Asymmetric training using virtual reality reflection equipment and the enhancement of upper limb function in stroke patients: a randomized controlled trial

Effects of font size, stroke, and background on the legibility of Chinese characters in virtual reality for the elderly

To investigate the legibility of Chinese characters' font size, text background opacity, and font stroke for the elderly in virtual reality, we recruited old and young participants to conduct experiments with VR and used eye-tracking technology to record the data of task completion time and error rate. After analysis, we concluded that the minimum recognition font size for the elderly is 30 dmm, and the best font size is 60 dmm, which is 20 and 40 dmm for young people. The font style has a significant effect on old people (p = 0.000*). Besides, for font sizes smaller than 20 dmm and bigger than 50 dmm, text with strokes and over 50% semi-transparent backgrounds can improve legibility for the elderly. With a suitable font size, the influence of font style on the elderly is not significant. These conclusions can provide a reference for the elderly-oriented Chinese font design in VR.

Video augmented mirror therapy for upper extremity rehabilitation after stroke: a randomized controlled trial

PURPOSE

To investigate the effects of mirror therapy using a newly developed video augmented wearable reflection device on reach-to-grasp motor control and upper extremity motor function.

METHODS

Participants were randomly allocated to one of three groups: mirror therapy using a video augmented wearable reflection device group (MTVADG), n = 12; traditional mirror therapy group (TMTG), n = 12; and control group (CG), n = 12. Participants in the MTVADG and TMTG received conventional rehabilitation in addition to mirror therapy. Motor control during the reach-to-grasp movement was assessed using kinematic analysis. Each participant's upper extremity motor function was assessed using the Fugl-Meyer Assessment, Manual Function Test, and Box and Block Test.

RESULTS

While both the MTVADG and TMTG showed significantly improved reach-to-grasp movement. The MTVADG showed greater efficiency in kinematic performance than the TMTG. Moreover, while both the MTVADG and TMTG showed improved upper extremity motor function, the MTVADG showed significantly greater improvement in proximal upper limb function compared to the TMTG.

CONCLUSION

Our results suggested that mirror therapy using a video augmented wearable reflection device is more efficient compared to traditional mirror therapy for patients with stroke.

CLINICAL TRIAL REGISTRATION UNIQUE IDENTIFIER

KCT0003047.

Perspectives of Motor Functional Upper Extremity Recovery with the Use of Immersive Virtual Reality in Stroke Patients

Stroke is one of the leading causes of disability, including loss of hand manipulative skills. It constitutes a major limitation in independence and the ability to perform everyday tasks. Among the numerous accessible physiotherapeutic methods, it is becoming more common to apply Virtual Reality "VR”. The aim of this study was to establish whether immersive VR was worth considering as a form of physical therapy and the advisability of applying it in restoring post-stroke hand function impairment. A proprietary application Virtual Mirror Hand 1.0 was used in the research and its effectiveness in therapy was compared to classical mirror therapy. A total of 20 survivors after ischaemic stroke with comparable functional status were divided into a study group (n = 10) and control group (n = 10). Diagnostic tools included 36-Item Short Form Survey “SF-36” and the Fugl-Meyer Assessment Upper Extremity “FMA-UE”. Collected metrics showed a normal distribution and the differences in mean values were tested by the student’s t-test. In both, the study and control groups’ changes were recorded. A statistically significant outcome for FMA-UE and SF-36 measured by the student’s t-test for dependent or independent samples (p > 0.05) were obtained in both groups. Importantly, proven by conducted studies, an advantage of VR proprietary application was subjective sensations amelioration in pain and sensory impressions. Applying Virtual Mirror Hand 1.0 treatment to patients after a stroke appears to be a good solution and definitely provides the opportunity to consider VR applications as an integral part of the neurorehabilitation process. These results give a basis to plan further larger-scale observation attempts. Moreover, the development of the Virtual Mirror Hand 1.0 as an innovative application in physiotherapy may become equivalent to classical mirror therapy in improving the quality and effectiveness of the treatment used for post-stroke patients.

Virtual reality in post-stroke neurorehabilitation - a systematic review and meta-analysis

BACKGROUND

Stroke is a neurological disorder and one of the leading causes of disability worldwide. The patient may lose the ability to adequately move the extremities, perceive sensations, or ambulate independently. Recent experimental studies have reported the beneficial influence of virtual reality training strategies on improving overall functional abilities for stroke survivors.

METHODS

Conducted a systematic review of the literature using the following keywords to retrieve the data: stroke, virtual reality, motor deficits, neurorehabilitation, cognitive impairments, and sensory deficits. A random-effect meta-analysis was performed for seven scales - one cognitive (MMSE) and six motor (Fugl-Meyer, Berg Balance Scale, Time up and go, Wolf motor function, 10 m walk, Brunnstrom score).

OBJECTIVE

To organize and compare all the available data regarding the effectiveness of virtual reality for stroke rehabilitation.

RESULTS

This literature reviewed 150 studies and included 46 for qualitative and 27 for quantitative analysis. There was no statistically significant difference between groups in MMSE score (MD = 0.24, 95%CI = ((-0.42) -(0.9)), p = .47, I² = 0%) and Fugl-Meyer score (MD = (-0.38), 95%CI = ((-12.88)-(12.11)), p = .95, I² = 98%) . The statistical significance was not reached in any of the other outcomes.

CONCLUSIONS

This review supports that stroke rehabilitation programs incorporating virtual reality are associated with improved functional outcomes, but there is no statistically significant difference compared to standard therapy.

Effect of different modalities of artificial intelligence rehabilitation techniques on patients with upper limb dysfunction after stroke-A network meta-analysis of randomized controlled trials

Background

This study aimed to observe the effects of six different types of AI rehabilitation techniques (RR, IR, RT, RT + VR, VR and BCI) on upper limb shoulder-elbow and wrist motor function, overall upper limb function (grip, grasp, pinch and gross motor) and daily living ability in subjects with stroke. Direct and indirect comparisons were drawn to conclude which AI rehabilitation techniques were most effective in improving the above functions.

Methods

From establishment to 5 September 2022, we systematically searched PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI, VIP and Wanfang. Only randomized controlled trials (RCTs) that met the inclusion criteria were included. The risk of bias in studies was evaluated using the Cochrane Collaborative Risk of Bias Assessment Tool. A cumulative ranking analysis by SUCRA was performed to compare the effectiveness of different AI rehabilitation techniques for patients with stroke and upper limb dysfunction.

Results

We included 101 publications involving 4,702 subjects. According to the results of the SUCRA curves, RT + VR (SUCRA = 84.8%, 74.1%, 99.6%) was most effective in improving FMA-UE-Distal, FMA-UE-Proximal and ARAT function for subjects with upper limb dysfunction and stroke, respectively. IR (SUCRA = 70.5%) ranked highest in improving FMA-UE-Total with upper limb motor function amongst subjects with stroke. The BCI (SUCRA = 73.6%) also had the most significant advantage in improving their MBI daily living ability.

Conclusions

The network meta-analysis (NMA) results and SUCRA rankings suggest RT + VR appears to have a greater advantage compared with other interventions in improving upper limb motor function amongst subjects with stroke in FMA-UE-Proximal and FMA-UE-Distal and ARAT. Similarly, IR had shown the most significant advantage over other interventions in improving the FMA-UE-Total upper limb motor function score of subjects with stroke. The BCI also had the most significant advantage in improving their MBI daily living ability. Future studies should consider and report on key patient characteristics, such as stroke severity, degree of upper limb impairment, and treatment intensity/frequency and duration.

Systematic review registration

www.crd.york.ac.uk/prospero/#recordDetail, identifier: CRD42022337776.

Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

INTRODUCTION

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).

METHODS

This study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.

RESULTS

The most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70-6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47-7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = - 0.58-4.72, P = 0.13), CONCLUSIONS: VAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

Enhancing Mirror Therapy via Scaling and Shared Control: A Novel Open-Source Virtual Reality Platform for Stroke Rehabilitation

Mirror therapy is increasingly used in stroke rehabilitation to improve functional movements of the affected limb. However, the extent of mirroring in conventional mirror therapy is typically fixed (1:1) and cannot be tailored based on the patient's impairment level. Further, the movements of the affected limb are not actively incorporated in the therapeutic process. To address these issues, we developed an immersive VR system using HTC Vive and Leap Motion, which communicates with our free and open-source software environment programmed using SteamVR and the Unity 3D gaming engine. The mirror therapy VR environment was incorporated with two novel features: (1) scalable mirroring and (2) shared control. In the scalable mirroring, mirror movements were programmed to be scalable between 0 and 1, where 0 represents no movements, 0.5 represents 50% mirroring, and 1 represents 100% mirroring. In shared control, the contribution of the mirroring limb to the movements was programmed to be scalable between 0 to 1, where 0 represents 100% contribution from the mirroring limb (i.e., no mirroring), 0.5 represents 50% of movements from the mirrored limb and 50% of movements from the mirroring limb, and 1 represents full mirroring (i.e., no shared movements). Validation experiments showed that these features worked appropriately. The proposed VR-based mirror therapy is the first fully developed system that is freely available to the rehabilitation science community. The scalable and shared control features can diversify mirror therapy and potentially augment the outcomes of rehabilitation, although this needs to be verified through future experiments.

A Novel Approach to Increase Attention during Mirror Therapy among Stroke Patients: A Video-Based Behavioral Analysis

Stroke is a major cause of disability and an evident rehabilitation strategy is crucial. Mirror therapy (MT) is one of the popular rehabilitation methods that is known to be effective as the patients benefit from the mirror illusion. However, the patient’s attention to the mirror illusion during treatment is unclear. Therefore, the present study assesses the duration and frequency of the mirror gaze, distraction, and preparation of sixteen stroke patients during two MT methods using a behavioral coding software. During the 30 min treatment, the total mirror gaze duration during conventional bilateral MT (BMT) was 564.04 s, while it was 1482.45 s in unilateral MT using a screen (UMT). The total distracted time was 945.61 s in BMT, while it was only 162.03 s in UMT. The total preparatory duration was 290.35 s in BMT and 155.53 s in UMT. The total number of distracted bouts were 136.45 in BMT, while it was 73.38 in UMT. The total number of preparatory bouts were 18.42 in BMT and 9.56 in UMT. The average times of gaze duration per bout were 5.52 s in BMT and 21.81 s in UMT. The average times of distraction per bout were 9.22 s in BMT and 3.00 s in UMT. The total number of mirror gaze bouts and average time of preparation per bout did not present a statistical significance in the comparisons of the two methods. This study assesses two methods of MT using observational coding software to evaluate the duration and frequency of the mirror gaze during treatment. The results suggest that UMT may be an alternative option to provide MT for stroke patients to increase their attention towards the mirror.

Development and user experience of an innovative multi-mode stroke rehabilitation system for the arm and hand for patients with stroke

Many individuals with stroke experience upper-limb motor deficits, and a recent trend is to develop novel devices for enhancing their motor function. This study aimed to develop a new upper-limb rehabilitation system with the integration of two rehabilitation therapies into one system, digital mirror therapy (MT) and action observation therapy (AOT), and to test the usability of this system. In the part I study, the new system was designed to operate in multiple training modes of digital MT (i.e., unilateral and bilateral modes) and AOT (i.e., pre-recorded and self-recorded videos) with self-developed software. In the part II study, 4 certified occupational therapists and 10 stroke patients were recruited for evaluating usability. The System Usability Scale (SUS) (maximum score = 100) and a self-designed questionnaire (maximum score = 50) were used. The mean scores of the SUS were 79.38 and 80.00, and those of the self-designed questionnaire were 41.00 and 42.80, respectively, for the therapists and patients after using this system, which indicated good usability and user experiences. This novel upper-limb rehabilitation system with good usability might be further used to increase the delivery of two emerging rehabilitation therapies, digital AOT and MT, to individuals with stroke.

Effects of virtual reality training in the upper limb motor coordination of individuals post- stroke: a systematic review with meta-analysis

ABSTRACT After a stroke, 75% of people are affected in their upper limbs, remaining with sequelae at these limbs. Results from recent clinical trials have been contradictory regarding the effectiveness of Virtual Reality (VR) therapy in rehabilitating upper limb motor coordination in this population. This study aimed to perform a systematic literature review with meta-analysis to investigate the effects of VR training on upper limb motor coordination in patients post-stroke. Searches were performed in the electronic databases PubMed, LILACS, SciELO, PEDro, in addition to manual searches. The whole process was performed by two independent raters. The methodological quality of the studies was assessed by the PEDro scale. In total, we selected 18 studies, out of which only 13 were included in the meta-analysis. In general, VR training was effective in improving upper limb motor coordination (SMD 0.32; 95% CI 0.08-0.56; I2=42%; p<0.01). When subgroup analysis assessed control group type, VR training was superior than no intervention (SMD 0.36; 95% CI: 0.06-0.66; p<0.05). However, when compared to other interventions, we found no significant difference (SMD 0.26; 95% CI: −0.12-0.64; p=0.18). Overall, VR training is effective in improving upper limb motor coordination in post-stroke individuals compared to no intervention. However, it shows no superiority when compared to other types of intervention used in the rehabilitation of upper limb motor coordination in these patients.

Efeitos do treino de realidade virtual na coordenação motora dos membros superiores de indivíduos após acidente vascular encefálico: uma revisão sistemática com meta-análise

RESUMO Após um acidente vascular encefálico (AVE), 75% das pessoas tem o membro superior acometido, permanecendo com sequelas nessa extremidade. Resultados de ensaios clínicos recentes são contraditórios quanto à eficácia da terapia de realidade virtual (RV) na reabilitação da coordenação motora dos membros superiores dessa população. Assim, o objetivo deste trabalho foi realizar uma revisão sistemática da literatura, com meta-análise, a fim de investigar os efeitos do treinamento com RV na coordenação motora dos membros superiores em pacientes pós-AVE. Para isso, foram feitas buscas nas bases de dados PubMed, LILACS, SciELO, PEDro e buscas manuais. Esse processo foi realizado por dois avaliadores independentes, e a qualidade metodológica dos estudos foi avaliada pela escala PEDro. Foram selecionados 18 estudos, sendo que apenas 13 foram incluídos na meta-análise. De forma geral, o treino de RV se mostrou eficaz na melhora da coordenação motora dos membros superiores da população (SMD 0,32; IC95% 0,08 a 0,56; I2=42%; p<0,01). Após uma análise de subgrupos, o treino de RV demonstrou ser superior quando comparado a nenhuma intervenção (SMD 0,36; IC95% 0,06 a 0,66; p<0,05). No entanto, quando comparado a outras intervenções, não houve diferença significativa (SMD 0,26; IC95% −0,12 a 0,64; p=0,18). De forma geral, o treino de RV é eficaz na melhora da coordenação motora dos membros superiores de indivíduos pós-AVE em comparação a nenhuma intervenção. No entanto, não é superior quando comparado a outros tipos de intervenção utilizados na reabilitação da coordenação motora dos membros superiores dos pacientes.

Postural Difference between the Interventions Reflecting the Concept of Mirror Therapy in Healthy Subjects

(1) Background: Mirror therapy is one of the promising interventions for the upper limb rehabilitation of stroke patients. Postural asymmetry during mirror therapy was pointed out as a possibility to influence stroke patients’ rehabilitation negatively. However, it is still difficult to find studies on the postural changes in mirror therapy concept interventions. This study compared three methods of postural differences as follows: traditional mirror therapy (mirror); displaying the real-time movement of the unaffected side on the screen above the affected side (screen); and playing a pre-recorded movement of the unaffected side on a tablet placed on a movable box where the affected hand is put inside (movable). (2) Methods: to observe a kinematic difference, we recruited 16 healthy volunteers to go through three different interventions (mirror, screen, movable). The motion capture system made observations on the postures before and during interventions, then compared and analyzed. (3) Results: while using the mirror, the sitting posture was observed to become asymmetric, and the following unique posture was observed where the target hand went further from the trunk while performing tasks. In addition, the shoulder of the target side came forward, and the difference between both elbow flexion angles was also observed. On the other hand, the screen or movable device did not cause a significant change in the sitting posture, and no additional postural differences were observed either. (4) Conclusions: mirror therapy showed a tendency to cause lateral flexion opposite the target hand, thus, creating additional postural change. However, developed methods controlled spine tilt, and enabled the keeping of the midline while sitting during the intervention.

Mirror Visual Feedback Prior to Robot-Assisted Training Facilitates Rehabilitation After Stroke: A Randomized Controlled Study

Purpose: Robot-assisted training has been widely used in neurorehabilitation, but its effect on facilitating recovery after stroke remains controversial. One possible reason might be lacking consideration of the role of embodiment in robotic systems. Mirror visual feedback is an ideal method to approach embodiment. Thus, we hypothesized that mirror visual feedback priming with subsequent robot-assisted training might provide additional treatment benefits in rehabilitation. Method: This is a prospective, assessor-blinded, randomized, controlled study. Forty subacute stroke patients were randomly assigned into an experimental group (N = 20) or a control group (N = 20). They received either mirror visual feedback or sham-mirror visual feedback prior to robot-assisted training for 1.5 h/day, 5 days/week for 4 weeks. Before and after intervention, the Fugl-Meyer Assessment Upper Limb subscale, the Functional Independence Measure, the modified Barthel Index, and grip strength were measured. Scores of four specified games were recorded pre and post one-time mirror visual feedback priming before intervention in the experimental group. Results: All measurements improved significantly in both groups following interventions. Moreover, the Fugl-Meyer Assessment Upper Limb subscale, self-care subscale of the Functional Independence Measure, and the grip strength were improved significantly in the experimental group after a 4-week intervention, compared with the control group. Significantly higher scores of two games were revealed after one-time priming. Conclusions: Mirror visual feedback prior to robot-assisted training could prompt motor recovery, increase ability of self-care, and potentially enhance grip strength in stroke patients, compared to control treatment. Moreover, mirror visual feedback priming might have the capability to improve the patient's performance and engagement during robot-assisted training, which could prompt the design and development of robotic systems. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: ChiCTR1900023356.

Continuous Increase of Efficacy under Repetitive Injections of Botulinum Toxin Type/A beyond the First Treatment for Adult Spastic Foot Drop

The objective of this study was to quantify the increase in efficacy during the first four cycles of treatment with botulinum toxin type/A (BoNT/A) in 24 free-walking BoNT/A naïve adult patients with post-stroke hemispasticity and spastic foot drop. Patients were followed over 390 days and received five injections of 800 U aboBoNT/A every three months. Patients assessed the treatment effect at eight visits using a global assessment scale, physicians scored the muscle tone at the ankle joint, measured active and passive ranges of motion (aRoMs, pRoMs) at the knee and ankle joint and determined the distance patients succeeded to walk during a minute. Patients' assessments significantly (p < 0.006) increased with time and significantly correlated with all parameters measured. The best correlation (r = 0.927; p < 0.0001) was found with the sum of the aRoMs of knee and ankle joint. After one year of treatment outcome measures were better than and significantly correlated with the peak effect of the first injection. This correlation was higher for pRoMs (r = 0.855; p < 0.00001) compared to aRoMs (r = 0.567; p < 0.009). When BoNT/A treatment of the spastic foot in chronic hemispasticity is performed regularly every three months for at least one year, patients will experience a significant increase of benefit beyond the first treatment, but have to learn how to adapt to and use the new degree of freedom induced by the injections.

Speed-Interactive Pedaling Training Using Smartphone Virtual Reality Application for Stroke Patients: Single-Blinded, Randomized Clinical Trial

This study aimed to investigate the effects of speed-interactive pedaling training (SIPT) using a smartphone virtual reality application to improve lower limb motor function, trunk sitting balance, and gait in stroke patients. Forty-two patients who had previously experienced a stroke and could sit independently participated in the study. The subjects were assigned to the SIPT group (n = 21) and the control group (n = 21). The SIPT group had cycle training with SIPT for 40 min a day, five days a week, in a six-week period, in addition to conventional therapy. The control group had cycle training without SIPT and conventional therapy. The Fugl–Meyer Assessment, postural sway, modified functional reach test, trunk impairment scale, and spatiotemporal parameters of gait were used to assess the changes in lower extremity function, the static balance of sitting, the dynamic balance of sitting, and gait ability after the intervention. The Fugl–Meyer Assessment, postural sway, modified functional reach test, trunk impairment scale, and gait ability in the SIPT group were significantly better compared to that of the control group (p < 0.05). Based on this result, we propose that SIPT, which improves function, balance, and gait, could be used as an effective training method to improve patients’ functional activities in the clinical setting. The results of this study suggest that SIPT could be used as an effective training method to restore a patient’s function by improving trunk balance and motor function.

Virtual rehabilitation of upper extremity function and independence for stoke: a meta-analysis

We aimed to conduct a systematic literature review with a meta-analysis to investigate whether virtual reality (VR) approaches have beneficial effects on the upper extremity function and independent activities of stroke survivors. Experimental studies published between 2007 and 2017 were searched from two databases (EBSCOhost and PubMed). This study reviewed abstracts and assessed full articles to obtain evidence on qualitative studies. For the meta-analysis, the studies that estimated the standardized mean between the two groups analyzed the statistical values necessary for calculating the effect size. The present study also evaluated the statistical heterogeneity. In total, 34 studies with 1,604 participants were included, and the number of participants in each study ranged from 10 to 376. Nine studies were assessed to evaluate the quantitative statistical analysis for 698 patients with hemiparetic stroke. The results of the meta-analysis were as follows: The overall effect size was moderate (0.41, P<0.001). The 95% confidence interval ranged from 0.25 to 0.57. However, no significant heterogeneity and publication bias were observed. The results of this study showed that VR approaches are effective in improving upper extremity function and independent activities in stroke survivors.

The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis

Objective

The aim of this study was to perform a meta-analysis to examine whether virtual reality (VR) training is effective for lower limb function as well as upper limb and overall function in chronic stroke patients.

Methods

Three databases, OVID, PubMed, and EMBASE, were used to collect articles. The search terms used were “cerebrovascular accident (CVA),” “stroke”, and “virtual reality”. Consequently, twenty-one studies were selected in the second screening of meta-analyses. The PEDro scale was used to assess the quality of the selected studies.

Results

The total effect size for VR rehabilitation programs was 0.440. The effect size for upper limb function was 0.431, for lower limb function it was 0.424, and for overall function it was 0.545. The effects of VR programs on specific outcomes were most effective for improving muscle tension, followed by muscle strength, activities of daily living (ADL), joint range of motion, gait, balance, and kinematics.

Conclusion

The VR training was effective in improving the function in chronic stroke patients, corresponding to a moderate effect size. Moreover, VR training showed a similar effect for improving lower limb function as it did for upper limb function.

Effects of camera-based mirror visual feedback therapy for patients who had a stroke and the neural mechanisms involved: protocol of a multicentre randomised control study

INTRODUCTION

As a combination of visual stimulation and motor imagery, mirror visual feedback (MVF) is an effective treatment for motor impairment after stroke; however, few studies have investigated its effects on relevant cognitive processes such as visual perception and motor imagery. Camera-based MVF (camMVF) overcomes the intrinsic limitations of real mirrors and is recognised as an optimal setup. This study aims to investigate the effects of camMVF as an adjunct treatment for stroke patients, compare camMVF outcomes with those of conventional therapy and elucidate neural mechanisms through which MVF influences cognition and brain networks.

METHODS AND ANALYSIS

This will be a multicentre, single-blinded, randomised controlled trial including 90 patients randomised into three groups: camera-based mirror visual feedback intervention group (30), shielded mirror visual feedback intervention group (30) and conventional group (30). Patients in each group will receive a 60 min intervention 5 days per week over 4 weeks. The primary outcome will be the Fugl-Meyer Assessment Upper Limb subscale measurement. Secondary outcomes include the modified Ashworth Scale, Grip Strength test, Modified Barthel Index, Functional Independence Measure, Berg Balance Scale, 10-metre walking test, hand-laterality task and electroencephalography .

ETHICS AND DISSEMINATION

Ethics approval was granted by the Huashan Hospital Institutional Review Board on 15 March (KY2017-230). We plan to submit the results to a peer-reviewed journal and present them at conferences, rehabilitation forums and to the general public.

TRIAL REGISTRATION NUMBER

ChiCTR-INR-17013644; Pre-results.

Camera-Based Mirror Visual Feedback: Potential to Improve Motor Preparation in Stroke Patients

Mirror visual feedback (MVF) is used widely for motor recovery after stroke, but an optimal training setup and systematic procedure are lacking. New optimization strategies have been proposed, one of which is a camera technique. We investigated the effects of a camera-based MVF setup on motor function and motor processes upstream for upper-limb rehabilitation. Seventy-nine stroke patients were assigned randomly to the MVF group (MG; ${N} = {38}$ ) or conventional group (CG; ${N} = {41}$ ), which, respectively, received camera-based MVF and dosage-equivalent physiotherapy or/and occupational therapy for 1 h/day and five days/week for four weeks. Two clinical scales were used to quantify the effect of the intervention methods: the Fugl-Meyer assessment-upper limb (FMA-UL) subscale and Barthel index. The hand laterality task was used to evaluate the ability of mental rotation, including the reaction time and accuracy. All measurements were improved significantly for both groups following intervention. FMA-UL was improved significantly in the MG compared with that in the CG. In lateralization tasks, the RT of the MG was significantly shorter than that of the CG at the endpoint. For all patients, judgments for the affected side were significantly slower and less accurate than for the less-affected side. Subgroup analyses suggested greater benefits of motor function, the activities of daily life, and mental rotation were achieved in subacute patients after MVF. A trend toward greater improvements in motor function for patients with severe-moderate motor impairment and patients with right-hemisphere damage were also revealed. Camera-based MVF has improved the motor function and ability of mental rotation for stroke patients, especially for patients in the subacute stage, which indicates the potential to improve motor preparation. Further studies might combine mental rotation with electroencephalography to investigate the neuro-mechanism of MVF.

Mirror therapy for improving motor function after stroke

BACKGROUND

Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the person's midsagittal plane, thus reflecting movements of the non-paretic side as if it were the affected side.

OBJECTIVES

To summarise the effectiveness of mirror therapy compared with no treatment, placebo or sham therapy, or other treatments for improving motor function and motor impairment after stroke. We also aimed to assess the effects of mirror therapy on activities of daily living, pain, and visuospatial neglect.

SEARCH METHODS

We searched the Cochrane Stroke Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, PsycINFO and PEDro (last searched 16 August 2017). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists, and contacted trialists, researchers and experts in our field of study.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and randomised cross-over trials comparing mirror therapy with any control intervention for people after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality, assessed risks of bias in the included studies, and extracted data. We assessed the quality of the evidence using the GRADE approach. We analysed the results as standardised mean differences (SMDs) or mean differences (MDs) for continuous variables, and as odds ratios (ORs) for dichotomous variables.

MAIN RESULTS

We included 62 studies with a total of 1982 participants that compared mirror therapy with other interventions. Of these, 57 were randomised controlled trials and five randomised cross-over trials. Participants had a mean age of 59 years (30 to 73 years). Mirror therapy was provided three to seven times a week, between 15 and 60 minutes for each session for two to eight weeks (on average five times a week, 30 minutes a session for four weeks).When compared with all other interventions, we found moderate-quality evidence that mirror therapy has a significant positive effect on motor function (SMD 0.47, 95% CI 0.27 to 0.67; 1173 participants; 36 studies) and motor impairment (SMD 0.49, 95% CI 0.32 to 0.66; 1292 participants; 39 studies). However, effects on motor function are influenced by the type of control intervention. Additionally, based on moderate-quality evidence, mirror therapy may improve activities of daily living (SMD 0.48, 95% CI 0.30 to 0.65; 622 participants; 19 studies). We found low-quality evidence for a significant positive effect on pain (SMD -0.89, 95% CI -1.67 to -0.11; 248 participants; 6 studies) and no clear effect for improving visuospatial neglect (SMD 1.06, 95% CI -0.10 to 2.23; 175 participants; 5 studies). No adverse effects were reported.

AUTHORS' CONCLUSIONS

The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, motor impairment, activities of daily living, and pain, at least as an adjunct to conventional rehabilitation for people after stroke. Major limitations are small sample sizes and lack of reporting of methodological details, resulting in uncertain evidence quality.

Synergistic effect of acupuncture and mirror therapy on post-stroke upper limb dysfunction: a study protocol for a randomized controlled trial

Background

Upper limb dysfunction is common after stroke, posing an important challenge for post-stroke rehabilitation. The clinical efficacy of acupuncture for the recovery of post-stroke upper limb function has been previously demonstrated. Mirror therapy (MT) has also been found to be effective. However, the effects of acupuncture and MT have not been systematically compared. This trial aims to elucidate the synergistic effects of acupuncture and MT on upper limb dysfunction after stroke.

Methods

A 2 × 2 factorial randomized controlled trial will be conducted at the rehabilitation hospitals affiliated with Fujian University of Traditional Chinese Medicine. A total of 136 eligible subjects will be randomly divided into acupuncture treatment (AT), MT, combined treatment, and control groups in a 1:1:1:1 ratio. All subjects will receive conventional treatment. The interventions will be performed 5 days per week for 4 weeks. AT, MT, and combined treatment will be performed for 30 min per day (combined treatment: AT 15 min + MT 15 min). The primary outcomes in this study will be the mean change in scores on both the FMA and WMFT from baseline to 4 weeks intervention and at 12 weeks follow-up between the two groups and within groups. The secondary outcomes are the mean change in the scores on the Visual Analogue Scale, Stroke Impact Scale, and modified Barthel index. Medical abstraction of adverse events will be assessed at each visit.

Discussion

The results of this trial will demonstrate the synergistic effect of acupuncture and MT on upper limb motor dysfunction after stroke. In addition, whether AT and MT, either combined or alone, are more effective than the conventional treatment in the management of post-stroke upper limb dysfunction will also be determined.

Trial registration

Chinese Clinical Trial Registry: ChiCTR-IOR-17011118. Registered on April 11, 2017. Version number: 01.2016.09.1.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2585-8) contains supplementary material, which is available to authorized users.

Kinematic analysis of head, trunk, and pelvic motion during mirror therapy for stroke patients

[Purpose] The purpose of this study was to investigate mirror therapy (MT) condition by analyzing kinematic parameters according to mirror size and angle. [Subjects and Methods] Three hemiparesis stroke patients and five healthy adults participated in this cross-sectional study. Kinematic parameters during the MT were collected over a total of 5 trials for each subject (3 mirror angles × 3 mirror sizes). Center of pressure (COP) excursion data was collected by force plate, and other kinematic parameters by infra-red cameras. [Results] The larger the size and smaller the angle, the overall dependent variables decreased in all participants. Particularly, when virtual reality reflection equipment (VRRE) was used, the value of the flexion and the lateral tilt was the closest to the midline compared to all other independent variables. Moreover, it showed tendency of moving towards the affected side. Based on the results, MT for stroke patients has a disadvantage of shifting weight and leaning towards the unaffected side during therapy. [Conclusion] Therefore, it seems to be more effective in terms of clinics to apply VRRE to make up for the weak parts and provide more elaborate visual feedback.

Virtual reality for stroke rehabilitation

BACKGROUND

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

OBJECTIVES

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

MAIN RESULTS

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

PRIMARY OUTCOME

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

SECONDARY OUTCOMES

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Effects of virtual reality for stroke individuals based on the International Classification of Functioning and Health: a systematic review

OBJECTIVE

This review determines the effects of virtual reality interventions for stroke subjects based on the International Classification of Functioning, Disability,and Health (ICF) framework. Virtual reality is a promising tool for therapy for stroke rehabilitation, but the effects of virtual reality interventions on post-stroke patients based on the specific ICF domains (Body Structures, Body Functions, Activity, and Participation) have not been investigated.

METHOD

A systematic review was conducted, including trials with adults with a clinical diagnosis of a chronic, subacute, or acute stroke. Eligible trials had to include studies with an intervention protocol and follow-up, with a focus on upper limbs and/or lower limbs and/or balance. The Physiotherapy Evidence Database (PEDro) was used to assess the methodological quality of randomized controlled trials. Each trial was separated according to methodological quality into a high-quality trial (PEDro ≥ 6) and a low-quality trial (PEDro ≤ 6). Only high-quality trials were analyzed specifically based on the outcome of these trials.

RESULTS

In total, 54 trials involving 1811 participants were included. Of the papers included and considered high quality, 14 trials evaluated areas of the Body Structures component, 20 trials of the Body Functions domain, 17 trials of the Activity component, and 8 trials of the Participation domain. In relation to ICF Part 2, four trials evaluated areas of the Personal Factors component and one trial evaluated domains of the Environmental Factors component.

DISCUSSION

The effects of virtual reality on stroke rehabilitation based on the ICF framework are positive in Body Function and Body Structure. However, the results in the domains Activity and Participation are inconclusive. More high-quality clinical trials are needed to confirm the effectiveness of virtual reality in the domains of Activity and Participation.