The Efficacy of Wii-Based Movement Therapy for Upper Limb Rehabilitation in the Chronic Poststroke Period: A Randomized Controlled Trial

Bound by Experience: Updating the Body Representation When Using Virtual Objects

OBJECTIVE

Four web-based experiments investigated flexibility of disembodiment of a virtual object that is no longer actively controlled. Emphasis was on possibilities to modify the timescale of this process.

BACKGROUND

Interactions with virtual objects are commonplace in settings like teleoperation, rehabilitation, and computer-aided design. These objects are quickly integrated into the operator's body schema (embodiment). Less is known about how long such embodiment lasts. Understanding the dynamics of this process is crucial because different applied settings either profit from fast or slow disembodiment.

METHOD

To induce embodiment, participants moved a 2D virtual hand through operating a computer mouse or touchpad. After initial embodiment, participants either stopped or continued moving for a fixed period of time. Embodiment ratings were collected continuously during each trial.

RESULTS

Results across all experiments indicated that embodiment for the virtual hand gradually increased during active use and gradually decreased after stopping to use it. Disembodiment unfolded nearly twice as fast as embodiment and showed a curved decay pattern. These dynamics remained unaffected by anticipation of active control that would be required in an upcoming task.

CONCLUSION

The results highlight the importance of continuously experiencing active control in virtual interactions if aiming at inducing stable embodiment of a virtual object.

APPLICATION

Our findings suggest that applications of virtual disembodiment such as virtual tools or interventions to affect a person's body representation critically depend on continuous updating of sensorimotor experience. However, if switching between virtual objects, for example, during teleoperation or video gaming, after-effects are unlikely to affect performance.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

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.

Virtual Reality Intervention and Its Impact on Upper Extremity Function in the Stroke Population: A Scoping Review

The aim of this scoping review was to examine virtual reality (VR) interventions used within rehabilitation and their effect on the functional outcomes of individuals with stroke. Specifically, this study sought to determine the impact of VR on the upper extremity (UE) use of participants as it relates to body function, occupational participation, and overall UE function (UEfxn). Twenty-six articles were selected for inclusion and results were extracted to determine common themes of outcomes among the effects of VR intervention (VRI). Thematic analysis included details about the VRIs used, as well as the change in UE outcomes post-VRI. Overall, positive change in UEfxn was found across many of the studies, indicating that VR technologies may be an effective intervention technique for individuals, poststroke. Findings of this review encourage clinicians to conduct further research regarding VR technology for UE rehabilitation poststroke.

Clinicians' perspectives and usage of rehabilitation technology: a survey

PURPOSE

The aim of this study was to investigate clinicians' perspectives regarding their usage of rehabilitation technology in their day-to-day practice and uncover the factors that impact clinicians' use of rehabilitation technology in their daily practice.

MATERIALS AND METHODS

An online survey was used to gather cross-sectional data from American occupational therapists, occupational therapy assistants, physical therapists, physical therapy assistants, and speech language pathologists. This survey used Likert-scale, multiple choice, and free-response questions.

RESULTS

Approximately half (n = 56/105, 53.3%) of our clinicians reported using rehabilitation in their daily practice. Less than 20% (n = 18/105, 17.1%) of the respondents strongly agreed that they felt comfortable implementing new rehabilitation technology, and few reported that their workplace encouraged (n = 16/85, 18.8%) or strongly encouraged (n = 14/85, 16.5%) the use of rehabilitation technology in practice. Additionally, excluding the 2011-2020 graduate clinicians that reported that they had not learned about rehabilitation technology in school or fieldwork, few reported feeling prepared (n = 14/97, 14.4%) or very prepared (n = 4/97, 4.1%) to use rehabilitation technology after graduation.

CONCLUSIONS

Our findings have revealed a sizable knowledge-to-practice gap in regard to clinicians' preparedness to engage with and advocate for rehabilitation technology in their day-to-day practice.

An Exploration of the Effectiveness of Different Intensity Protocols of Modified Constraint-Induced Therapy in Stroke: A Systematic Review

Purpose

To examine the effectiveness of different modified Constraint-Inuced Therapy (mCIMT) protocol intensities on upper extremity motor function in adults with hemiplegia.

Methods

A search was conducted in PubMed, Scopus, EBSCO, and Cochrane Library for articles published between April 2010 and December 2021. Only randomized controlled trials (RCTs) were included. Studies were excluded if they used a sample of less than five, mCIMT in combination with other therapy, and/or if they were not written in English. Methodologic quality was assessed using the Cochrane collaboration risk of bias tool-2.

Results

Thirty-six RCTs with a total of 721 participants were included. Most researchers followed a moderate to low protocol intensity in terms of total treatment time and moderate to high intensity with regard to restriction time. Almost all of the upper limb motor function measures showed statistically significant improvements (p < .05) after mCIMT, irrespective of the protocol's intensity, but there was lack of high-quality studies. Statistically significant improvements did not always translate to clinical importance.

Conclusions

Low-intensity CIMT protocols may result in comparable improvements to more intensive ones but caution has to be taken when drawing conclusions due to high risk of bias studies.

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

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.

A Systematic Review and Meta-Analysis of the Effectiveness of Virtual Reality-Based Rehabilitation Therapy on Reducing the Degree of Pain Experienced by Individuals with Low Back Pain

BACKGROUND

The concept of virtual reality (VR)-based rehabilitation therapy for treating people with low back pain is of growing research interest. However, the effectiveness of such therapy for pain reduction in clinical settings remains controversial.

METHODS

The present study was conducted according to the reporting guidelines presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We searched the PubMed, Embase, CENTRAL, and ProQuest databases for both published and unpublished papers. The Cochrane risk of bias tool (version 2) was used to evaluate the quality of the selected studies. GRADEprofiler software (version 3.6.4) was used to evaluate the level of evidence. We analyzed the included research results using RevMan software (version 5.4.1).

RESULTS

We included a total of 11 articles in the systematic review and meta-analysis, with a total of 1761 subjects. Having assessed the quality of these studies, the risk of bias was generally low with high heterogeneity. The results revealed a small to medium effect (standardized mean difference = ±0.37, 95% confidence interval: 0.75 to 0) based on evidence of moderate overall quality.

CONCLUSION

There is evidence that treatment using VR improves patients' pain. The effect size was small to medium, with the studies presenting evidence of moderate overall quality. VR-based treatment can reduce pain; therefore, it may help in rehabilitation therapy.

Additional therapy promotes a continued pattern of improvement in upper-limb function and independence post-stroke

BACKGROUND

Upper-limb motor impairment after stroke is common and disabling. Growing evidence suggests that rehabilitation is effective in the chronic period. However, there is limited knowledge on the effects of ongoing targeted rehabilitation programs on patient outcomes.

OBJECTIVES

This study investigated the effects of delivering two programs of dose-matched evidence-based upper-limb rehabilitation to community-dwelling post-acute stroke patients with low, moderate and high motor-function.

MATERIALS AND METHODS

12 patients (2 female) aged 50.5±18.2 years and 13.8±10.8 months post-stroke completed 2-weeks of modified-Constraint-Induced Movement Therapy followed by 2-weeks of Wii-based Movement Therapy after a mean interval of 9.6±1.1 months (range 6-19months). Function was assessed at 6 time points (i.e. before and after each therapy program and 6-month follow-up after each program). Primary outcome measures were the Wolf Motor Function Test timed-tasks (WMFT-tt), upper-limb Fugl-Meyer Assessment (F-M) and the Motor Activity Log Quality of Movement Scale (MALQOM). Improvement and maintenance was analyzed using Paired T-Tests and Wilcoxon Signed Rank Tests.

RESULTS

Upper-limb function significantly improved on all primary outcome measures with the first therapy program (WMFT-tt p=0.008, F-M p=0.007 and MALQOM p<0.0001). All scores continued to improve with the second therapy program with significant improvements in the F-M (p=0.048) and the MALQOM (p=0.001).

CONCLUSIONS

All patients showed a pattern of continued improvement in upper-limb motor-function and independence in activities of daily living. These improvements demonstrate the benefit of ongoing post-stroke rehabilitation for community-dwelling stroke survivors for individuals of varying baseline functional status.

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.

Technology-Dependent Rehabilitation Involving Action Observation and Movement Imagery for Adults with Stroke: Can It Work? Feasibility of Self-Led Therapy for Upper Limb Rehabilitation after Stroke

BACKGROUND

Motor (re)learning via technology-dependent therapy has the potential to complement traditional therapies available to older adults living with stroke after hospital discharge and increase therapy dose. To date, little is known about the feasibility of technology-dependent therapy in a home setting for this population.

OBJECTIVE

To develop a technology-dependent therapy that provides mental and physical training for older adults with stroke and assess feasibility. Specifically we ask, "Can it work"?

DESIGN

Single group repeated measures.

METHODS

13 participants, aged 18 years and over, were recruited over a six-month period. All participants had mild upper limb impairment following a stoke and were no longer receiving intensive rehabilitation. All participants received 18 days of technology-dependent therapy in their own home. Information was gathered on recruitment and retention, usability, and suitability of outcome measures.

RESULTS

11 participants completed the study. The recruitment rate (number recruited/number canvassed; 10.7%) suggests 1907 participants would need to be canvassed to recruit the necessary sample size (n = 204) for a definitive trial designed to provide 90% power at 5% level of significance to detect a clinically meaningful difference of 5.7 points on the Action Research Arm Test. The usability of the application was rated as exceptional on the System Usability Scale. Effectiveness cannot be determined from this study; however, there was a trend for improvement in measures of upper limb function and emotional well-being. Limitations. The study was limited by a relatively small sample size and lack of control group.

CONCLUSIONS

This study demonstrated proof of concept of a technology-dependent therapy for upper limb rehabilitation following stroke. The data suggest a definitive trial is feasible, additional strategies to improve recruitment should be considered. Outcome measures aligned with the residual motor function of participants are required.

Haptic Glove Systems in Combination with Semi-Immersive Virtual Reality for Upper Extremity Motor Rehabilitation after Stroke: A Systematic Review and Meta-Analysis

Background: The effectiveness of the virtual reality (VR) for the upper extremity (UE) motor rehabilitation after stroke has been widely studied. However, the effectiveness of the combination between rehabilitation gloves and semi-immersive VR (SVR) compared to conventional treatment has not yet been studied. Methods: A systematic search was conducted in Pubmed, Web of Science, PEDRo, and Scopus, Cochrane, CINHAAL databases from inception to May 2022. Randomized controlled trials were included if patients were under rehabilitation with haptic gloves combined with SVR intervention focused on the UE rehabilitation in stroke patients. Risk of bias and methodological quality were evaluated with the Physiotherapy Evidence Database (PEDro), and the modified Cochrane library criteria. A random effects model was used for the quantitative assessment of the included studies using the standard mean difference with a 95% confidence interval. Heterogeneity among the included studies was assessed using Cochran’s Q test and the incoherence index (I2). Results: After a first screening, seven studies were included. Significant differences with a 95% confidence interval were obtained in favor of the rehabilitation glove combined with SVR in the short term (SMD—standardized mean differences = 0.38, 95% CI—confidence interval = 0.20; 0.56; Z: 4.24; p =< 0.001). In the long term, only the studies that performed an intervention based in rehabilitation glove combined with SVR with also included rehabilitation were able to maintain the improvements (SMD = 0.71, 95% CI = 0.40; 1.02; Z: 4.48; p =< 0.001). Conclusions: The combined use of rehabilitation haptic gloves and SVR with conventional rehabilitation produces significant improvements with respect to conventional rehabilitation treatment alone in terms of functionality of the UE in stroke patients.

Measured and Perceived Effects of Upper Limb Home-Based Exergaming Interventions on Activity after Stroke: A Systematic Review and Meta-Analysis

After discharge from the hospital to home, stroke patients may experience weakness and reduced movement in their hemiparetic arms that limits their ability to perform daily activities. Therapists can use exercise games (exergames) to maintain functional abilities and daily use of the arm at home. A systematic review and meta-analysis was conducted to determine the efficiency of upper limb home-based rehabilitation, using exergaming on activity abilities in stroke.&amp;nbsp;Randomized controlled trials were reviewed in the CENTRAL, MEDLINE, CINAHL, EMBASE, and SCOPUS online databases. Clinical measures of observation and self-reporting were studied in post-intervention and follow-up. Nine studies were included in this systematic review (535 participants). The Physiotherapy Evidence Database (PEDro) score was 6.6/10 (SD 1.0, range 5-8), indicating good quality. This systematic review and meta-analysis showed that upper limb home-based exergaming interventions were no more effective in terms of activity than conventional therapy after stroke, according to the observational and subjective assessments in post-intervention and follow-up. Using this same approach, future studies should focus on evaluating home-based exergames through subgroup analysis to be able to propose recommendations.

Effectiveness of Using Virtual Reality-Supported Exercise Therapy for Upper Extremity Motor Rehabilitation in Patients With Stroke: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

In recent years, efforts have been made to implement virtual reality (VR) to support the delivery of poststroke upper extremity motor rehabilitation exercises. Therefore, it is important to review and analyze the existing research evidence of its effectiveness.

Objective

Through a systematic review and meta-analysis of randomized controlled trials, this study examined the effectiveness of using VR-supported exercise therapy for upper extremity motor rehabilitation in patients with stroke.

Methods

This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The CINAHL Plus, MEDLINE, Web of Science, Embase, and Cochrane Library databases were searched on December 31, 2021. Changes in outcomes related to impairments in upper extremity functions and structures, activity limitations, and participation restrictions in life situations from baseline to after intervention, after intervention to follow-up assessment, and baseline to follow-up assessment were examined. Standardized mean differences (SMDs) were calculated using a random-effects model. Subgroup analyses were performed to determine whether the differences in treatment outcomes depended on age, stroke recovery stage, VR program type, therapy delivery format, similarities in intervention duration between study groups, intervention duration in VR groups, and trial length.

Results

A total of 42 publications representing 43 trials (aggregated sample size=1893) were analyzed. Compared with the control groups that used either conventional therapy or no therapy, the intervention groups that used VR to support exercise therapy showed significant improvements in upper extremity motor function (Fugl-Meyer Assessment-Upper Extremity; SMD 0.45, 95% CI 0.21-0.68; P<.001), range of motion (goniometer; SMD 1.01, 95% CI 0.50-1.52; P<.001), muscle strength (Manual Muscle Testing; SMD 0.79, 95% CI 0.28-1.30; P=.002), and independence in day-to-day activities (Functional Independence Measure; SMD 0.23, 95% CI 0.06-0.40; P=.01, and modified Rankin Scale; SMD 0.57, 95% CI 0.01-1.12; P=.046). Significant subgroup differences were observed in hand dexterity (Box and Block Test), spasticity (Ashworth Scale or modified Ashworth Scale), arm and hand motor ability (Wolf Motor Function Test and Manual Function Test), hand motor ability (Jebsen Hand Function Test), and quality of life (Stroke Impact Scale). There was no evidence that the benefits of VR-supported exercise therapy were maintained after the intervention ended.

Conclusions

VR-supported upper extremity exercise therapy can be effective in improving motor rehabilitation results. Our review showed that of the 12 rehabilitation outcomes examined during the course of VR-based therapy, significant improvements were detected in 2 (upper extremity motor function and range of motion), and both significant and nonsignificant improvements were observed in another 2 (muscle strength and independence in day-to-day activities), depending on the measurement tools or methods used.

Trial Registration

PROSPERO CRD42021256826; https://tinyurl.com/2uarftbh

Gamified Neurorehabilitation Strategies for Post-stroke Motor Recovery: Challenges and Advantages

Abstract

Purpose of Review

Stroke is the leading cause of permanent motor disability in the United States (US), but there has been little progress in developing novel, effective strategies for treating post-stroke motor deficits. The past decade has seen the rapid development of many promising, gamified neurorehabilitation technologies; however, clinical adoption remains limited. The purpose of this review is to evaluate the recent literature surrounding the adoption and use of gamification in neurorehabilitation after stroke.

Recent Findings

Gamification of neurorehabilitation protocols is both feasible and effective. Deployment strategies and scalability need to be addressed with more rigor. Relationship between engaged time on task and rehabilitation outcomes should be explored further as it may create benefits beyond repetitive movement.

Summary

As gamification becomes a more common and feasible way of delivering exercise-based therapies, additional benefits of gamification are emerging. In spite of this, questions still exist about scalability and widespread clinical adoption.

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.

Applying Game-Based Approaches for Physical Rehabilitation of Poststroke Patients: A Systematic Review

Objective

A large number of patients need critical physical rehabilitation after the stroke. This study aimed to review and report the result of published studies, in which newly emerged games were employed for physical rehabilitating in poststroke patients.

Materials and Methods

This systematic review study was performed based on the PRISMA method. A comprehensive search of PubMed, Scopus, IEEE Xplore Digital Library, and ISI Web of Science was conducted from January 1, 2014, to November 9, 2020, to identify related articles. Studies have been entered in this review based on inclusion and exclusion criteria, in which new games have been used for physical rehabilitation.

Results

Of the 1326 retrieved studies, 60 of them met our inclusion criteria. Virtual reality-oriented games were the most popular type of physical rehabilitation approach for poststroke patients. “The Nintendo Wii Fit” game was used more than other games. The reviewed games were mostly operated to balance training and limb mobilization. Based on the evaluation results of the utilized games, only in three studies, applied games were not effective. In other studies, games had effective outcomes for target body members.

Conclusions

The results indicate that modern games are efficient in poststroke patients' physical rehabilitation and can be used alongside conventional methods.

Serious games as rehabilitation tools in neurological conditions: A comprehensive review

BACKGROUND

The use of serious games (SG) in rehabilitation has been on the rise in recent years and they are used as either a main interventional tool, or as an adjunct alongside conventional therapies. This is largely due to its virtue of being an electronic platform hence possessing game characteristics that facilitates patient progress.

OBJECTIVE

The present study aimed to provide a comprehensive review of the impact of SG on neurorehabilitation therapies as well as patients' perspectives on rehabilitation.

METHODS

The literature search was conducted in PubMed and Cochrane databases. The study was conducted in four different phases, consisting of the generation of MeSH terms and keywords, screening of articles, and data analysis based on the study characteristics.

RESULTS

This review included 47 studies that explored the use of custom designed experimental serious games (ESG) or commercially designed serious games (CSG) for rehabilitation in a few neurological conditions. The majority of CSG used Nintendo Wii as an adjunct to conventional therapies. Significant improvement in the primary outcomes such as motor functioning, balance, executive and cognitive functions were reported in 35 studies. 17 studies also indicated patient perspectives on rehabilitation. There was no difference between the overall impact of either CSG or ESG.

CONCLUSION

Evidently, SG are efficient exergame tools. However, future studies should explore patient perspectives that could help to design evidence-based games for rehabilitation purposes.

Commercial videogames in stroke rehabilitation: systematic review and meta-analysis

Objective: The aim of this article was to perform a systematic review of all studies (both observational and experimental) wherein commercial video games were used in comprehensive rehabilitation (both physical and cognitive areas) after stroke.Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed, and all observational and experimental studies that met at least six PEDro scale criteria were included. A total of 50 studies were included in the Meta-Analysis. Data analysis was performed using RevMan 5.3 and the bias with JAMOVI.Results: In observational studies, results favored intervention with video games in terms of functionality such as Fulg-Meyer Assessment scores [standard mean difference (SMD) = -0.45; 95% CI = -0.74 to -0.15; p = .94; I2 = 0%)] and when measured in the upper limbs using the Wolf Motor Function Test (SMD = 0.41; 95% CI = 0.07 to 0.74; p = .47; I2 = 0%). Other results showed heterogeneity. In the experimental group, most results tended to favor the experimental group and showed homogeneity, but they were not significant. Fail Safe N was calculated, and the results were not biased.Conclusions: Results tend to favor intervention with commercial video games, but the heterogeneity of the measuring instruments and small sample size do not allow for significant results to be obtained. Future research should provide the number of participants, mean, and standard deviation to facilitate future meta-analyses. Commercial video games appear to be a feasible tool in physical and cognitive stroke rehabilitation.

Improvement of Acupuncture Based on Smart Medical Care for Post-Stroke Hemiplegic Shoulder Pain and Upper Limb Motor Function

As a new stage in the development of medicine and health, smart medicine has attracted attention from all parties in recent years. Especially, under the impetus of the Internet, due to the development of new technologies, smart medical care has made considerable progress, and it has also brought us new challenges. The concept, hypothesis, and design of intelligent medical care are analyzed, and the design objects and design principles of intelligent medical care are highlighted. In Africa, 79 patients with shoulder pain after stroke and hemiplegia in the recession period were disintegrated and divided into observation group (40 people) and control group (39 people). The observation group and the control group used two different treatment methods, acupuncture treatment and traditional western medicine treatment. Finally, the situation of the two groups is checked. From the results, the treatment effect of the control group was not as good as that of the observation group (P < 0.05). After treatment, the effects of capillary disease and patients' living conditions in the observation group were better than those in the control group (P < 0.05). It is concluded that the therapeutic effect of wisdom acupuncture treatment has a certain effect and can be used in medical treatment.

Home Activity-based Interventions for the Neurologically Impaired Upper Extremity: A Scoping Review

Background:

Activity-based therapy (ABT) for the upper extremity (UE) enables neurologic recovery with tasks that are functional, intense, and highly repetitive. A large proportion of rehabilitation occurs in the home and there is a gap in literature on the application of ABT within the home. The objective of this scoping review was to describe ABT in the home-setting for the neurologically-impaired UE.

Methods:

A systematic scoping review included searches of: MEDLINE, CINAHL, Cochrane, and OTSeeker.

Results:

A systematic search yielded 51 final studies. About 61% of ABT studies were exclusively within the home, others included outpatient visits (37%). Telerehabilitation was used in 37% of the studies with live-video and store forward techniques equally represented. ABT supported by technology was used in 61% of studies. Dosing of intervention ranged from 7 to 120 hours, with a mean of 34.5 hours of practice. Adherence with intended dosing was reported in 27% of studies and subjects completed a mean of 86% of the intended practice time. Sixty-seven percent of studies reported some degree of practice without therapist supervision.

Conclusions:

The results showed wide variability in the intervention methods, dosing and technology used in homebased settings. The high rate of adherence with dosing is encouraging for the application of homebased neurologic UE interventions. This scoping review highlights feasibility of UE ABT within the home and need for further research.

Revisiting Poststroke Upper Limb Stratification: Resilience in a Larger Cohort

BACKGROUND

Upper limb (UL) impairment in stroke survivors is both multifactorial and heterogeneous. Stratification of motor function helps identify the most sensitive and appropriate assessments, which in turn aids the design of effective and individualized rehabilitation strategies. We previously developed a stratification method combining the Grooved Pegboard Test (GPT) and Box and Block Test (BBT) to stratify poststroke UL motor function.

OBJECTIVE

To investigate the resilience of the stratification method in a larger cohort and establish its appropriateness for clinical practice by investigating limitations of the GPT completion time.

METHODS

Post hoc analysis of motor function for 96 community-dwelling participants with stroke (n = 68 male, 28 female, age 60.8 ± 14 years, 24.4 ± 36.6 months poststroke) was performed using the Wolf Motor Function Test (WMFT), Fugl-Meyer Assessment (F-M), BBT, and GPT. Hypothesis-free and hypothesis-based hierarchical cluster analyses were conducted to determine the resilience of the stratification method.

RESULTS

The hypothesis-based analysis identified the same functional groupings as the hypothesis-free analysis: low (n = 32), moderate (n = 26), and high motor function (n = 38), with 3 exceptions. Thirty-three of the 38 participants with fine manual dexterity completed the GPT in ≤5 minutes. The remaining 5 participants took 6 to 25 minutes to place all 25 pegs but used alternative movement strategies to complete the test. The GPT time restriction changed the functional profile of the moderate and high motor function groups leading to more misclassifications.

CONCLUSION

The stratification method unambiguously classifies participants by UL motor function. While the inclusion of a 5-minute cutoff time for the GPT is preferred for clinical practice, it is not recommended for stratification purposes.

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

Background

Rehabilitation is crucial for maximizing recovery after stroke. Rehabilitation activities that are fun and rewarding by themselves can be more effective than those who are not. Gamification with virtual reality (VR) exploits this principle. This single-case design study probes the potential for using commercial off-the-shelf, room-scale head-mounted virtual reality for upper extremity rehabilitation in individuals with chronic stroke, the insights of which can inform further research.

Methods

A heterogeneous volunteer sample of seven participants living with stroke were recruited through advertisement. A single-case design was employed with a 5-week baseline (A), followed by a 10-week intervention (B) and a 6-month follow-up. Upper extremity motor function was assessed with validated kinematic analysis of drinking task. Activity capacity was assessed with Action Research Arm Test, Box and Block Test and ABILHAND questionnaire. Assessments were done weekly and at follow-up. Playing games on a VR-system with head-mounted display (HTC Vive) was used as rehabilitation intervention. Approximately 300 games were screened and 6 tested. Visual analysis and Tau-U statistics were used to interpret the results.

Results

Visual analysis of trend, level shift and overlap as well as Tau-U statistics indicated improvement of Action Research Arm Test in six participants. Four of these had at least a moderate Tau-U score (0.50–0.92), in at least half of the assessed outcomes. These four participants trained a total of 361 to 935 min. Two out of four participants who were able to perform the drinking task, had the highest training dose (> 900 min) and showed also improvements in kinematics. The predominant game played was Beat Saber. No serious adverse effects related to the study were observed, one participant interrupted the intervention phase due to a fall at home.

Conclusions

This first study of combining commercial games, a commercial head-mounted VR, and commercial haptic hand controls, showed promising results for upper extremity rehabilitation in individuals with chronic stroke. By being affordable yet having high production values, as well as being an easily accessible off-the-shelf product, this variant of VR technology might facilitate widespread adaption. Insights garnered in this study can facilitate the execution of future studies.

Trial registration The study was registered at researchweb.org (project number 262331, registered 2019-01-30, https://www.researchweb.org/is/vgr/project/262331) prior to participant enrolment.

Caring Stroke Patients with Musculoskeletal Problem: A Narrative Review

Background: The purpose of this paper is to narratively review the literature on caring for stroke patients with a musculoskeletal problem which involves rehabilitation of nursing and health care. Through the review, this paper addresses five questions: What are the typical difficulties of a stroke patient? What are the effects of a stroke on the musculoskeletal system? How to take care of musculoskeletal problem and pain? What is good musculoskeletal care for patients with stroke? How to take care of the musculoskeletal problem through active rehabilitation? Method: The relevant articles published between 2010-2020 were identified through searches in PubMed, Google Scholar, CINAHL, PsychInfo and by inspecting the reference list using keywords of ‘stroke’ and ‘musculoskeletal’.  Result: A total of 19 selected address this topic and consequently answer the questions posed. Findings flow with the typical difficulties of a stroke patient, the effects of a stroke on the musculoskeletal system, caring for musculoskeletal problem and pain, good musculoskeletal care for patients with stroke and caring for the musculoskeletal problem through active rehabilitation. Conclusion: This paper highlights that stroke patients with the musculoskeletal problem have restricted day-to-day movement functions and needed interdisciplinary care approaches from nursing, physical and occupational therapies, and other health care professionals. Stroke patients may need a structured programme to improve the outcome of stroke rehabilitation for the musculoskeletal problem.  

Virtual reality interventions to enhance upper limb motor improvement after a stroke: commonly used types of platform and outcomes

Introduction: Virtual Reality (VR) based platforms are useful in enhancing post-stroke sub-optimal upper limb (UL) motor improvement. A variety of options are available from expensive highly customizable platforms to low cost turnkey solutions. Clinical outcomes primarily help assess the effects of VR-based platforms. These outcomes mainly quantify how much improvement has occurred. Very few outcomes characterize the type (i.e. how) of recovery. We categorized the types of VR-based platforms and outcome measures commonly used for post-stroke UL motor improvement.Methods: We reviewed the published literature in English from 2000-2019. Different types of VR-based platforms were grouped into those available commercially and those developed by the various research groups. We initially classified outcomes from the retrieved studies under the appropriate International Classification of Functioning categories. Then, we divided the outcomes as those quantifying the type or extent of improvement.Results: We found a total of 125 studies. Majority of the studies used commercially available platforms. A total of 42 different outcome measures were used. Seventeen different outcomes were used to assess body structure and functions as well as in activity limitations. Eight outcomes assessed the effects of contextual factors and participation restrictions. The Fugl Meyer Assessment, Wolf Motor Function Test and Stroke Impact Scale were most often used across the three categories. Of the 125 studies, 52 used outcomes characterizing the type of recovery. Although a smaller proportion, 24 studies included movement patterns outcomes.Conclusion: A standardized set of outcomes can promote better comparisons between studies using different VR-based platforms for post-stroke UL motor improvement.Implications for RehabilitationA wide variety of commercially available systems are present from expensive customizable systems to low-cost turnkey systems.The Fugl-Meyer Assessment and Wolf Motor Function Test along with the Stroke Impact Scale-Social Participation subscale were used most often across all studies as assessments of body structure and function, activity limitations and participation restriction.It is essential to include movement pattern outcomes addressing whether recovery of compensation occurs with the use of VR-based platforms.

Low-cost equipment for the evaluation of reach and grasp in post-stroke individuals: a pilot study

Background

Reach–grasp movements are motor components commonly affected after stroke and directly related to the independence of these individuals. Evaluations of these activities can be performed using clinical instruments and assessed by detailed and costly kinematic analyses. The aim of this study was to develop an analysis of reach–grasp movements in post-stroke patients using a simple, inexpensive, and manageable instrument.

Results

A Mann–Whitney test was used to compare paretic and non-paretic limb motor performance. A statistically significant difference was found between the variables of total time (p = 0.02) and speed to reach target 3 (p = 0.04) for task 1, while in task 2 significance was found only in the aspect of speed to reach target 2 (p = 0.04). The correlation between clinical tests and variables of tasks was then performed using Spearman’s rank correlation coefficient. At task 1, when compared with the REACH instrument, the close target sub-item; there was a high positive correlation between the parameters of total time (p = 0.028), target velocity 3 (p = 0.028), and target acceleration 3 (p = 0.028). Another instrument that showed a high positive correlation with the target time 3 (p = 0.01) and target acceleration 3 (p = 0.028) variables was the Box and Block Test. When correlated, the data between the task 2 variables and clinical instruments did not present statistically significant data.

Conclusion

Our instrument—the Temporal Data Acquisition Instrument—TDAI—fulfilled the expected objectives and can be used as an option to evaluate the movements of reach and grasp of upper limb post-stroke, using an easy and fast application, without the need for calibration.

Trial registration Trial Registration: Research Ethics Committee of the Trairi School of Health Sciences—Number 2.625.609, approved on April 13, 2018; Brazilian Registry of Clinical Trials—RBR-4995cr approved on July 4, 2019 retrospectively registered (http://www.ensaiosclinicos.gov.br/rg/RBR-4995cr/)

Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review

BACKGROUND

With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness.

OBJECTIVE

This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors.

METHODS

Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs.

RESULTS

In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants' stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P≤.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years.

CONCLUSIONS

This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery.

TRIAL REGISTRATION

PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=57715.

Home program practices for supporting and measuring adherence in post-stroke rehabilitation: a scoping review

BACKGROUND

After stroke, individuals face a variety of impairments that impact function. Increasingly, rehabilitation for these impairments has moved into the community and home settings through the use of home programs. However, adherence to these programs is often low, limiting effectiveness.

OBJECTIVE

This scoping review investigated home program implementation and measurement of adherence with persons post-stroke to identify commonly reported practices and determine areas for further research.

METHODS

The electronic databases of PubMed, CINAHL, Scopus, Cochrane Database of Systematic Reviews, and PEDro were searched. Studies focused on post-stroke rehabilitation with an independent home program were selected. Qualitative studies, commentaries, and single-case studies were excluded. Title and abstract screenings were completed by two reviewers with a third for tie-breaking. The full-text review was completed by two reviewers using consensus to resolve any differences. Of the 1,197 articles initially found only 6% (n = 70) met criteria for data extraction. Elements for data extraction included: type of study, area of intervention, description of home program, presence of strategies to support adherence, methods to measure adherence and reported adherence.

RESULTS

Most commonly reported strategies to support home practice were the use of technology, personalization, and written directions. Only 20 studies reported achieving adherence at or greater than 75% and 18 studies did not report adherence outcomes.

CONCLUSIONS

Future investigations that directly compare and identify the most effective strategies to support adherence to home programs for this population are warranted. The implementation of guidelines for reporting adherence to home programs is recommended.

Unilateral vs Bilateral Hybrid Approaches for Upper Limb Rehabilitation in Chronic Stroke: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of unilateral hybrid therapy (UHT) and bilateral hybrid therapy (BHT) compared with robot-assisted therapy (RT) alone in patients with chronic stroke.

DESIGN

A single-blind, randomized controlled trial.

SETTING

Four hospitals.

PARTICIPANTS

Outpatients with chronic stroke and mild to moderate motor impairment (N=44).

INTERVENTION

UHT combined unilateral RT (URT) and modified constraint-induced therapy. BHT combined bilateral RT (BRT) and bilateral arm training. The RT group received URT and BRT. The intervention frequency for the 3 groups was 90 min/d 3 d/wk for 6 weeks.

MAIN OUTCOME MEASURES

Fugl-Meyer Assessment (FMA, divided into the proximal and distal subscale) and Stroke Impact Scale (SIS) version 3.0 scores before, immediately after, and 3 months after treatment and Wolf Motor Function Test (WMFT) and Nottingham Extended Activities of Daily Living (NEADL) scale scores before and immediately after treatment.

RESULTS

The results favored BHT over UHT on the FMA total score and distal score at the posttest (P=.03 and .04) and follow-up (P=.01 and .047) assessment and BHT over RT on the follow-up FMA distal scores (P=.03). At the posttest assessment, the WMFT and SIS scores of the 3 groups improved significantly without between-group differences, and the RT group showed significantly greater improvement in the mobility domain of NEADL compared with the BHT group (P<.01).

CONCLUSIONS

BHT was more effective for improving upper extremity motor function, particularly distal motor function at follow-up, and individuals in the RT group demonstrated improved functional ambulation post intervention.

optimizing self-exercise scheduling in motor stroke using Challenge Point Framework theory

An important challenge for technology-assisted self-led rehabilitation is how to automate appropriate schedules of exercise that are responsive to patients' needs, and optimal for learning. While random scheduling has been found to be superior for long-term learning relative to fixed scheduling (Contextual Interference), this method is limited by not adequately accounting for task difficulty, or skill acquisition during training. One method that combines contextual interference with adaptation of the challenge to the skill-level of the player is Challenge Point Framework (CPF) theory. In this pilot study we test whether self-led motor training based upon CPF scheduling achieves faster learning than deterministic, fixed scheduling. Training was implemented in a mobile gaming device adapted for arm disability, allowing for grip and wrist exercises. We tested 11 healthy volunteers and 12 hemiplegic stroke patients in a single-blinded no crossover controlled randomized trial. Results suggest that patients training with CPF-based adaption performed better than those training with fixed conditions. This was not seen for healthy volunteers whose performance was close to ceiling. Further data collection is required to determine the significance of the results.

Effect of the Wii Sports Resort on the improvement in attention, processing speed and working memory in moderate stroke

BACKGROUND

Stroke is the most common neurological disease in the world. After the stroke, some people suffer a cognitive disability. Commercial videogames have been used after stroke for physical rehabilitation; however, their use in cognitive rehabilitation has hardly been studied. The objectives of this study were to analyze attention, processing speed, and working memory in patients with moderate stroke after an intervention with Wii Sports Resort and compared these results with a control group.

METHODS

A pre-post design study was conducted with 30 moderate stroke patients aged 65 ± 15. The study lasted eight weeks. 15 participated in the intervention group and 15 belong to the control group. They were assessed in attention and processing speed (TMT-A and B) and working memory (Digit Span of WAIS-III). Parametric and effect size tests were used to analyze the improvement of those outcomes and compared both groups.

RESULTS

At the baseline, there was no difference between TMT-A and B. A difference was found in the scalar score of TMT-B, as well as in Digit Backward Span and Total Digit Task. In TMT-A and B, the intervention group had better scores than the control group. The intervention group in the Digit Forward Span and the Total Digit obtained a moderate effect size and the control group also obtained a moderate effect size in Total Digit. In the Digit scalar scores, the control group achieved better results than the intervention group.

CONCLUSIONS

The results on attention, processing speed and working memory improved in both groups. However, according to the effect sizes, the intervention group achieved better results than the control group. In addition, the attention and processing speed improved more than the working memory after the intervention. Although more studies are needed in this area, the results are encouraging for cognitive rehabilitation after stroke.

Upper limb muscle activation during sports video gaming of persons with spinal cord injury

OBJECTIVE

Video gaming as a therapeutic tool has largely been studied within the stroke population with some benefits reported in upper limb motor performance, balance, coordination, and cardiovascular status. To date, muscle activation of upper limb muscles in persons with spinal cord injuries (SCI) has not been studied during video game play. In this paper, we provide descriptive and comparative data for muscle activation and strength during gaming for players with tetraplegia and paraplegia, as well as, compare these results with data from traditional arm exercises (ie, biceps curl and shoulder press) with light weights which are commonly prescribed for a home program.

PARTICIPANTS

Fourteen individuals with chronic SCI (9 tetraplegia, 5 paraplegia).

DESIGN

We measured upper limb muscle activation with surface electromyography (EMG) during Wii Sports video game play. Muscle activation was recorded from the playing arm during 4 selected games and normalized to a maximum voluntary contraction (MVC).

OUTCOME MEASURES

Heart rate and upper limb motion were recorded simultaneously with EMG. Wilcoxon signed rank tests were used to analyze differences in muscle activation between participants with paraplegia versus tetraplegia and compare gaming with traditional arm exercises with light weights. A Friedman 2-way analysis of variance identified key muscle groups active during game play.

RESULTS

Overall muscle activation across the games was not different between those with paraplegia and tetraplegia. Heart rate during video game play for tennis and boxing were on average 10 to 20 beats/minute above resting heart rate. The magnitude of EMG was relatively greater for traditional arm exercises with light weights compared with game play.

CONCLUSION

The selected Wii games were able to elicit upper extremity muscle activation and elevated heart rates for individuals with SCI that may be used to target therapeutic outcomes.

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.

Innovating With Rehabilitation Technology in the Real World: Promises, Potentials, and Perspectives

In this article, we discuss robotic-assisted therapy as an emerging and significant field of clinical rehabilitation and its value proposition for innovating rehabilitation clinical practice. Attempts to achieve integration among clinicians' practices and bioengineers' machines often generate new challenges and controversies. To date, the literature is indicative of a sizeable number and variety of robotic devices in the field of clinical rehabilitation, some are commercially available; however, large-scale clinical outcomes are less positive than expected. The following main themes related to integrating rehabilitation technology in real-world clinical practice will be discussed: the application of current evidence-based practice and knowledge in relation to treatment in the rehabilitation clinic, perspectives from rehabilitation professionals using robotic-aided therapy with regard to challenges, and strategies for problem solving. Lastly, we present innovation philosophies with regard to sustainability of clinical rehabilitation technologies.

A Longitudinal Electromyography Study of Complex Movements in Poststroke Therapy. 1: Heterogeneous Changes Despite Consistent Improvements in Clinical Assessments

Poststroke weakness on the more-affected side may arise from reduced corticospinal drive, disuse muscle atrophy, spasticity, and abnormal coordination. This study investigated changes in muscle activation patterns to understand therapy-induced improvements in motor-function in chronic stroke compared to clinical assessments and to identify the effect of motor-function level on muscle activation changes. Electromyography (EMG) was recorded from five upper limb muscles on the more-affected side of 24 patients during early and late therapy sessions of an intensive 14-day program of Wii-based Movement Therapy (WMT) and for a subset of 13 patients at 6-month follow-up. Patients were classified according to residual voluntary motor capacity with low, moderate, or high motor-function levels. The area under the curve was calculated from EMG amplitude and movement duration. Clinical assessments of upper limb motor-function pre- and post-therapy included the Wolf Motor Function Test, Fugl-Meyer Assessment and Motor Activity Log Quality of Movement scale. Clinical assessments improved over time (p < 0.01) with an effect of motor-function level (p < 0.001). The pattern of EMG change by late therapy was complex and variable, with differences between patients with low compared to moderate or high motor-function levels. The area under the curve (p = 0.028) and peak amplitude (p = 0.043) during Wii-tennis backhand increased for patients with low motor-function, whereas EMG decreased for patients with moderate and high motor-function levels. The reductions included movement duration during Wii-golf (p = 0.048, moderate; p = 0.026, high) and Wii-tennis backhand (p = 0.046, moderate; p = 0.023, high) and forehand (p = 0.009, high) and the area under the curve during Wii-golf (p = 0.018, moderate) and Wii-baseball (p = 0.036, moderate). For the pooled data over time, there was an effect of motor-function (p = 0.016) and an interaction between time and motor-function (p = 0.009) for Wii-golf movement duration. Wii-baseball movement duration decreased as a function of time (p = 0.022). There was an effect on Wii-tennis forehand duration for time (p = 0.002), an interaction of time and motor-function (p = 0.005) and an effect of motor-function level on the area under the curve (p = 0.034) for Wii-golf. This study demonstrated different patterns of EMG changes according to residual voluntary motor-function levels, despite heterogeneity within each level that was not evident following clinical assessments alone. Thus, rehabilitation efficacy might be underestimated by analyses of pooled data.

A Longitudinal Electromyography Study of Complex Movements in Poststroke Therapy. 2: Changes in Coordinated Muscle Activation

Fine motor control is achieved through the coordinated activation of groups of muscles, or "muscle synergies." Muscle synergies change after stroke as a consequence of the motor deficit. We investigated the pattern and longitudinal changes in upper limb muscle synergies during therapy in a largely unconstrained movement in patients with a broad spectrum of poststroke residual voluntary motor capacity. Electromyography (EMG) was recorded using wireless telemetry from 6 muscles acting on the more-affected upper body in 24 stroke patients at early and late therapy during formal Wii-based Movement Therapy (WMT) sessions, and in a subset of 13 patients at 6-month follow-up. Patients were classified with low, moderate, or high motor-function. The Wii-baseball swing was analyzed using a non-negative matrix factorization (NMF) algorithm to extract muscle synergies from EMG recordings based on the temporal activation of each synergy and the contribution of each muscle to a synergy. Motor-function was clinically assessed immediately pre- and post-therapy and at 6-month follow-up using the Wolf Motor Function Test, upper limb motor Fugl-Meyer Assessment, and Motor Activity Log Quality of Movement scale. Clinical assessments and game performance demonstrated improved motor-function for all patients at post-therapy (p < 0.01), and these improvements were sustained at 6-month follow-up (p > 0.05). NMF analysis revealed fewer muscle synergies (mean ± SE) for patients with low motor-function (3.38 ± 0.2) than those with high motor-function (4.00 ± 0.3) at early therapy (p = 0.036) with an association trend between the number of synergies and the level of motor-function. By late therapy, there was no significant change between groups, although there was a pattern of increase for those with low motor-function over time. The variability accounted for demonstrated differences with motor-function level (p < 0.05) but not time. Cluster analysis of the pooled synergies highlighted the therapy-induced change in muscle activation. Muscle synergies could be identified for all patients during therapy activities. These results show less complexity and more co-activation in the muscle activation for patients with low motor-function as a higher number of muscle synergies reflects greater movement complexity and task-related phasic muscle activation. The increased number of synergies and changes within synergies by late-therapy suggests improved motor control and movement quality with more distinct phases of movement.

Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique designed to improve upper extremity motor functions after stroke. This review aimed to investigate evidence of the effect of CIMT on upper extremity in stroke patients and to identify optimal methods to apply CIMT. Four databases (MEDLINE, EMBASE, CINHAL, and PEDro) and reference lists of relevant articles and reviews were searched. Randomized clinical trials that studied the effect of CIMT on upper extremity outcomes in stroke patients compared with other rehabilitative techniques, usual care, or no intervention were included. Methodological quality was assessed using the PEDro score. The following data were extracted for each trial: patients' characteristics, sample size, eligibility criteria, protocols of CIMT and control groups, outcome measurements, and the PEDro score. A total of 38 trials were identified according to the inclusion criteria. The trials included were heterogeneous in CIMT protocols, time since stroke, and duration and frequency of treatment. The pooled meta-analysis of 36 trials found a heterogeneous significant effect of CIMT on upper extremity. There was no significant effect of CIMT at different durations of follow-up. The majority of included articles did not fulfill powered sample size and quality criteria. The effect of CIMT changed in terms of sample size and quality features of the articles included. These meta-analysis findings indicate that evidence for the superiority of CIMT in comparison with other rehabilitative interventions is weak. Information on the optimal dose of CIMT and optimal time to start CIMT is still limited.

A benefit-cost framework of motivation for a specific activity

How can an individual be motivated to perform a target exercise or activity? This question arises in training, therapeutic, and education settings alike, yet despite-or even because of-the large range of extant motivation theories, finding a clear answer to this question can be challenging. Here we propose an application-friendly framework of motivation for a specific activity or exercise that incorporates core concepts from several well-regarded psychological and economic theories of motivation. The key assumption of this framework is that motivation for performing a given activity is determined by the expected benefits and the expected costs of (performance of) the activity. Benefits comprise positive feelings, gains, and rewards experienced during performance of the activity (intrinsic benefits) or achieved through the activity (extrinsic benefits). Costs entail effort requirements, time demands, and other expenditure (intrinsic costs) as well as unwanted associated outcomes and missing out on alternative activities (extrinsic costs). The expected benefits and costs of a given exercise are subjective and state dependent. We discuss convergence of the proposed framework with a selection of extant motivation theories and briefly outline neurobiological correlates of its main components and assumptions. One particular strength of our framework is that it allows to specify five pathways to increasing motivation for a target exercise, which we illustrate and discuss with reference to previous empirical data.

Effect of Virtual Reality-based Bilateral Upper Extremity Training on Upper Extremity Function after Stroke: A Randomized Controlled Clinical Trial

In the present study, we aimed to investigate the effect of virtual reality-based bilateral upper extremity training (VRBT) on paretic upper limb function and muscle strength in patients with stroke. Eighteen stroke survivors were assigned to either the VRBT group (n = 10) or the bilateral upper limb training group (BT, n = 8). Patients in the VRBT group performed bilateral upper extremity exercises in a virtual reality environment, whereas those in the BT group performed conventional bilateral upper extremity exercises. All training was conducted for 30 minutes day^-1 , 3 days a week, for a period of 6 weeks. Patients were assessed for upper extremity function and hand strength. Compared with the BT group, the VRBT group exhibited significant improvements in upper extremity function and muscle strength (p < 0.05) after the 6-week training programme. The Box and Block test results revealed that upper extremity function and elbow flexion in hand strength were significantly improved in terms of group, time and interaction effect of group by time. Furthermore, the VRBT group demonstrated significant improvements in upper extremity function, as measured by the Jebsen Hand Function Test and Grooved Pegboard test, and in the hand strength test, as measured by elbow extension, grip, palmar pinch, lateral pinch and tip pinch, in both time and the interaction effect of group by time. These results suggest that VRBT is a feasible and beneficial means of improving upper extremity function and muscle strength in individuals following stroke. Copyright © 2016 John Wiley & Sons, Ltd.

Does the use of Nintendo Wii SportsTM improve arm function? Trial of WiiTM in Stroke: a randomized controlled trial and economics analysis

OBJECTIVE

The Trial of Wii™ in Stroke investigated the efficacy of using the Nintendo Wii Sports™ (Wii^TM) to improve affected arm function after stroke.

DESIGN

Multicentre, pragmatic, parallel group, randomized controlled trial.

SETTING

Home-based rehabilitation.

SUBJECTS

A total of 240 participants aged 24-90 years with arm weakness following a stroke within the previous six months.

INTERVENTION

Participants were randomly assigned to exercise daily for six weeks using the Wii^TM or arm exercises at home.

MAIN MEASURES

Primary outcome was change in the affected arm function at six weeks follow-up using the Action Research Arm Test. Secondary outcomes included occupational performance, quality of life, arm function at six months and a cost effectiveness analysis.

RESULTS

The study was completed by 209 participants (87.1%). There was no significant difference in the primary outcome of affected arm function at six weeks follow-up (mean difference -1.7, 95% CI -3.9 to 0.5, p = 0.12) and no significant difference in secondary outcomes, including occupational performance, quality of life or arm function at six months, between the two groups. No serious adverse events related to the study treatment were reported. The cost effectiveness analysis showed that the Wii^TM was more expensive than arm exercises £1106 (SD 1656) vs. £730 (SD 829) (probability 0.866).

CONCLUSION

The trial showed that the Wii^TM was not superior to arm exercises in home-based rehabilitation for stroke survivors with arm weakness. The Wii^TM was well tolerated but more expensive than arm exercises.

BDNF Genotype Interacts with Motor Function to Influence Rehabilitation Responsiveness Poststroke

BACKGROUND

Persistent motor impairment is common but highly heterogeneous poststroke. Genetic polymorphisms, including those identified on the brain-derived neurotrophic factor (BDNF) and apolipoprotein E (APOE) genes, may contribute to this variability by limiting the capacity for use-dependent neuroplasticity, and hence rehabilitation responsiveness.

OBJECTIVE

To determine whether BDNF and APOE genotypes influence motor improvement facilitated by poststroke upper-limb rehabilitation.

METHODS

BDNF-Val66Met and APOE isoform genotypes were determined using leukocyte DNA for 55 community-dwelling patients 2-123 months poststroke. All patients completed a dose-matched upper-limb rehabilitation program of either Wii-based Movement Therapy or Constraint-induced Movement Therapy. Upper-limb motor function was assessed pre- and post-therapy using a suite of functional measures.

RESULTS

Motor function improved for all patients post-therapy, with no difference between therapy groups. In the pooled data, there was no significant effect of BDNF or APOE genotype on motor function at baseline, or following the intervention. However, a significant interaction between the level of residual motor function and BDNF genotype was identified (p = 0.029), whereby post-therapy improvement was significantly less for Met allele carriers with moderate and high, but not low motor function. There was no significant association between APOE genotype and therapy outcomes.

CONCLUSION

This study identified a novel interaction between the BDNF-Val66Met polymorphism, motor-function status, and the magnitude of improvement with rehabilitation in chronic stroke. This polymorphism does not preclude, but may reduce, the magnitude of motor improvement with therapy, particularly for patients with higher, but not lower residual motor function. BDNF genotype should be considered in the design and interpretation of clinical trials.