way toward further investigation for the deployment of combined soft robotic/telerehabilitive systems at-home for autonomous usage for stroke rehabilitation.
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Affiliation(s)
- Tommaso Proietti
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Kristin Nuckols
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Jesse Grupper
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Diogo Schwerz de Lucena
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Bianca Inirio
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | | | - Diana Wagner
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Tazzy Cole
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Christina Glover
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Sarah Mendelowitz
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Maxwell Herman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Joan Breen
- Whittier Rehabilitation Hospital, Bradford, MA, USA
| | - David Lin
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI, USA
| | - Conor Walsh
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
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19
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Seo NJ, Coupland K, Finetto C, Scronce G. Wearable Sensor to Monitor Quality of Upper Limb Task Practice for Stroke Survivors at Home. SENSORS (BASEL, SWITZERLAND) 2024; 24:554. [PMID: 38257646 PMCID: PMC10821060 DOI: 10.3390/s24020554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Many stroke survivors experience persistent upper extremity impairment that limits performance in activities of daily living. Upper limb recovery requires high repetitions of task-specific practice. Stroke survivors are often prescribed task practices at home to supplement rehabilitation therapy. A poor quality of task practices, such as the use of compensatory movement patterns, results in maladaptive neuroplasticity and suboptimal motor recovery. There currently lacks a tool for the remote monitoring of movement quality of stroke survivors' task practices at home. The objective of this study was to evaluate the feasibility of classifying movement quality at home using a wearable IMU. Nineteen stroke survivors wore an IMU sensor on the paretic wrist and performed four functional upper limb tasks in the lab and later at home while videorecording themselves. The lab data served as reference data to classify home movement quality using dynamic time warping. Incorrect and correct movement quality was labeled by a therapist. The home task practice movement quality was classified with an accuracy of 92% and F1 score of 0.95 for all tasks combined. Movement types contributing to misclassification were further investigated. The results support the feasibility of a home movement quality monitoring system to assist with upper limb rehabilitation post stroke.
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Affiliation(s)
- Na Jin Seo
- Department of Rehabilitation Sciences, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA; (K.C.); (C.F.); (G.S.)
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
| | - Kristen Coupland
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA; (K.C.); (C.F.); (G.S.)
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
| | - Christian Finetto
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA; (K.C.); (C.F.); (G.S.)
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
| | - Gabrielle Scronce
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA; (K.C.); (C.F.); (G.S.)
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
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20
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Klaic M, Fong J, Crocher V, Davies K, Brock K, Sutton E, Oetomo D, Tan Y, Galea MP. Application of the extended technology acceptance model to explore clinician likelihood to use robotics in rehabilitation. Disabil Rehabil Assist Technol 2024; 19:52-59. [PMID: 35400278 DOI: 10.1080/17483107.2022.2060356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/26/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Evidence suggests that patients with upper limb impairment following a stroke do not receive recommended amounts of motor practice. Robotics provide a potential solution to address this gap, but clinical adoption is low. The aim of this study was to utilize the technology acceptance model as a framework to identify factors influencing clinician adoption of robotic devices into practice. MATERIALS AND METHOD Mixed methods including survey data and focus group discussions with allied health clinicians whose primary caseload was rehabilitation of the neurologically impaired upper limb. Surveys based on the technology acceptance measure were completed pre/post exposure to and use of a robotic device. Focus groups discussions based on the theory of planned behaviour were conducted at the conclusion of the study. RESULTS A total of 34 rehabilitation clinicians completed the surveys with pre-implementation data indicating that rehabilitation clinicians perceive robotic devices as complex to use, which influenced intention to use such devices in practice. The focus groups found that lack of experience and time to learn influenced confidence to implement robotic devices into practice. CONCLUSION This study found that perceived usefulness and perceived ease of use of a robotic device in clinical rehabilitation can be improved through experience, training and embedded technological support. However, training and embedded support are not routinely offered, suggesting there is a discordance between current implementation and the learning needs of rehabilitation clinicians.IMPLICATIONS FOR REHABILITATIONPatients do not receive adequate amounts of upper limb motor practice following a stroke, and although robotic devices have the potential to address this gap, clinical adoption is low.The technology acceptance model identified that clinicians perceive robotic devices to be complex to use with current implementation efforts failing to consider their training needs.Implementation adoption of robotic devices in rehabilitation should be supported with adequate training and technological support if sustainable practice change is to be achieved.
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Affiliation(s)
- Marlena Klaic
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
- Allied Health Department, The Royal Melbourne Hospital, Melbourne, Australia
| | - Justin Fong
- Department of Mechanical Engineering, University of Melbourne & Fourier Intelligence Joint Laboratory, The University of Melbourne, Melbourne, Australia
| | - Vincent Crocher
- Department of Mechanical Engineering, University of Melbourne & Fourier Intelligence Joint Laboratory, The University of Melbourne, Melbourne, Australia
| | - Katie Davies
- The Neurological Rehabilitation Group, Melbourne, Australia
| | - Kim Brock
- St Vincent's Hospital, Melbourne, Australia
| | | | - Denny Oetomo
- Department of Mechanical Engineering, University of Melbourne & Fourier Intelligence Joint Laboratory, The University of Melbourne, Melbourne, Australia
| | - Ying Tan
- Department of Mechanical Engineering, University of Melbourne & Fourier Intelligence Joint Laboratory, The University of Melbourne, Melbourne, Australia
| | - Mary P Galea
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Melbourne, Australia
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21
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Evron I, Schwartz O, Sajina A, Grosman-Rimon L, Dudkiewicz I. A digital exercise and augmented reality training system improved mobility among stroke patients: A randomized control trial. Technol Health Care 2024; 32:89-101. [PMID: 37302046 DOI: 10.3233/thc-220521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND The Selfit system was developed to improve the mobility and gait-related functions of stroke patients by providing digital exercises and augmented reality training system. OBJECTIVE To evaluate the effects of a digital exercise and augmented reality training system on mobility, gait-related functions and self-efficacy outcomes in stroke patients. METHODS A randomized control trial was conducted on 25 men and women diagnosed with an early sub-acute stroke. Patients were randomly assigned to either the intervention (N= 11) or the control groups (N= 14). Patients in the intervention group received a digital exercise and augmented reality training using the Selfit system in addition to the standard physical therapy treatment. Patients in the control group were treated with a conventional physical therapy program. Timed Up and Go (TUG) test, 10-meter walk test, the Dynamic Gait Index (DGI), and the Activity-specific Balance Confidence (ABC) scale were completed before and after the intervention. Feasibility and satisfaction among patients and therapists were also assessed after the completion of the study. RESULTS The intervention group practiced proportionally more time per session than the control group with a mean change of 19.7% following 6 sessions (p= 0.002). The intervention group showed better improvement in post-TUG score compared to the control group (p= 0.04). ABC, DGI, and the 10-meter walk test scores were not significantly different between the groups. Both therapists and participants demonstrated high satisfaction with the Selfit system. CONCLUSION The findings suggest that Selfit holds promise as an effective intervention for improving mobility and gait-related functions among patients with an early sub-acute stroke as compared to conventional physical therapy treatments.
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Affiliation(s)
- Ilanit Evron
- Department of Physiotherapy, Sourasky Medical Center, Tel Aviv, Israel
- Department of Rehabilitation, Sourasky Medical Center, Tel Aviv, Israel
- Department of Physiotherapy, Sourasky Medical Center, Tel Aviv, Israel
| | - Oren Schwartz
- Department of Day Care Rehabilitation, Reuth Rehabilitation Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Physiotherapy, Sourasky Medical Center, Tel Aviv, Israel
| | - Anna Sajina
- Department of Rehabilitation, Sourasky Medical Center, Tel Aviv, Israel
| | | | - Israel Dudkiewicz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rehabilitation Division, Sheba Medical Center, Tel Hashomer, Israel
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22
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Olsen S, Alder G, Rashid U, Gomes E, Aislabie M, Chee F, Smith C, Kean B, Towersey N, Signal N. Challenge Level Contributes to the Efficacy of Treadmill Interventions after Stroke: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:1729. [PMID: 38137177 PMCID: PMC10741427 DOI: 10.3390/brainsci13121729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Intervention parameters such as the challenge, amount, and dosage (challenge × amount) have the potential to alter the efficacy of rehabilitation interventions after stroke. This systematic review investigated the effect of intervention parameters of challenge, amount, and dosage on improvements in walking outcomes following treadmill training (TT) and comparison interventions in people with stroke. Randomized controlled trials were included if they: (i) investigated interventions of TT or bodyweight-supported TT (BWSTT); (ii) made comparisons with other physiotherapy interventions, other types of TT, or no intervention; (iii) studied people with stroke; (iv) reported sufficient data on challenge and amount parameters; and (v) measured walking speed or endurance. Completeness of reporting was evaluated using the TIDieR-Rehab checklist and risk of bias was assessed using the revised Cochrane risk-of-bias tool. The review included 26 studies; 15 studies compared TT or BWSTT with other physiotherapy interventions and 11 studies compared different types of TT. Meta-analyses provided evidence with low to moderate certainty that greater differences in challenge and dosage between treadmill and comparison physiotherapy interventions produced greater effects on walking endurance (p < 0.01). However, challenge and dosage did not influence walking speed outcomes. The analysis of intervention amount was limited by the lack of studies that manipulated the amount of intervention. Overall, the findings indicate that, after stroke, some of the efficacy of TT on walking endurance can be explained by the challenge level during training. This supports the implementation of TT at higher challenge levels in stroke rehabilitation practice.
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Affiliation(s)
- Sharon Olsen
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Gemma Alder
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Usman Rashid
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland 1060, New Zealand
| | - Emeline Gomes
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Madeleine Aislabie
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Fran Chee
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Caitlin Smith
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Brody Kean
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Nicola Towersey
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
| | - Nada Signal
- Rehabilitation Innovation Centre, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 0627, New Zealand; (G.A.); (U.R.); (E.G.); (N.T.); (N.S.)
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Hao J, Yao Z, Harp K, Gwon DY, Chen Z, Siu KC. Effects of virtual reality in the early-stage stroke rehabilitation: A systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract 2023; 39:2569-2588. [PMID: 35801290 DOI: 10.1080/09593985.2022.2094302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/25/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Virtual reality (VR) is an emerging technology and has shown promising outcomes in stroke rehabilitation. VR can create an enriched environment, facilitate task-specific training, and provide multimodal sensorimotor feedback to augment functional recovery by driving the experience-dependent plasticity, which is prominent in the early-stage after stroke. PURPOSE This review aimed to systematically identify and examine the feasibility and effectiveness of VR intervention applied within one-month after stroke on functional outcomes of patients. METHODS Randomized controlled trials were searched across six databases published between 2000 and 2021. Two independent reviewers conducted study selection, data extraction, and quality assessment. Physiotherapy Evidence Database (PEDro) scale was used to evaluate the quality of included studies. Qualitative synthesis and meta-analysis were conducted to compare VR-based rehabilitation and conventional rehabilitation. RESULTS Seventeen randomized controlled trials were included in this review, and all of them meet the criteria for good quality. The results confirmed the feasibility of applying VR in early stroke rehabilitation. In the meta-analyses, there were no significant differences between VR and control on upper extremity function (SMD = 0.22, P = .10), Activities of Daily Living outcomes (SMD = 0.15, P = .11), balance (SMD = 0.18, P = .86), and cognition (SMD = 0.34, P = .06). CONCLUSION VR is a feasible approach and demonstrates comparable effectiveness in functional outcomes with conventional rehabilitation in patients with stroke at the early-stage. Further research focusing on the application of VR in acute stroke survivors with adequate sample size, additional follow-up evaluation and valid outcome measures are warranted.
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Affiliation(s)
- Jie Hao
- Division of Physical Therapy Education, Department of Health and Rehabilitation Sciences, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, United States
| | - Zixuan Yao
- Division of Physical Therapy Education, Department of Health and Rehabilitation Sciences, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, United States
| | - Kimberly Harp
- McGoogan Health Sciences Library, University of Nebraska Medical CenterLeon S. , Omaha, NE, United States
| | - Dr Yeongjin Gwon
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, United States
| | - Zhen Chen
- d Department of Neurorehabilitation, the First Rehabilitation Hospital of Shanghai, Shanghai, China
| | - Ka-Chun Siu
- Division of Physical Therapy Education, Department of Health and Rehabilitation Sciences, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, United States
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Tobaiqi MA, Albadawi EA, Fadlalmola HA, Albadrani MS. Application of Virtual Reality-Assisted Exergaming on the Rehabilitation of Children with Cerebral Palsy: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:7091. [PMID: 38002703 PMCID: PMC10672287 DOI: 10.3390/jcm12227091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/15/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Rehabilitation programs for children with cerebral palsy (CP) aim to improve their motor and cognitive skills through repeated and progressively challenging exercises. However, these exercises can be tedious and demotivating, which can affect the effectiveness and feasibility of the programs. To overcome this problem, virtual reality VR-assisted exergaming has emerged as a novel modality of physiotherapy that combines fun and motivation with physical activity. VR exergaming allows children with CP to perform complex movements in a secure and immersive environment, where they can interact with virtual objects and scenarios. This enhances their active engagement and learning, as well as their self-confidence and enjoyment. We aim to provide a comprehensive overview of the current state of research on VR exergaming for CP rehabilitation. The specific objectives are: To identify and describe the existing studies that have investigated the effects of VR exergaming on motor function and participation outcomes in children with CP. In addition, we aim to identify and discuss the main gaps, challenges, and limitations in the current research on VR exergaming for CP rehabilitation. Finally, we aim to provide recommendations and suggestions for future research and practice in this field. METHODS In June 2023, we conducted a systematic search on Scopus, Web of Science, PubMed, Cochrane, and Embase for randomized trials and cohort studies that applied VR-assisted exergaming to rehabilitating patients with CP. The inclusion criteria encompassed the following: (1) Randomized controlled trials (RCTs) and cohort studies involving the rehabilitation of children with CP; (2) the application of VR-based exergaming on the rehabilitation; (3) in comparison with conventional rehabilitation/usual care. The quality of the selected RCTs was evaluated using Cochrane's tool for risk of bias assessment bias includes. Whereas the quality of cohort studies was assessed using the National Institutes of Health (NIH) tool. RESULTS The systematic search of databases retrieved a total of 2576 studies. After removing 863 duplicates, 1713 studies underwent title and abstract screening, and 68 studies were then selected as eligible for full-text screening. Finally, 45 studies were involved in this review (n = 1580), and 24 of those were included in the quantitative analysis. The majority of the included RCTs had a low risk of bias regarding study reporting, participants' attrition, and generating a random sequence. Nearly half of the RCTs ensured good blinding of outcomes assessors. However, almost all the RCTs were unclear regarding the blinding of the participants and the study personnel. The 2020 retrospective cohort study conducted at Samsung Changwon Hospital, investigating the effects of virtual reality-based rehabilitation on upper extremity function in children with cerebral palsy, demonstrated fair quality in its methodology and findings. VR-assisted exergaming was more effective than conventional physiotherapy in improving the Gross Motor Function Measurement (GMFM)-88 score (MD = 0.81; 95% CI [0.15, 1.47], p-value = 0.02) and the GMFM walking and standing dimensions (MD = 1.45; 95% CI [0.48, 2.24], p-value = 0.003 and MD = 3.15; 95% CI [0.87, 5.42], p-value = 0.007), respectively. The mobility and cognitive domains of the Pediatric Evaluation of Disability Inventory score (MD = 1.32; 95% CI [1.11, 1.52], p-value < 0.001) and (MD = 0.81; 95% CI [0.50, 1.13], p-value < 0.0001) were also improved. The Canadian Occupational Performance Measure performance domain (MD = 1.30; 95% CI [1.04, 1.56], p-value < 0.001), the WeeFunctional Independence Measure total score (MD = 6.67; 95% CI [6.36, 6.99], p-value < 0.0001), and the Melbourne Assessment of Unilateral Upper Limb Function-2 score (p-value < 0.001) improved as well. This new intervention is similarly beneficial as conventional therapy in improving other efficacy measures. CONCLUSIONS Our findings suggest that VR-assisted exergaming may have some advantages over conventional rehabilitation in improving CP children's functioning and performance in daily life activities, upper and lower limb mobility, and cognition. VR-assisted exergaming seems to be as effective as conventional physiotherapy in the other studied function measures. With its potential efficacy, better feasibility, no reported side effects, and entertaining experience, VR-assisted exergaming may be a viable complementary approach to conventional physiotherapy in rehabilitating children with CP.
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Affiliation(s)
- Muhammad Abubaker Tobaiqi
- Department of Family and Community Medicine, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42353, Saudi Arabia
| | - Emad Ali Albadawi
- Department of Anatomy, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42353, Saudi Arabia;
| | - Hammad Ali Fadlalmola
- Department of Community Health Nursing, Nursing College, Taibah University, Al-Madinah Al-Munawara 42353, Saudi Arabia;
| | - Muayad Saud Albadrani
- Department of Family and Community Medicine, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42353, Saudi Arabia
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25
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Porciuncula F, Arumukhom Revi D, Baker TC, Sloutsky R, Walsh CJ, Ellis TD, Awad LN. Effects of high-intensity gait training with and without soft robotic exosuits in people post-stroke: a development-of-concept pilot crossover trial. J Neuroeng Rehabil 2023; 20:148. [PMID: 37936135 PMCID: PMC10629136 DOI: 10.1186/s12984-023-01267-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION High-intensity gait training is widely recognized as an effective rehabilitation approach after stroke. Soft robotic exosuits that enhance post-stroke gait mechanics have the potential to improve the rehabilitative outcomes achieved by high-intensity gait training. The objective of this development-of-concept pilot crossover study was to evaluate the outcomes achieved by high-intensity gait training with versus without soft robotic exosuits. METHODS In this 2-arm pilot crossover study, four individuals post-stroke completed twelve visits of speed-based, high-intensity gait training: six consecutive visits of Robotic Exosuit Augmented Locomotion (REAL) gait training and six consecutive visits without the exosuit (CONTROL). The intervention arms were counterbalanced across study participants and separated by 6 + weeks of washout. Walking function was evaluated before and after each intervention using 6-minute walk test (6MWT) distance and 10-m walk test (10mWT) speed. Moreover, 10mWT speeds were evaluated before each training visit, with the time-course of change in walking speed computed for each intervention arm. For each participant, changes in each outcome were compared to minimal clinically-important difference (MCID) thresholds. Secondary analyses focused on changes in propulsion mechanics and associated biomechanical metrics. RESULTS Large between-group effects were observed for 6MWT distance (d = 1.41) and 10mWT speed (d = 1.14). REAL gait training resulted in an average pre-post change of 68 ± 27 m (p = 0.015) in 6MWT distance, compared to a pre-post change of 30 ± 16 m (p = 0.035) after CONTROL gait training. Similarly, REAL training resulted in a pre-post change of 0.08 ± 0.03 m/s (p = 0.012) in 10mWT speed, compared to a pre-post change of 0.01 ± 06 m/s (p = 0.76) after CONTROL. For both outcomes, 3 of 4 (75%) study participants surpassed MCIDs after REAL training, whereas 1 of 4 (25%) surpassed MCIDs after CONTROL training. Across the training visits, REAL training resulted in a 1.67 faster rate of improvement in walking speed. Similar patterns of improvement were observed for the secondary gait biomechanical outcomes, with REAL training resulting in significantly improved paretic propulsion for 3 of 4 study participants (p < 0.05) compared to 1 of 4 after CONTROL. CONCLUSION Soft robotic exosuits have the potential to enhance the rehabilitative outcomes produced by high-intensity gait training after stroke. Findings of this development-of-concept pilot crossover trial motivate continued development and study of the REAL gait training program.
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Affiliation(s)
- Franchino Porciuncula
- Department of Physical Therapy, Center for Neurorehabilitation, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
- Department of Physical Therapy, Neuromotor Recovery Lab, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
- Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Dheepak Arumukhom Revi
- Department of Physical Therapy, Neuromotor Recovery Lab, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
- Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- Department of Mechanical Engineering, Boston University, Boston, MA, USA
| | - Teresa C Baker
- Department of Physical Therapy, Center for Neurorehabilitation, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
- Department of Physical Therapy, Neuromotor Recovery Lab, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
| | - Regina Sloutsky
- Department of Physical Therapy, Neuromotor Recovery Lab, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
| | - Conor J Walsh
- Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Terry D Ellis
- Department of Physical Therapy, Center for Neurorehabilitation, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
| | - Louis N Awad
- Department of Physical Therapy, Neuromotor Recovery Lab, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA.
- Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA.
- Department of Mechanical Engineering, Boston University, Boston, MA, USA.
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LaMarca AL, Krenn MJ, Kelso-Trass MA, MacDonald KC, Demeo CC, Bazarek SF, Brown JM. Selective Tibial Neurotomy Outcomes for Spastic Equinovarus Foot: Patient Expectations and Functional Assessment. Neurosurgery 2023; 93:1026-1035. [PMID: 37199494 DOI: 10.1227/neu.0000000000002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/27/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Spastic equinovarus foot (SEF) is a common dysfunctional foot posture after stroke that impairs balance and mobility. Selective tibial neurotomy (STN) is a simple but underutilized surgical option that can effectively address critical aspects of SEF and thereby provide enduring quality of life gains. There are few studies that examine both functional outcomes and patient satisfaction with this treatment option. OBJECTIVE To elucidate the patient goals that motivated their decision to undergo the procedure and compare subjective and objective changes in balance and functional mobility as a consequence of surgery. METHODS Thirteen patients with problematic SEF who had previously failed conservative measures were treated with STN. Preoperative and postoperative (on average 6 months) assessments evaluated gait quality and functional mobility. In addition, a custom survey was conducted to investigate patient perspectives on STN intervention. RESULTS The survey showed that participants who opted for STN were dissatisfied with their previous spasticity management. The most common preoperative expectation for STN treatment was to improve walking, followed by improving balance, brace comfort, pain, and tone. Postoperatively, participants rated the improvement in their expectations and were, on average, 71 on a 100-point scale, indicating high satisfaction. The gait quality, assessed with the Gait Intervention and Assessment Tool, improved significantly between preoperative and postoperative assessment (M = -4.1, P = .01) with a higher average difference in stance of -3.3 than in swing -0.5. Improvement in both gait endurance (M = 36 m, P = .01) and self-selected gait speed (M = .12 m/s, P = .03) was statistically significant. Finally, static balance (M = 5.0, P = .03) and dynamic balance (M = 3.5, P = .02) were also significantly improved. CONCLUSION STN improved gait quality and functional mobility and was associated with high satisfaction in patients with SEF.
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Affiliation(s)
- Amber L LaMarca
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Physical Therapy Department, Spaulding Rehabilitation Hospital, Boston , Massachusetts , USA
| | - Matthias J Krenn
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson , Mississippi , USA
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson , Mississippi , USA
| | - Molly A Kelso-Trass
- Physical Therapy Department, Wentworth-Douglass Hospital, Dover , New Hampshire , USA
| | - Kathryn C MacDonald
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Physical Therapy Department, Spaulding Rehabilitation Hospital, Boston , Massachusetts , USA
- Physical Therapy Department, Wentworth-Douglass Hospital, Dover , New Hampshire , USA
| | - Cristina C Demeo
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Stanley F Bazarek
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Harvard Medical School, Cambridge , Massachusetts , USA
- Brigham and Women's Hospital, Boston , Massachusetts , USA
| | - Justin M Brown
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Harvard Medical School, Cambridge , Massachusetts , USA
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Krishnan S, Mandala MA, Wolf SL, Howard A, Kesar TM. Perceptions of stroke survivors regarding factors affecting adoption of technology and exergames for rehabilitation. PM R 2023; 15:1403-1410. [PMID: 36787167 DOI: 10.1002/pmrj.12963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 11/29/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Task-specific motor training and repetitive practice are essential components of clinical rehabilitation. Emerging evidence suggests that incorporating gaming interfaces (also referred to as "exergames"), including virtual reality and augmented reality (VR/AR)-based interfaces for motor training, can enhance the engagement and efficacy of poststroke rehabilitation. OBJECTIVE To investigate perceptions of individuals with stroke regarding technology and exergames for rehabilitation. DESIGN This qualitative phenomenological study included a convenience sample of 11 individuals with stroke (61.7 ± 12.4 years, 6 women and 5 men, 63.5 ± 41.2 months post stroke). SETTING Community. INTERVENTIONS N/A. OUTCOME MEASURES Semistructured open-ended focus-group interviews to understand their perceptions on technology and exergames to improve recovery were coded using thematic content analysis. RESULTS Individuals with stroke were comfortable using smartphones, computers, and rehabilitation technologies but had limited experiences using exergames and VR/AR devices. Individuals with stroke were motivated to use technologies and exergames to improve their functional recovery. Participants identified facilitators (eg, enhancing functional recovery, feedback, therapist supervision) and barriers (eg, safety, inaccessibility, inadequate knowledge) to adopting exergames in their daily lives. Participants wanted the exergames to be customizable, goal oriented, and enjoyable to maintain their engagement. They were willing to use exergames to improve their functional recovery but indicated that these games could not replace the therapist's supervision. CONCLUSIONS Despite having limited experiences with exergames, people post stroke perceived that exergames could promote functional recovery. The perspectives gained from the present study can inform user-centered game design for neurorehabilitation.
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Affiliation(s)
- Shilpa Krishnan
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mahender A Mandala
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Steven L Wolf
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Center for Visual and Neurocognitive Rehabilitation, Atlanta Veterans Affairs Health Care Center
| | - Ayanna Howard
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, Georgia, USA
- The Ohio State University, College of Engineering, Columbus, Ohio, USA
| | - Trisha M Kesar
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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28
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Gunduz ME, Bucak B, Keser Z. Advances in Stroke Neurorehabilitation. J Clin Med 2023; 12:6734. [PMID: 37959200 PMCID: PMC10650295 DOI: 10.3390/jcm12216734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain-computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.
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Affiliation(s)
- Muhammed Enes Gunduz
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Bilal Bucak
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA; (B.B.); (Z.K.)
| | - Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA; (B.B.); (Z.K.)
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Bhatt T, Dusane S, Gangwani R, Wang S, Kannan L. Motor adaptation and immediate retention to overground gait-slip perturbation training in people with chronic stroke: an experimental trial with a comparison group. Front Sports Act Living 2023; 5:1195773. [PMID: 37780126 PMCID: PMC10533933 DOI: 10.3389/fspor.2023.1195773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/21/2023] [Indexed: 10/03/2023] Open
Abstract
Background Perturbation-based training has shown to be effective in reducing fall-risk in people with chronic stroke (PwCS). However, most evidence comes from treadmill-based stance studies, with a lack of research focusing on training overground perturbed walking and exploring the relative contributions of the paretic and non-paretic limbs. This study thus examined whether PwCS could acquire motor adaptation and demonstrate immediate retention of fall-resisting skills following bilateral overground gait-slip perturbation training. Methods 65 PwCS were randomly assigned to either (i) a training group, that received blocks of eight non-paretic (NP-S1 to NP-S8) and paretic (P-S1 to P-S8) overground slips during walking followed by a mixed block (seven non-paretic and paretic slips each interspersed with unperturbed walking trials) (NP-S9/P-S9 to NP-S15/P-S15) or (ii) a control group, that received a single non-paretic and paretic slip in random order. The assessor and training personnel were not blinded. Immediate retention was tested for the training group after a 30-minute rest break. Primary outcomes included laboratory-induced slip outcomes (falls and balance loss) and center of mass (CoM) state stability. Secondary outcomes to understand kinematic contributors to stability included recovery strategies, limb kinematics, slipping kinematics, and recovery stride length. Results PwCS within the training group showed reduced falls (p < 0.01) and improved post-slip stability (p < 0.01) from the first trial to the last trial of both paretic and non-paretic slip blocks (S1 vs. S8). During the mixed block training, there was no further improvement in stability and slipping kinematics (S9 vs. S15) (p > 0.01). On comparing the first and last training trial (S1 vs. S15), post-slip stability improved on both non-paretic and paretic slips, however, pre-slip stability improved only on the non-paretic slip (p < 0.01). On the retention trials, the training group had fewer falls and greater post-slip stability than the control group on both non-paretic and paretic slips (p < 0.01). Post-slip stability on the paretic slip was lower than that on the non-paretic slip for both groups on retention trials (p < 0.01). Conclusion PwCS can reduce laboratory-induced slip falls and backward balance loss outcomes by adapting their post-slip CoM state stability after bilateral overground gait-slip perturbation training. Such reactive adaptations were better acquired and retained post-training in PwCS especially on the non-paretic slips than paretic slips, suggesting a need for higher dosage for paretic slips. Clinical registry number NCT03205527.
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Affiliation(s)
- Tanvi Bhatt
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
| | - Shamali Dusane
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
- Ph.D. program in Rehabilitation Sciences, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
| | - Rachana Gangwani
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
- MS program in Rehabilitation Sciences, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
| | - Shuaijie Wang
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
| | - Lakshmi Kannan
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
- Ph.D. program in Rehabilitation Sciences, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, United States
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Reeves B, Smith E, Broussard M, Martin R. Activity based restorative therapy considerations for children: medical and therapeutic perspectives for the pediatric population. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1186212. [PMID: 37744428 PMCID: PMC10511641 DOI: 10.3389/fresc.2023.1186212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
Well-established scientific evidence demonstrates that activity is essential for the development and repair of the central nervous system, yet traditional rehabilitation approaches target muscles only above the lesion as a means of compensation. Activity-Based Rehabilitation (ABR) represents an evolving paradigm shift in neurorehabilitation targeting activation of the neuromuscular system below the lesion. Based on activity-dependent plasticity, ABR offers high intensity activation of the nervous system to optimize the capacity for recovery, while working to offset the chronic complications that occur as a result of neurologic injury. Treatment focus shifts from compensatory training to promotion of restoration of function with special emphasis on normalizing sensory cues and movement kinematics. ABR in children carries special considerations for a developing nervous system and the focus is not just restoring functions but advancing functions in line with typical development. Application of activity-based interventions includes traditional rehabilitation strategies at higher intensity and frequency than in traditional models, including locomotor training, functional electrical stimulation, massed practice, and task specific training, applied across the continuum of care from early intervention to the chronic condition.
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Affiliation(s)
- Brooke Reeves
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, United States
| | - Emily Smith
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, United States
| | - Miranda Broussard
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, United States
| | - Rebecca Martin
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Vasquez ED, Simpson CS, Zhou G, Lansberg M, Okamura AM. Evaluation of a Passive Wearable Device for Post-Stroke Shoulder Abduction Support. IEEE Int Conf Rehabil Robot 2023; 2023:1-6. [PMID: 37941216 DOI: 10.1109/icorr58425.2023.10304815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Post-stroke upper extremity function can be improved by devices that support shoulder abduction. However, many of these devices provide limited assistance in activities of daily living due to their complexity and encumbrance. We developed and evaluated a passive, lightweight (0.6 kg) wearable device consisting of an aluminum frame and elastic bands attached to a posture vest to aid in shoulder abduction. The number and thickness of bands can be adjusted to provide supportive forces to the affected arm. We measured reachable workspace area and Wolf Motor Function Test (WMFT) performance in people with a history of stroke (n = 11) with and without the wearable. The device increased workspace area in 6 participants and improved average WMFT functional and timing scores in 7 and 12 tasks, respectively, out of 16 total tasks. On average, participants increased their arm motion within 20 cm of shoulder level by 22.4% and decreased their hand's average distance from trunk by 15.2%, both improvements in the device case.
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Gardas SS, Lysaght C, McMillan AG, Kantak S, Willson JD, Patterson CG, Surkar SM. Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy. Behav Sci (Basel) 2023; 13:681. [PMID: 37622821 PMCID: PMC10451828 DOI: 10.3390/bs13080681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
The purpose of this study was to quantify characteristics of bimanual movement intensity during 30 h of hand-arm bimanual intensive therapy (HABIT) and bimanual performance (activities and participation) in real-world settings using accelerometers in children with unilateral cerebral palsy (UCP). Twenty-five children with UCP participated in a 30 h HABIT program. Data were collected from bilateral wrist-worn accelerometers during 30 h of HABIT to quantify the movement intensity and three days pre- and post-HABIT to assess real-world performance gains. Movement intensity and performance gains were measured using six standard accelerometer-derived variables. Bimanual capacity (body function and activities) was assessed using standardized hand function tests. We found that accelerometer variables increased significantly during HABIT, indicating increased bimanual symmetry and intensity. Post-HABIT, children demonstrated significant improvements in all accelerometer metrics, reflecting real-world performance gains. Children also achieved significant and clinically relevant changes in hand capacity following HABIT. Therefore, our findings suggest that accelerometers can objectively quantify bimanual movement intensity during HABIT. Moreover, HABIT enhances hand function as well as activities and participation in real-world situations in children with UCP.
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Affiliation(s)
- Shailesh S. Gardas
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Christine Lysaght
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Amy Gross McMillan
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Shailesh Kantak
- Moss Rehabilitation Research Institute, Elkins Park, PA 19027, USA
- Department of Physical Therapy, Arcadia University, Glenside, PA 19038, USA
| | - John D. Willson
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Charity G. Patterson
- Department of Physical Therapy and School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Swati M. Surkar
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
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Abdullahi A, Wong TWL, Ng SSM. Variation in the rate of recovery in motor function between the upper and lower limbs in patients with stroke: some proposed hypotheses and their implications for research and practice. Front Neurol 2023; 14:1225924. [PMID: 37602245 PMCID: PMC10435271 DOI: 10.3389/fneur.2023.1225924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background Stroke results in impairment of motor function of both the upper and lower limbs. However, although it is debatable, motor function of the lower limb is believed to recover faster than that of the upper limb. The aim of this paper is to propose some hypotheses to explain the reasons for that, and discuss their implications for research and practice. Method We searched PubMED, Web of Science, Scopus, Embase and CENTRAL using the key words, stroke, cerebrovascular accident, upper extremity, lower extremity, and motor recovery for relevant literature. Result The search generated a total of 2,551 hits. However, out of this number, 51 duplicates were removed. Following review of the relevant literature, we proposed four hypotheses: natural instinct for walking hypothesis, bipedal locomotion hypothesis, central pattern generators (CPGs) hypothesis and role of spasticity hypothesis on the subject matter. Conclusion We opine that, what may eventually account for the difference, is the frequency of use of the affected limb or intensity of the rehabilitation intervention. This is because, from the above hypotheses, the lower limb seems to be used more frequently. When limbs are used frequently, this will result in use-dependent plasticity and eventual recovery. Thus, rehabilitation techniques that involve high repetitive tasks practice such as robotic rehabilitation, Wii gaming and constraint induced movement therapy should be used during upper limb rehabilitation.
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Kesar T. The Effects of Stroke and Stroke Gait Rehabilitation on Behavioral and Neurophysiological Outcomes:: Challenges and Opportunities for Future Research. Dela J Public Health 2023; 9:76-81. [PMID: 37701480 PMCID: PMC10494801 DOI: 10.32481/djph.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Stroke continues to be a leading cause of adult disability, contributing to immense healthcare costs. Even after discharge from rehabilitation, post-stroke individuals continue to have persistent gait impairments, which in turn adversely affect functional mobility and quality of life. Multiple factors, including biomechanics, energy cost, psychosocial variables, as well as the physiological function of corticospinal neural pathways influence stroke gait function and training-induced gait improvements. As a step toward addressing this challenge, the objective of the current perspective paper is to outline knowledge gaps pertinent to the measurement and retraining of stroke gait dysfunction. The paper also has recommendations for future research directions to address important knowledge gaps, especially related to the measurement and rehabilitation-induced modulation of biomechanical and neural processes underlying stroke gait dysfunction. We posit that there is a need for leveraging emerging technologies to develop innovative, comprehensive, methods to measure gait patterns quantitatively, to provide clinicians with objective measure of gait quality that can supplement conventional clinical outcomes of walking function. Additionally, we posit that there is a need for more research on how the stroke lesion affects multiple parts of the nervous system, and to understand the neuroplasticity correlates of gait training and gait recovery. Multi-modal clinical research studies that can combine clinical, biomechanical, neural, and computational modeling data provide promise for gaining new information about stroke gait dysfunction as well as the multitude of factors affecting recovery and treatment response in people with post-stroke hemiparesis.
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Affiliation(s)
- Trisha Kesar
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine
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Silva RC, Lourenço BG, Ulhoa PHF, Dias EAF, da Cunha FL, Tonetto CP, Villani LG, Vimieiro CBS, Lepski GA, Monjardim M, Andrade RM. Biomimetic Design of a Tendon-Driven Myoelectric Soft Hand Exoskeleton for Upper-Limb Rehabilitation. Biomimetics (Basel) 2023; 8:317. [PMID: 37504205 PMCID: PMC10807486 DOI: 10.3390/biomimetics8030317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023] Open
Abstract
Degenerative diseases and injuries that compromise hand movement reduce individual autonomy and tend to cause financial and psychological problems to their family nucleus. To mitigate these limitations, over the past decade, hand exoskeletons have been designed to rehabilitate or enhance impaired hand movements. Although promising, these devices still have limitations, such as weight and cost. Moreover, the movements performed are not kinematically compatible with the joints, thereby reducing the achievements of the rehabilitation process. This article presents the biomimetic design of a soft hand exoskeleton actuated using artificial tendons designed to achieve low weight, volume, and cost, and to improve kinematic compatibility with the joints, comfort, and the sensitivity of the hand by allowing direct contact between the hand palm and objects. We employed two twisted string actuators and Bowden cables to move the artificial tendons and perform the grasping and opening of the hand. With this configuration, the heavy part of the system was reallocated to a test bench, allowing for a lightweight set of just 232 g attached to the arm. The system was triggered by the myoelectric signals of the biceps captured from the user's skin to encourage the active participation of the user in the process. The device was evaluated by five healthy subjects who were asked to simulate a paralyzed hand, and manipulate different types of objects and perform grip strength. The results showed that the system was able to identify the intention of movement of the user with an accuracy of 90%, and the orthosis was able to enhance the ability of handling objects with gripping force up to 1.86 kgf.
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Affiliation(s)
- Rodrigo C. Silva
- Department of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil; (R.C.S.); (B.G.L.); (F.L.d.C.); (C.P.T.); (L.G.V.)
| | - Bruno. G. Lourenço
- Department of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil; (R.C.S.); (B.G.L.); (F.L.d.C.); (C.P.T.); (L.G.V.)
| | - Pedro H. F. Ulhoa
- Department of Electrical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil;
| | - Eduardo A. F. Dias
- Graduate Program of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil;
| | - Fransergio L. da Cunha
- Department of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil; (R.C.S.); (B.G.L.); (F.L.d.C.); (C.P.T.); (L.G.V.)
| | - Cristiane P. Tonetto
- Department of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil; (R.C.S.); (B.G.L.); (F.L.d.C.); (C.P.T.); (L.G.V.)
| | - Luis G. Villani
- Department of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil; (R.C.S.); (B.G.L.); (F.L.d.C.); (C.P.T.); (L.G.V.)
| | - Claysson B. S. Vimieiro
- Graduate Program of Mechanical Engineering, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil;
| | - Guilherme A. Lepski
- Departments of Neurology and Psychiatry, Medical School, Universidade de São Paulo, São Paulo 05403-010, Brazil;
| | - Marina Monjardim
- Graduate Program of Animal Biology, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil;
| | - Rafhael M. Andrade
- Department of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil; (R.C.S.); (B.G.L.); (F.L.d.C.); (C.P.T.); (L.G.V.)
- Graduate Program of Mechanical Engineering, Universidade Federal do Espírito Santo, Vitória 29.075-910, Brazil;
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Li M, Scronce G, Finetto C, Coupland K, Zhong M, Lambert ME, Baker A, Luo F, Seo NJ. Application of Deep Learning Algorithm to Monitor Upper Extremity Task Practice. SENSORS (BASEL, SWITZERLAND) 2023; 23:6110. [PMID: 37447958 DOI: 10.3390/s23136110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/25/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
Upper extremity hemiplegia is a serious problem affecting the lives of many people post-stroke. Motor recovery requires high repetitions and quality of task-specific practice. Sufficient practice cannot be completed during therapy sessions, requiring patients to perform additional task practices at home on their own. Adherence to and quality of these home task practices are often limited, which is likely a factor reducing rehabilitation effectiveness post-stroke. However, home adherence is typically measured by self-reports that are known to be inconsistent with objective measurement. The objective of this study was to develop algorithms to enable the objective identification of task type and quality. Twenty neurotypical participants wore an IMU sensor on the wrist and performed four representative tasks in prescribed fashions that mimicked correct, compensatory, and incomplete movement qualities typically seen in stroke survivors. LSTM classifiers were trained to identify the task being performed and its movement quality. Our models achieved an accuracy of 90.8% for task identification and 84.9%, 81.1%, 58.4%, and 73.2% for movement quality classification for the four tasks for unseen participants. The results warrant further investigation to determine the classification performance for stroke survivors and if quantity and quality feedback from objective monitoring facilitates effective task practice at home, thereby improving motor recovery.
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Affiliation(s)
- Mingqi Li
- Department of Computer Science, School of Computing, Clemson University, Clemson, SC 29634, USA
| | - Gabrielle Scronce
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
| | - Christian Finetto
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kristen Coupland
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
| | - Matthew Zhong
- Department of Computer Science, School of Computing, Clemson University, Clemson, SC 29634, USA
- Summer Intern, Research Experience for Undergraduates, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Melanie E Lambert
- Department of Computer Science, School of Computing, Clemson University, Clemson, SC 29634, USA
| | - Adam Baker
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
| | - Feng Luo
- Department of Computer Science, School of Computing, Clemson University, Clemson, SC 29634, USA
| | - Na Jin Seo
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Health Care System, Charleston, SC 29401, USA
- Department of Rehabilitation Sciences, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
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King EC, Pedi E, Stoykov ME, Corcos DM, Urday S. Combining high dose therapy, bilateral motor priming, and vagus nerve stimulation to treat the hemiparetic upper limb in chronic stroke survivors: a perspective on enhancing recovery. Front Neurol 2023; 14:1182561. [PMID: 37448744 PMCID: PMC10336216 DOI: 10.3389/fneur.2023.1182561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Stroke is a leading cause of disability worldwide and upper limb hemiparesis is the most common post-stroke disability. Recent studies suggest that clinically significant motor recovery is possible in chronic stroke survivors with severe impairment of the upper limb. Three promising strategies that have been investigated are (1) high dose rehabilitation therapy (2) bilateral motor priming and (3) vagus nerve stimulation. We propose that the future of effective and efficient upper limb rehabilitation will likely require a combination of these approaches.
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Affiliation(s)
- Erin C. King
- Northwestern University, Evanston, IL, United States
| | - Elizabeth Pedi
- Physical Therapy & Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Mary Ellen Stoykov
- Shirley Ryan AbilityLab, Chicago, IL, United States
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniel M. Corcos
- Physical Therapy & Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sebastian Urday
- The Ken & Ruth Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Lipson-Smith R, Zeeman H, Muns L, Jeddi F, Simondson J, Bernhardt J. The role of the physical environment in stroke recovery: Evidence-based design principles from a mixed-methods multiple case study. PLoS One 2023; 18:e0280690. [PMID: 37294748 PMCID: PMC10256226 DOI: 10.1371/journal.pone.0280690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/05/2023] [Indexed: 06/11/2023] Open
Abstract
Hospital design can impact patient outcomes, but there is very little healthcare design evidence specific to stroke rehabilitation facilities. Our aim was to explore, from the patient perspective, the role of the physical environment in factors crucial to stroke recovery, namely, stroke survivor activity (physical, cognitive, social), sleep, emotional well-being, and safety. We conducted a mixed-methods multiple-case study at two inpatient rehabilitation facilities in Victoria, Australia, (n = 20 at Case 1, n = 16 at Case 2) using "walk-through" semi-structured interviews, behavioural mapping, questionnaires, and retrospective audit. Four interrelated themes emerged: 1) entrapment and escape; 2) power, dependency, and identity in an institutional environment; 3) the rehabilitation facility is a shared space; and 4) the environment should be legible and patient-centred. Quantitative data revealed patterns in patient activity; stroke survivors spent over 75% of their time in bedrooms and were often inactive. Convergent mixed methods analysis was used to generate a new conceptual model of the role of the physical environment in stroke survivors' behaviour and well-being, highlighting the importance of variety and interest, privacy without isolation, and patient-centred design. This model can be used by designers, healthcare providers, and policy makers to inform the design of rehabilitation environments.
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Affiliation(s)
- Ruby Lipson-Smith
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Heidi Zeeman
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Leanne Muns
- Bendigo Health, Clinical Operations, Bendigo, Victoria, Australia
| | - Faraz Jeddi
- Bendigo Health, Department of Integrated Medicine, Bendigo, Victoria, Australia
| | - Janine Simondson
- St Vincent’s Hospital Melbourne, Physiotherapy and Rehabilitation Unit, St George’s Hospital, Kew, Victoria, Australia
| | - Julie Bernhardt
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
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Badran BW, Peng X, Baker-Vogel B, Hutchison S, Finetto P, Rishe K, Fortune A, Kitchens E, O’Leary GH, Short A, Finetto C, Woodbury ML, Kautz S. Motor Activated Auricular Vagus Nerve Stimulation as a Potential Neuromodulation Approach for Post-Stroke Motor Rehabilitation: A Pilot Study. Neurorehabil Neural Repair 2023; 37:374-383. [PMID: 37209010 PMCID: PMC10363288 DOI: 10.1177/15459683231173357] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Implanted vagus nerve stimulation (VNS), when synchronized with post-stroke motor rehabilitation improves conventional motor rehabilitation training. A non-invasive VNS method known as transcutaneous auricular vagus nerves stimulation (taVNS) has emerged, which may mimic the effects of implanted VNS. OBJECTIVE To determine whether taVNS paired with motor rehabilitation improves post-stroke motor function, and whether synchronization with movement and amount of stimulation is critical to outcomes. METHODS We developed a closed-loop taVNS system for motor rehabilitation called motor activated auricular vagus nerve stimulation (MAAVNS) and conducted a randomized, double-blind, pilot trial investigating the use of MAAVNS to improve upper limb function in 20 stroke survivors. Participants attended 12 rehabilitation sessions over 4-weeks, and were assigned to a group that received either MAAVNS or active unpaired taVNS concurrently with task-specific training. Motor assessments were conducted at baseline, and weekly during rehabilitation training. Stimulation pulses were counted for both groups. RESULTS A total of 16 individuals completed the trial, and both MAAVNS (n = 9) and unpaired taVNS (n = 7) demonstrated improved Fugl-Meyer Assessment upper extremity scores (Mean ± SEM, MAAVNS: 5.00 ± 1.02, unpaired taVNS: 3.14 ± 0.63). MAAVNS demonstrated greater effect size (Cohen's d = 0.63) compared to unpaired taVNS (Cohen's d = 0.30). Furthermore, MAAVNS participants received significantly fewer stimulation pulses (Mean ± SEM, MAAVNS: 36 070 ± 3205) than the fixed 45 000 pulses unpaired taVNS participants received (P < .05). CONCLUSION This trial suggests stimulation timing likely matters, and that pairing taVNS with movements may be superior to an unpaired approach. Additionally, MAAVNS effect size is comparable to that of the implanted VNS approach.
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Affiliation(s)
- Bashar W. Badran
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
- Deparment of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Xiaolong Peng
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
- Deparment of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Brenna Baker-Vogel
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
| | - Scott Hutchison
- Deparment of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Patricia Finetto
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly Rishe
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI, USA
| | - Andrew Fortune
- Deparment of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Ellen Kitchens
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
| | - Georgia H. O’Leary
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
| | - Abigail Short
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, USA
| | - Christian Finetto
- Deparment of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Michelle L. Woodbury
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA
| | - Steve Kautz
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA
- Ralph H Johnson VA Health Care System, Charleston, SC, USA
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Pila O, Duret C, Koeppel T, Jamin P. Performance-Based Robotic Training in Individuals with Subacute Stroke: Differences between Responders and Non-Responders. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23094304. [PMID: 37177508 PMCID: PMC10181678 DOI: 10.3390/s23094304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
The high variability of upper limb motor recovery with robotic training (RT) in subacute stroke underscores the need to explore differences in responses to RT. We explored differences in baseline characteristics and the RT dose between responders (ΔFugl-Meyer Assessment (FMA) score ≥ 9 points; n = 20) and non-responders (n = 16) in people with subacute stroke (mean [SD] poststroke time at baseline, 54 (26) days, baseline FMA score, 23 (17) points) who underwent 16 RT sessions combined with conventional therapies. Baseline characteristics were compared between groups. During RT sessions, the actual practice time (%), number of movements performed, and total distance covered (cm) in assisted and unassisted modalities were compared between groups. At baseline, participant characteristics and FMA scores did not differ between groups. During the RT, non-responders increased practice time (+15%; p = 0.02), performed more movements (+285; p = 0.004), and covered more distance (+4037 cm; p < 10-3), with no difference between physical modalities. In contrast, responders decreased practice time (-21%; p = 0.01) and performed fewer movements (-338; p = 0.03) in the assisted modality while performing more movements (+328; p < 0.05) and covering a greater distance (+4779 cm; p = 0.01) in unassisted modalities. Despite a large amount of motor practice, motor outcomes did not improve in non-responders compared to responders: the difficulty level in RT may have been too low for them. Future studies should combine robot-based parameters to describe the treatment dose, especially in people with severe-to-moderate arm paresis, to optimize the RT and improve the recovery prognosis.
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Affiliation(s)
- Ophélie Pila
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, 77310 Boissise-Le-Roi, France
| | - Christophe Duret
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, 77310 Boissise-Le-Roi, France
| | - Typhaine Koeppel
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, 77310 Boissise-Le-Roi, France
| | - Pascal Jamin
- Institut Robert Merle d'Aubigné, Rééducation et Appareillage, 94460 Valenton, France
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Morrow C, Woodbury M, Simpson AN, Almallouhi E, Simpson KN. Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing. Arch Phys Med Rehabil 2023; 104:547-553. [PMID: 36513124 PMCID: PMC10967225 DOI: 10.1016/j.apmr.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.
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Affiliation(s)
- Corey Morrow
- College of Health Professions, Medical University of South Carolina, Charleston, SC; Department of Occupational Therapy, Whitworth University, Spokane, WA.
| | - Michelle Woodbury
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Annie N Simpson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Eyad Almallouhi
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kit N Simpson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
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Affiliation(s)
- David J Lin
- Department of Neurology, Division of Neurocritical Care and Stroke Service, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Veterans Affairs, Rehabilitation Research and Development Service, Center for Neurorestoration and Neurotechnology, Providence, Rhode Island
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, New York
- Department of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York
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Boyne P, Billinger SA, Reisman DS, Awosika OO, Buckley S, Burson J, Carl D, DeLange M, Doren S, Earnest M, Gerson M, Henry M, Horning A, Khoury JC, Kissela BM, Laughlin A, McCartney K, McQuaid T, Miller A, Moores A, Palmer JA, Sucharew H, Thompson ED, Wagner E, Ward J, Wasik EP, Whitaker AA, Wright H, Dunning K. Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial. JAMA Neurol 2023; 80:342-351. [PMID: 36822187 PMCID: PMC9951105 DOI: 10.1001/jamaneurol.2023.0033] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/08/2022] [Indexed: 02/25/2023]
Abstract
Importance For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization. Objective To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke. Design, Setting, and Participants This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled. Interventions Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated. Main Outcomes and Measures The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training. Results Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, -9 to 33 m]; mean difference, 15 m [95% CI, -13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue. Conclusions and Relevance These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains. Trial Registration ClinicalTrials.gov Identifier: NCT03760016.
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Affiliation(s)
- Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Sandra A. Billinger
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
- Department of Cell Biology and Integrative Physiology, School of Medicine, University of Kansas Medical Center, Kansas City
- University of Kansas Alzheimer’s Research Disease Center, Fairway
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Darcy S. Reisman
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Oluwole O. Awosika
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sofia Buckley
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Jamiah Burson
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Daniel Carl
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Matthew DeLange
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Sarah Doren
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Melinda Earnest
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Myron Gerson
- Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Department of Cardiology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Madison Henry
- Department of Physical Therapy, Rehabilitation Sciences, and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City
| | - Alli Horning
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Abigail Laughlin
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Kiersten McCartney
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Thomas McQuaid
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Allison Miller
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Alexandra Moores
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Jacqueline A. Palmer
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth D. Thompson
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Erin Wagner
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Jaimie Ward
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Emily Patton Wasik
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Alicen A. Whitaker
- Department of Physical Therapy, Rehabilitation Sciences, and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City
| | - Henry Wright
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Kari Dunning
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
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Mischler B, Hilfiker R, Hund-Georgiadis M, Maguire C. Physical activity based on daily step-count in inpatient setting in stroke and traumatic brain injury patients in subacute stage: A cross-sectional observational study. NeuroRehabilitation 2023; 52:435-450. [PMID: 37005896 DOI: 10.3233/nre-220248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Daily step-count is important post-insult in the subacute phase to influence neuroplasticity, functional recovery and as a predictive factor for activity level one-year post event. OBJECTIVE Measure daily step-count in subacute patients follow-ing brain injury in an inpatient neurorehabilitation setting and compare these to evi-dence-based recommendations. METHODS 30 participants measured of daily step-count over a seven-day period, throughout the day to assess when and how activity varied. Step-counts were analyzed in sub-groups based on walking ability using the Functional Ambulation Categories (FAC). Correlations between steps-count and FAC level, walking speed, light touch, joint position sense, cognition, and fear of falling were calculated. RESULTS Median (IQR) daily steps for all patients was 2512 (568.5,4070.5). Not independently walkers took 336 (5–705), the value is below the recommendation. Participants walking with assistance took 700 (31–3080), significantly below recommended value (p = 0.002), independent walkers took 4093 (2327–5868) daily steps, significantly below recommended value (p = < 0.001). Step-count showed moderate to high and statistically-significant correlations: positive for walking speed, joint position sense, negative for fear of falling, and number of medications. CONCLUSIONS Only 10% of all participants reached the recommended daily steps. Interdisciplinary team-work and strategies to increase daily activity between therapies may be crucial to achieve recommended step-levels in subacute inpatient settings.
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Affiliation(s)
- Brigitte Mischler
- Center for Neurorehabilitation and Paraplegiology, REHAB Basel, Basel, Switzerland
- Bern University of Applied Science, Department of Health, Bern, Switzerland
| | - Roger Hilfiker
- Bern University of Applied Science, Department of Health, Bern, Switzerland
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne, Lausanne, Switzerland
| | | | - Clare Maguire
- Center for Neurorehabilitation and Paraplegiology, REHAB Basel, Basel, Switzerland
- Bern University of Applied Science, Department of Health, Bern, Switzerland
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Moskiewicz D, Mraz M, Chamela-Bilińska D. Botulinum Toxin and Dynamic Splint Restore Grasping Function after Stroke: A Case Report. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4873. [PMID: 36981781 PMCID: PMC10049400 DOI: 10.3390/ijerph20064873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 06/18/2023]
Abstract
Evidence on the effectiveness of upper extremity rehabilitation post-stroke is inconclusive. We evaluated a tailored therapeutic program with dynamic splint and botulinum toxin injections for the treatment of upper extremity muscle spasticity. A case of a 43-year-old woman with chronic spastic hemiparesis after ischemic stroke with significant mobility impairment in the left upper extremity was described. A 16-week program consisted of three 50-min sessions daily and focused on grasping and releasing with and without the splint. The patient was evaluated before botulinum toxin injection and after 6, 12 and 16 weeks according to the International Classification of Functioning, Disability and Health, and included the following scales: Fugl-Meyer Upper Extremity Assessment (FMA-UE), Modified Ashworth Scale, Numerical Rating Scale (NRS), MyotonPro, Stroke Impact Scale, Box and Blocks. Photographic documentation made before and after the experiment was compared. Motor functions improved by 19.7% on FMA-UE, spasticity was reduced by one degree and pain at rest and during activity decreased by one score on NRS. A reduction in the oscillation frequency of the relaxed muscle and the stiffness of the examined muscles was observed. The patient regained grasping function. Health-related quality of life was systematically improving with a 35% increase at week 16 compared to the baseline. The combination treatment for spasticity based on botulinum toxin and SaeboFlex® dynamic splint in a patient with chronic spastic hemiparesis reduces disability and improves quality of life. However, further research is needed to investigate the treatment results.
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Affiliation(s)
- Denis Moskiewicz
- Department of Physiotherapy, Wroclaw University of Health and Sport Sciences, 51-612 Wrocław, Poland
- Rehabilitation Department, T. Marciniak Lower Silesian Specialist Hospital, Emergency Medicine Center, 54-049 Wrocław, Poland
| | - Małgorzata Mraz
- Department of Physiotherapy, Wroclaw University of Health and Sport Sciences, 51-612 Wrocław, Poland
| | - Dagmara Chamela-Bilińska
- Department of Physiotherapy, Wroclaw University of Health and Sport Sciences, 51-612 Wrocław, Poland
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Edwards D, Kumar S, Brinkman L, Ferreira IC, Esquenazi A, Nguyen T, Su M, Stein S, May J, Hendrix A, Finley C, Howard E, Cramer SC. Telerehabilitation Initiated Early in Post-Stroke Recovery: A Feasibility Study. Neurorehabil Neural Repair 2023; 37:131-141. [PMID: 36876946 PMCID: PMC10080366 DOI: 10.1177/15459683231159660] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Enhanced neural plasticity early after stroke suggests the potential to improve outcomes with intensive rehabilitation therapy. Most patients do not get such therapy, however, due to limited access, changing rehabilitation therapy settings, low therapy doses, and poor compliance. OBJECTIVE To examine the feasibility, safety, and potential efficacy of an established telerehabilitation (TR) program after stroke initiated during admission to an inpatient rehabilitation facility (IRF) and completed in the patient's home. METHODS Participants with hemiparetic stroke admitted to an IRF received daily TR targeting arm motor function in addition to usual care. Treatment consisted of 36, 70-minute sessions (half supervised by a licensed therapist via videoconference), over a 6-week period, that included functional games, exercise videos, education, and daily assessments. RESULTS Sixteen participants of 19 allocated completed the intervention (age 61.3 ± 9.4 years; 6 female; baseline Upper Extremity Fugl-Meyer [UEFM] score 35.9 ± 6.4 points, mean ± SD; NIHSS score 4 (3.75, 5.25), median, IQR; intervention commenced 28.3 ± 13.0 days post-stroke). Compliance was 100%, retention 84%, and patient satisfaction 93%; 2 patients developed COVID-19 and continued TR. Post-intervention UEFM improvement was 18.1 ± 10.9 points (P < .0001); Box and Blocks, 22.4 ± 9.8 blocks (P = .0001). Digital motor assessments, acquired daily in the home, were concordant with these gains. The dose of rehabilitation therapy received as usual care during this 6-week interval was 33.9 ± 20.3 hours; adding TR more than doubled this to 73.6 ± 21.8 hours (P < .0001). Patients enrolled in Philadelphia could be treated remotely by therapists in Los Angeles. CONCLUSIONS These results support feasibility, safety, and potential efficacy of providing intense TR therapy early after stroke. CLINICAL TRIAL REGISTRATION clinicaltrials.gov; NCT04657770.
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Affiliation(s)
- Dylan Edwards
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Sapna Kumar
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Lorie Brinkman
- UCLA and California Rehabilitation Institute, Los Angeles, CA, USA
| | | | | | - Tiffany Nguyen
- UCLA and California Rehabilitation Institute, Los Angeles, CA, USA
| | - Michael Su
- UCLA and California Rehabilitation Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - Steven C Cramer
- UCLA and California Rehabilitation Institute, Los Angeles, CA, USA
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Johnson L, Burridge J, Ewings S, Westcott E, Gayton M, Demain S. Principles into Practice: An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation. Physiotherapy 2023; 118:20-30. [PMID: 36306569 PMCID: PMC9907222 DOI: 10.1016/j.physio.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 03/21/2022] [Accepted: 06/14/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE(S) To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation; and b) the context in which these principles are used, in relation to patient and/or task characteristics. DESIGN Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record: type of activity; repetitions; instructional and feedback statements (frequency and type); strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively. SETTING 6 UK Stroke Units PARTICIPANTS: 89 therapy sessions were observed, involving 55 clinicians and 57 patients. RESULTS Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cues/motivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset. CONCLUSIONS To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke. TRIAL REGISTRATION NUMBER Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.
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Affiliation(s)
- Louise Johnson
- University Hospitals Dorset NHS Foundation Trust, Castle Lane East, Bournemouth, Dorset, UK; School of Health Sciences, Faculty of Environmental and Life Sciences, Building 45, University of Southampton, Southampton SO17 1BJ.
| | - Jane Burridge
- School of Health Sciences, Faculty of Environmental and Life Sciences, Building 45, University of Southampton, Southampton SO17 1BJ
| | - Sean Ewings
- Southampton Clinical Trials Unit, University of Southampton, University Road, Southampton, SO17 1BJ
| | - Ellie Westcott
- University Hospitals Dorset NHS Foundation Trust, Castle Lane East, Bournemouth, Dorset, UK
| | - Marianne Gayton
- University Hospitals Dorset NHS Foundation Trust, Castle Lane East, Bournemouth, Dorset, UK
| | - Sara Demain
- School of Health Sciences, Faculty of Environmental and Life Sciences, Building 45, University of Southampton, Southampton SO17 1BJ
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MontJohnson A, Cronce A, Qiu Q, Patel J, Eriksson M, Merians A, Adamovich S, Fluet G. Laboratory-Based Examination of the Reliability and Validity of Kinematic Measures of Wrist and Finger Function Collected by a Telerehabilitation System in Persons with Chronic Stroke. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23052656. [PMID: 36904860 PMCID: PMC10007090 DOI: 10.3390/s23052656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 06/09/2023]
Abstract
We have developed the New Jersey Institute of Technology-Home Virtual Rehabilitation System (NJIT-HoVRS) to facilitate intensive, hand-focused rehabilitation in the home. We developed testing simulations with the goal of providing richer information for clinicians performing remote assessments. This paper presents the results of reliability testing examining differences between in-person and remote testing as well as discriminatory and convergent validity testing of a battery of six kinematic measures collected with NJIT-HoVRS. Two different groups of persons with upper extremity impairments due to chronic stroke participated in two separate experiments. Data Collection: All data collection sessions included six kinematic tests collected with the Leap Motion Controller. Measurements collected include hand opening range, wrist extension range, pronation-supination range, hand opening accuracy, wrist extension accuracy, and pronation-supination accuracy. The system usability was evaluated by therapists performing the reliability study using the System Usability Scale. When comparing the in-laboratory collection and the first remote collection, the intra-class correlation coefficients (ICC) for three of the six measurements were above 0.900 and the other three were between 0.500 and 0.900. Two of the first remote collection/second remote collection ICCs were above 0.900, and the other four were between 0.600 and 0.900. The 95% confidence intervals for these ICC were broad, suggesting that these preliminary analyses need to be confirmed by studies with larger samples. The therapist's SUS scores ranged from 70 to 90. The mean was 83.1 (SD = 6.4), which is consistent with industry adoption. There were statistically significant differences in the kinematic scores when comparing unimpaired and impaired UE for all six measures. Five of six impaired hand kinematic scores and five of six impaired/unimpaired hand difference scores demonstrated correlations between 0.400 and 0.700 with UEFMA scores. Reliability for all measures was acceptable for clinical practice. Discriminant and convergent validity testing suggest that scores on these tests may be meaningful and valid. Further testing in a remote setting is necessary to validate this process.
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Affiliation(s)
- Ashley MontJohnson
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ 07105, USA
- NeurotechR3 Inc., Warren, NJ 07059, USA
| | - Amanda Cronce
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ 07105, USA
- NeurotechR3 Inc., Warren, NJ 07059, USA
| | - Qinyin Qiu
- NeurotechR3 Inc., Warren, NJ 07059, USA
- School of Health Professions, Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA
| | - Jigna Patel
- School of Health Professions, Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA
| | | | - Alma Merians
- School of Health Professions, Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA
| | - Sergei Adamovich
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ 07105, USA
- School of Health Professions, Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA
| | - Gerard Fluet
- School of Health Professions, Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA
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Westlake K, Akinlosotu R, Udo J, Goldstein Shipper A, Waller SM, Whitall J. Some home-based self-managed rehabilitation interventions can improve arm activity after stroke: A systematic review and narrative synthesis. Front Neurol 2023; 14:1035256. [PMID: 36816549 PMCID: PMC9932529 DOI: 10.3389/fneur.2023.1035256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
Background There is an increased need for home-based, self-managed, and low maintenance stroke rehabilitation as well as interest in targeting the arm, which often lags behind leg recovery. Previous reviews have not controlled for concurrent standard of care and the ratio of self-managed care to therapist input. Objectives To determine the effectiveness of home-based, self-managed and low maintenance programs for upper-limb motor recovery in individuals after stroke. A secondary objective explored the adherence to home-based self-managed programs. Data sources We searched PubMed (1809-present), Embase (embase.com, 1974-present), Cochrane CENTRAL Register of Controlled Trials (Wiley), CINAHL (EBSCOhost, 1937-present), Physiotherapy Evidence Database (pedro.org.au), OTseeker (otseeker.com), and REHABDATA (National Rehabilitation Information Center). All searches were completed on June 9, 2022. Bibliographic references of included articles also were searched. Eligibility criteria Randomized controlled trials (RCT) in adults after stroke, where both intervention and control were home-based, at least 75% self-managed and did not involve concurrent therapy as a confounding factor. Primary outcome was performance in functional motor activities after training. Secondary outcome was sensorimotor impairment. All outcomes after a retention period were also considered secondary outcomes. Data collection and analysis Two review authors independently screened titles/abstracts, three review authors screened full papers and extracted data, and two review authors undertook assessment of risk of bias (i.e., allocation bias, measurement bias, confounding factors) using the NHLBI Study Quality Assessment Tool. Main results We identified seven heterogenous studies, including five with fair to good quality. All studies had an alternative treatment, dose-equivalent control. Only one trial reported a positive, sustained, between-group effect on activity for the experimental group. The remaining studies reported seven interventions having a within-group training effect with three interventions having sustained effects at follow up. One study reported a between group effect on an impairment measure with no follow-up. Overall adherence rates were high, but three studies reported differential group rates. Compliance with daily logs was higher when the logs were collected on a weekly basis. Limitations By excluding studies that allowed concurrent therapy, we likely minimized the number of studies that included participants in the early sub-acute post-stroke stage. By focusing on RCTs, we are unable to comment on other potentially promising home-based, self-managed single cohort programs. By including only published and English language studies, we may have included publication bias. Conclusions and implications There is some evidence that a variety of home-based, self-managed training program can be beneficial after stroke. Future research could compare such programs with natural history controls. Clinicians might utilize home exercise programs with explicit directions and some form of weekly contact to aid compliance.
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Affiliation(s)
- Kelly Westlake
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
| | - Ruth Akinlosotu
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
| | - Jean Udo
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
| | - Andrea Goldstein Shipper
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, United States
| | - Sandy McCombe Waller
- Division of Health, Business, Technology, and Science, Frederick Community College, Frederick, MD, United States
| | - Jill Whitall
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
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50
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Douglass-Kirk P, Grierson M, Ward NS, Brander F, Kelly K, Chegwidden W, Shivji D, Stewart L. Real-time auditory feedback may reduce abnormal movements in patients with chronic stroke. Disabil Rehabil 2023; 45:613-619. [PMID: 35238694 DOI: 10.1080/09638288.2022.2037751] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE The current pilot study assesses the use of real-time auditory feedback to help reduce abnormal movements during an active reaching task in patients with chronic stroke. MATERIALS AND METHODS 20 patients with chronic stroke completed the study with full datasets (age: M = 53 SD = 14; sex: male = 75%; time since stroke in months: M = 34, SD = 33). Patients undertook 100 repetitions of an active reaching task while listening to self-selected music which automatically muted when abnormal movement was detected, determined by thresholds set by clinical therapists. A within-subject design with two conditions (with auditory feedback vs. without auditory feedback) presented in a randomised counterbalanced order was used. The dependent variable was the duration of abnormal movement as a proportion of trial duration. RESULTS A significant reduction in the duration of abnormal movement was observed when patients received auditory feedback, F(1,18) = 9.424, p = 0.007, with a large effect size (partial η2 = 0.344). CONCLUSIONS Patients with chronic stroke can make use of real-time auditory feedback to increase the proportion of time they spend in optimal movement patterns. The approach provides a motivating framework that encourages high dose with a key focus on quality of movement. Trial Registration: ISRCTN12969079 https://www.isrctn.com/ISRCTN12969079 ISRTCN trial registration REF: ISRCTN12969079IMPLICATIONS FOR REHABILITATIONMovement quality during upper limb rehabilitation should be targeted as part of a well-balanced rehabilitation programme.Auditory feedback is a useful tool to help patients with chronic stroke reduce compensatory movements.
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Affiliation(s)
| | - Mick Grierson
- University of the Arts London, UAL Creative Computing Institute, London, UK
| | - Nick S Ward
- Department of clinical and Motor Neuroscience, UCL Queen Square Institute of Neurology.,National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK
| | - Fran Brander
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK
| | - Kate Kelly
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK
| | - Will Chegwidden
- Royal Free London NHS Foundation Trust, Royal Free London NHS Foundation Trust, London, UK
| | - Dhiren Shivji
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK
| | - Lauren Stewart
- Department of Psychology, Goldsmiths University of London, London, UK
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