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Choe YK, Asselin A, Foster T, Waymouth T, van Emmerik R. Congruent vs. incongruent tasks in interdisciplinary stroke rehabilitation: a single-case report. Disabil Rehabil 2024; 46:4711-4724. [PMID: 38084719 DOI: 10.1080/09638288.2023.2288670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 09/26/2024]
Abstract
PURPOSE Stroke survivors may experience challenges in multiple domains (e.g., speech-language, dexterity, mobility) and pursue services from multiple professionals. Clinicians typically provide rehabilitation services in back-to-back sessions (multidisciplinary). Alternatively, two or more clinicians can co-treat a stroke survivor in one session (interdisciplinary). This pilot project examined task congruency in interdisciplinary stroke care. METHOD A stroke survivor chronically challenged by non-fluent aphasia and right hemiparesis completed spoken-naming and upper-limb tasks simultaneously. The concurrent tasks were presented in two conditions: congruent (i.e., naming a pictured item while tracing the first letter of the name) and incongruent (i.e., naming a pictured item while tracing a non-symbolic shape). The sequence of the two conditions was: baseline probes, congruent practice (eight weeks), no practice (eight weeks), incongruent practice (eight weeks), and no practice (eight weeks). The entire treatment program was implemented as independent home practice utilizing a computer. RESULTS The participant made significant improvements in naming and clinically meaningful gains in arm movements during the congruent condition, but not during the incongruent condition. CONCLUSIONS Data from this study suggest a potentially positive effect of simultaneous speech-language and upper-limb tasks. More research is warranted to further examine the role of task congruency in interdisciplinary stroke rehabilitation.
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Affiliation(s)
| | | | - Tammie Foster
- Department of Occupational Therapy, Cooley Dickinson Hospital, Northampton, MA, USA
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Winterbottom L, Chen A, Mendonca R, Nilsen DM, Ciocarlie M, Stein J. Clinician perceptions of a novel wearable robotic hand orthosis for post-stroke hemiparesis. Disabil Rehabil 2024:1-10. [PMID: 38975689 DOI: 10.1080/09638288.2024.2375056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 06/27/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE Wearable robotic devices are currently being developed to improve upper limb function for individuals with hemiparesis after stroke. Incorporating the views of clinicians during the development of new technologies can help ensure that end products meet clinical needs and can be adopted for patient care. METHODS In this cross-sectional mixed-methods study, an anonymous online survey was used to gather clinicians' perceptions of a wearable robotic hand orthosis for post-stroke hemiparesis. Participants were asked about their clinical experience and provided feedback on the prototype device after viewing a video. RESULTS 154 participants completed the survey. Only 18.8% had previous experience with robotic technology. The majority of participants (64.9%) reported that they would use the device for both rehabilitative and assistive purposes. Participants perceived that the device could be used in supervised clinical settings with all phases of stroke. Participants also indicated a need for insurance coverage and quick setup time. CONCLUSIONS Engaging clinicians early in the design process can help guide the development of wearable robotic devices. Both rehabilitative and assistive functions are valued by clinicians and should be considered during device development. Future research is needed to understand a broader set of stakeholders' perspectives on utility and design.
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Affiliation(s)
- Lauren Winterbottom
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY, USA
| | - Ava Chen
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - Rochelle Mendonca
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY, USA
| | - Dawn M Nilsen
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Matei Ciocarlie
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
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Uchiyama Y, Takebayashi T, Takahashi K, Amano S, Gosho M, Sakai M, Hashimoto K, Hachisuka K, Domen K. Estimating the minimal clinically important difference of upper extremity outcome measures in chronic stroke patients with moderate to severe impairment: a cross-sectional study. Top Stroke Rehabil 2024; 31:409-417. [PMID: 37742304 DOI: 10.1080/10749357.2023.2259649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/09/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Approximately 70% of chronic stroke patients experience upper extremity (UE) functional impairments, and UE outcome measures are often used as quality-of-life indicators. OBJECTIVE The purpose of this study was to estimate minimal clinically important difference (MCID) values for UE outcome measures in chronic stroke patients with moderate to severe UE hemiplegia. METHODS This study was a cross-sectional study, conducted as a secondary analysis of data from the ReoGo-J study, a multicenter, prospective, randomized, parallel-group trial of robot-assisted self-training for UE hemiplegia in chronic stroke. The patients were randomized to 1 of 3 treatment groups. Treatment was provided 3 times a week for 10 weeks, and UE outcome measures were evaluated before and after treatment. The anchor-based method was used to estimate MCID values for UE outcome measures, with Stroke Impact Scale (SIS) subscales as anchors. MCID values were estimated by identifying cutoff values in a receiver operating characteristic (ROC) curve. RESULTS Between-group comparisons of UE outcome measures, based on the clinically important difference (CID) values of SIS subscales, revealed significant differences in both the Amount of Use (AOU) and Quality of Movement (QOM) components of the Motor Activity Log (MAL)-14. The estimated MCID values were 0.89 for the AOU component and 0.77 for the QOM component. CONCLUSIONS The estimated MCID values for the MAL-14 not only add information regarding the clinical characteristics of the MAL-14 but also facilitate interpretations of changing scores in chronic stroke patients with moderate to severe UE hemiplegia undergoing rehabilitation therapy. STUDY REGISTRATION https://www.umin.ac.jp/ctr/index.htm (UMIN000022509; 1 July 2016).
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Affiliation(s)
- Yuki Uchiyama
- Department of Rehabilitation Medicine, School of Medicine, Hyogo Medical University, Hyogo, Japan
| | - Takashi Takebayashi
- Department of Rehabilitation Science, School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kayoko Takahashi
- Department of Occupational Therapy, School of Allied Health Science, Kitasato University, Kanagawa, Japan
| | - Satoru Amano
- Department of Occupational Therapy, School of Allied Health Science, Kitasato University, Kanagawa, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masahiro Sakai
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Koichi Hashimoto
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | | | - Kazuhisa Domen
- Department of Rehabilitation Medicine, School of Medicine, Hyogo Medical University, Hyogo, Japan
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A Wearable Soft Fabric Sleeve for Upper Limb Augmentation. SENSORS 2021; 21:s21227638. [PMID: 34833719 PMCID: PMC8620533 DOI: 10.3390/s21227638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/02/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022]
Abstract
Soft actuators (SAs) have been used in many compliant robotic structure and wearable devices, due to their safe interaction with the wearers. Despite advances, the capability of current SAs is limited by scalability, high hysteresis, and slow responses. In this paper, a new class of soft, scalable, and high-aspect ratio fiber-reinforced hydraulic SAs is introduced. The new SA uses a simple fabrication process of insertion where a hollow elastic rubber tube is directly inserted into a constrained hollow coil, eliminating the need for the manual wrapping of an inextensible fiber around a long elastic structure. To provide high adaptation to the user skin for wearable applications, the new SAs are integrated into flexible fabrics to form a wearable fabric sleeve. To monitor the SA elongation, a soft liquid metal-based fabric piezoresistive sensor is also developed. To capture the nonlinear hysteresis of the SA, a novel asymmetric hysteresis model which only requires five model parameters in its structure is developed and experimentally validated. The new SAs-driven wearable robotic sleeve is scalable, highly flexible, and lightweight. It can also produce a large amount of force of around 23 N per muscle at around 30% elongation, to provide useful assistance to the human upper limbs. Experimental results show that the soft fabric sleeve can augment a user’s performance when working against a load, evidenced by a significant reduction on the muscular effort, as monitored by electromyogram (EMG) signals. The performance of the developed SAs, soft fabric sleeve, soft liquid metal fabric sensor, and nonlinear hysteresis model reveal that they can effectively modulate the level of assistance for the wearer. The new technologies obtained from this work can be potentially implemented in emerging assistive applications, such as rehabilitation, defense, and industry.
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McCrea MA, Cramer SC, Okonkwo DO, Mattke S, Paadre S, Bates D, Nejadnik B, Giacino JT. Determining minimally clinically important differences for outcome measures in patients with chronic motor deficits secondary to traumatic brain injury. Expert Rev Neurother 2021; 21:1051-1058. [PMID: 34402352 DOI: 10.1080/14737175.2021.1968299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine minimally clinically important differences (MCIDs) for Disability Rating Scale (DRS), Fugl-Meyer Upper Extremity Subscale (FM-UE), Fugl-Meyer Lower Extremity Subscale (FM-LE), and Fugl-Meyer Motor Scale (FMMS) in patients with chronic motor deficits secondary to traumatic brain injury (TBI). METHODS Retrospective analysis from the 1-year, double-blind, randomized, surgical sham-controlled, Phase 2 STEMTRA trial (NCT02416492), in which patients with chronic motor deficits secondary to TBI (N = 61) underwent intracerebral stereotactic implantation of modified bone marrow-derived mesenchymal stromal (SB623) cells. MCIDs for DRS, FM-UE, FM-LE, and FMMS were triangulated with distribution-based, anchor-based, and Delphi panel estimates. RESULTS Triangulated MCIDs were: 1) -1.5 points for the Disability Rating Scale; 2) 6.2 points for the Fugl-Meyer Upper Extremity Subscale; 3) 3.2 points for the Fugl-Meyer Lower Extremity Subscale; and 4) 8.4 points for the Fugl-Meyer Motor Scale. CONCLUSIONS For the first time in the setting of patients with chronic motor deficits secondary to TBI, this study reports triangulated MCIDs for: 1) DRS, a measure of global outcome; and 2) Fugl-Meyer Scales, measures of motor impairment. These findings guide the use of DRS and Fugl-Meyer Scales in the assessment of global disability outcome and motor impairment in future TBI clinical trials.
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Affiliation(s)
- Michael A McCrea
- Co-Director, Center For Neurotrauma Research; And Professor, Department Of Neurosurgery, Medical College Of Wisconsin, Milwaukee, USA
| | - Steven C Cramer
- Professor, Department Of Neurology, University Of California, Los Angeles; Los Angeles, Ca; And Medical Director Of Research, California Rehabilitation Institute; Los Angeles, CA, USA
| | - David O Okonkwo
- Director, Neurotrauma Clinical Trials Center; And Professor, Department Of Neurological Surgery, University Of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Soeren Mattke
- Director, Center For Improving Chronic Illness Care, USC Dornsife, Los Angeles, Ca, USA
| | - Susan Paadre
- Associate Director, Biostatistics, Biostatistical Consulting Inc., Lexington, MA, USA
| | - Damien Bates
- Consultant, SanBio, Inc., Mountain View, CA, USA
| | - Bijan Nejadnik
- Chief Medical Officer, Global Head Of Regulatory, Medical Affairs, Research and Clinical Development, SanBio Inc., CA, USA
| | - Joseph T Giacino
- Director Of Rehabilitation Neuropsychology; Director, SRN Disorders Of Consciousness Program; Project Director, Spaulding-Harvard TBI Model System, Spaulding Rehabilitation Hospital, Charlestown, MA; And Consulting Neuropsychologist, Department Of Psychiatry, Massachusetts General Hospital, Boston, MA; And Professor, Department Of Physical Medicine And Rehabilitation, Harvard Medical School, Boston, MA, USA
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Fernandez-Garcia C, Ternent L, Homer TM, Rodgers H, Bosomworth H, Shaw L, Aird L, Andole S, Cohen D, Dawson J, Finch T, Ford G, Francis R, Hogg S, Hughes N, Krebs HI, Price C, Turner D, Van Wijck F, Wilkes S, Wilson N, Vale L. Economic evaluation of robot-assisted training versus an enhanced upper limb therapy programme or usual care for patients with moderate or severe upper limb functional limitation due to stroke: results from the RATULS randomised controlled trial. BMJ Open 2021; 11:e042081. [PMID: 34035087 PMCID: PMC8154983 DOI: 10.1136/bmjopen-2020-042081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine whether robot-assisted training is cost-effective compared with an enhanced upper limb therapy (EULT) programme or usual care. DESIGN Economic evaluation within a randomised controlled trial. SETTING Four National Health Service (NHS) centres in the UK: Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Northwick Park Hospital, London Northwest Healthcare NHS Trust; Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde; and North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust. PARTICIPANTS 770 participants aged 18 years or older with moderate or severe upper limb functional limitation from first-ever stroke. INTERVENTIONS Participants randomised to one of three programmes provided over a 12-week period: robot-assisted training plus usual care; the EULT programme plus usual care or usual care. MAIN ECONOMIC OUTCOME MEASURES Mean healthcare resource use; costs to the NHS and personal social services in 2018 pounds; utility scores based on EQ-5D-5L responses and quality-adjusted life years (QALYs). Cost-effectiveness reported as incremental cost per QALY and cost-effectiveness acceptability curves. RESULTS At 6 months, on average usual care was the least costly option (£3785) followed by EULT (£4451) with robot-assisted training being the most costly (£5387). The mean difference in total costs between the usual care and robot-assisted training groups (£1601) was statistically significant (p<0.001). Mean QALYs were highest for the EULT group (0.23) but no evidence of a difference (p=0.995) was observed between the robot-assisted training (0.21) and usual care groups (0.21). The incremental cost per QALY at 6 months for participants randomised to EULT compared with usual care was £74 100. Cost-effectiveness acceptability curves showed that robot-assisted training was unlikely to be cost-effective and that EULT had a 19% chance of being cost-effective at the £20 000 willingness to pay (WTP) threshold. Usual care was most likely to be cost-effective at all the WTP values considered in the analysis. CONCLUSIONS The cost-effectiveness analysis suggested that neither robot-assisted training nor EULT, as delivered in this trial, were likely to be cost-effective at any of the cost per QALY thresholds considered. TRIAL REGISTRATION NUMBER ISRCTN69371850.
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Affiliation(s)
- Cristina Fernandez-Garcia
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Laura Ternent
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Tara Marie Homer
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Helen Bosomworth
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Sreeman Andole
- Stroke Medicine, Barking Havering and Redbridge Hospitals NHS Trust, Romford, UK
| | - David Cohen
- Northwick Park, London North West University Healthcare NHS Trust, Harrow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Tracy Finch
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Gary Ford
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Oxford Academic Health Science Network, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Francis
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Steven Hogg
- (Lay Investigator) Contact Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Niall Hughes
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - H I Krebs
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Christopher Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Duncan Turner
- School of Health Sport and Bioscience, University of East London, London, UK
| | - Frederike Van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Scott Wilkes
- School of Pharmacy, University of Sunderland, Sunderland, UK
| | - Nina Wilson
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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Upper Limb Robotic Rehabilitation After Stroke: A Multicenter, Randomized Clinical Trial. J Neurol Phys Ther 2021; 44:3-14. [PMID: 31834217 DOI: 10.1097/npt.0000000000000295] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE After stroke, only 12% of survivors obtain complete upper limb (UL) functional recovery, while in 30% to 60% UL deficits persist. Despite the complexity of the UL, prior robot-mediated therapy research has used only one robot in comparisons to conventional therapy. We evaluated the efficacy of robotic UL treatment using a set of 4 devices, compared with conventional therapy. METHODS In a multicenter, randomized controlled trial, 247 subjects with subacute stroke were assigned either to robotic (using a set of 4 devices) or to conventional treatment, each consisting of 30 sessions. Subjects were evaluated before and after treatment, with follow-up assessment after 3 months. The primary outcome measure was change from baseline in the Fugl-Meyer Assessment (FMA) score. Secondary outcome measures were selected to assess motor function, activities, and participation. RESULTS One hundred ninety subjects completed the posttreatment assessment, with a subset (n = 122) returning for follow-up evaluation. Mean FMA score improvement in the robotic group was 8.50 (confidence interval: 6.82 to 10.17), versus 8.57 (confidence interval: 6.97 to 10.18) in the conventional group, with no significant between-groups difference (adjusted mean difference -0.08, P = 0.948). Both groups also had similar change in secondary measures, except for the Motricity Index, with better results for the robotic group (adjusted mean difference 4.42, P = 0.037). At follow-up, subjects continued to improve with no between-groups differences. DISCUSSION AND CONCLUSIONS Robotic treatment using a set of 4 devices significantly improved UL motor function, activities, and participation in subjects with subacute stroke to the same extent as a similar amount of conventional therapy. Video Abstract is available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A291).
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The effect of VNS on the rehabilitation of stroke: A meta-analysis of randomized controlled studies. J Clin Neurosci 2020; 81:421-425. [PMID: 33222954 DOI: 10.1016/j.jocn.2020.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/07/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The efficacy of vagus nerve stimulation (VNS) for the rehabilitation of stroke remains controversial. We conduct a systematic review and meta-analysis to explore the influence of VNS on the rehabilitation of stroke. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through March 2020 for randomized controlled trials (RCTs) assessing the effect of VNS on the rehabilitation of stroke. This meta-analysis is performed using the random-effect model. RESULTS Three RCTs are included in the meta-analysis. Overall, compared with control group in stroke, VNS is associated with significantly improved FMA-UE (SMD = 3.86; 95% CI = 1.19 to 6.52; P = 0.005) and Motor Function Test (SMD = 0.33; 95% CI = 0.04 to 0.62; P = 0.03), but has no obvious impact on Box and Block Test (SMD = -0.31; 95% CI = -3.48 to 2.86; P = 0.85), Nine-Hole Peg Test (SMD = 8.35; 95% CI = -40.59 to 57.28; P = 0.74), atrial fibrillation (RR = 3.46; 95% CI = 0.39 to 30.57; P = 0.26) or adverse events (RR = 0.59; 95% CI = 0.21 to 1.61; P = 0.30). CONCLUSIONS VNS may be beneficial to the rehabilitation of stroke.
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Huber ME, Chiovetto E, Giese M, Sternad D. Rigid soles improve balance in beam walking, but improvements do not persist with bare feet. Sci Rep 2020; 10:7629. [PMID: 32376990 PMCID: PMC7203137 DOI: 10.1038/s41598-020-64035-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/31/2020] [Indexed: 01/03/2023] Open
Abstract
Maintaining balance while walking on a narrow beam is a challenging motor task. One important factor is that the foot's ability to exert torque on the support surface is limited by the beam width. Still, the feet serve as a critical interface between the body and the external environment, and it is unclear how the mechanical properties of the feet affect balance. This study examined how constraining the motion of the foot joints with rigid soles influenced balance performance when walking on a beam. We recorded whole-body kinematics of subjects with varying skill levels as they walked on a narrow beam with and without wearing flat, rigid soles on their feet. We computed changes in whole-body motion and angular momentum across the two conditions. Results showed that walking with rigid soles improved balance performance in both expert and novice subjects, but that improvements in balance performance with rigid soles did not affect or transfer to subsequent task performance with bare feet. The absence of any aftereffects suggested that the improved balance performance resulting from constraining the foot joints by a rigid sole was the result of a mechanical effect rather than a change in neural control. Although wearing rigid soles can be used to assist balance, there appears to be limited benefit for training or rehabilitation of balance ability.
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Affiliation(s)
- Meghan E Huber
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
| | - Enrico Chiovetto
- Section for Computational Sensomotorics, Department of Cognitive Neurology, Hertie Institute for Clinical Brain Research, Centre for Integrative Neuroscience, University Clinic Tübingen, Tübingen, Germany
| | - Martin Giese
- Section for Computational Sensomotorics, Department of Cognitive Neurology, Hertie Institute for Clinical Brain Research, Centre for Integrative Neuroscience, University Clinic Tübingen, Tübingen, Germany
| | - Dagmar Sternad
- Departments of Biology, Electrical and Computer Engineering, and Physics, Northeastern University, Boston, Massachusetts, USA
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Different Therapeutic Effects of Transcranial Direct Current Stimulation on Upper and Lower Limb Recovery of Stroke Patients with Motor Dysfunction: A Meta-Analysis. Neural Plast 2019; 2019:1372138. [PMID: 31827495 PMCID: PMC6881758 DOI: 10.1155/2019/1372138] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/09/2019] [Indexed: 12/21/2022] Open
Abstract
Objective To explore the effects of transcranial direct current stimulation (tDCS) on the motor recovery of stroke patients and the effect differences between the upper limb and lower limb. Methods Randomized control trials published until January 2019 were searched from PubMed, Embase, ScienceDirect, and Cochrane Library databases. The standardized mean difference (SMD) with 95% confidence interval (CI) was estimated separately for upper and lower limb motor outcomes to understand the mean effect size. Results Twenty-nine studies with 664 subjects were included in this meta-analysis. The overall analyses of tDCS demonstrated significant effect size both for the upper limb (SMD = 0.26, P = 0.002) and the lower limb (SMD = 0.47, P = 0.002). Compared with acute and subacute stroke patients, chronic stroke patients obtained significant effects after tDCS (SMD = 0.25, P = 0.03) in upper limb function. Furthermore, both anode and cathode stimulations produced significant effect size for stroke patients after ≤10 sessions of tDCS (anode: SMD = 0.40, P = 0.001; cathode: SMD = 0.79, P < 0.0001) with >0.029 mA/cm2 of density (anode: SMD = 0.46, P = 0.002; cathode: SMD = 0.79, P < 0.0001). But for lower limb function, more prominent effects were found in subacute stroke patients (SMD = 0.56, P = 0.001) with bilateral tDCS (SMD = 0.59, p = 0.009). Conclusion tDCS is effective for the recovery of stroke patients with motor dysfunction. In addition, upper limb and lower limb functions obtain distinct effects from different therapeutic parameters of tDCS at different stages, respectively.
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Steinberg GK, Kondziolka D, Wechsler LR, Lunsford LD, Kim AS, Johnson JN, Bates D, Poggio G, Case C, McGrogan M, Yankee EW, Schwartz NE. Two-year safety and clinical outcomes in chronic ischemic stroke patients after implantation of modified bone marrow-derived mesenchymal stem cells (SB623): a phase 1/2a study. J Neurosurg 2019; 131:1462-1472. [PMID: 30497166 DOI: 10.3171/2018.5.jns173147] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/10/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and clinical outcomes associated with stereotactic surgical implantation of modified bone marrow-derived mesenchymal stem cells (SB623) in patients with stable chronic ischemic stroke. METHODS This was a 2-year, open-label, single-arm, phase 1/2a study; the selected patients had chronic motor deficits between 6 and 60 months after nonhemorrhagic stroke. SB623 cells were administered to the target sites surrounding the subcortical stroke region using MRI stereotactic image guidance. RESULTS A total of 18 patients were treated with SB623 cells. All experienced at least 1 treatment-emergent adverse event (TEAE). No patients withdrew due to adverse events, and there were no dose-limiting toxicities or deaths. The most frequent TEAE was headache related to the surgical procedure (88.9%). Seven patients experienced 9 serious adverse events, which resolved without sequelae. In 16 patients who completed 24 months of treatment, statistically significant improvements from baseline (mean) at 24 months were reported for the European Stroke Scale (ESS) score, 5.7 (95% CI 1.4-10.1, p < 0.05); National Institutes of Health Stroke Scale (NIHSS) score, -2.1 (95% CI -3.3 to -1.0, p < 0.01), Fugl-Meyer (F-M) total score, 19.4 (95% CI 9.9-29.0, p < 0.01); and F-M motor scale score, 10.4 (95% CI 4.0-16.7, p < 0.01). Measures of efficacy reached plateau by 12 months with no decline thereafter. There were no statistically significant changes in the modified Rankin Scale score. The size of transient lesions detected by T2-weighted FLAIR imaging in the ipsilateral cortex at weeks 1-2 postimplantation significantly correlated with improvement in ESS (0.619, p < 0.05) and NIHSS (-0.735, p < 0.01) scores at 24 months. CONCLUSIONS In this completed 2-year phase 1/2a study, implantation of SB623 cells in patients with stable chronic stroke was safe and was accompanied by improvements in clinical outcomes.Clinical trial registration no.: NCT01287936 (clinicaltrials.gov).
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Affiliation(s)
- Gary K Steinberg
- 1Department of Neurosurgery and Stanford Stroke Center and
- 2Department of Neurology and Neurological Sciences and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California
| | - Douglas Kondziolka
- 3Department of Neurosurgery, New York University and NYU Langone Medical Center, New York, New York
| | | | - L Dade Lunsford
- 5Neurosurgery, University of Pittsburgh Medical School and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anthony S Kim
- 6Department of Neurology, University of California, San Francisco, California
| | | | | | - Gene Poggio
- 8Biostatistical Consulting Inc., Lexington, Massachusetts
| | - Casey Case
- 7SanBio, Inc., Mountain View, California; and
| | | | | | - Neil E Schwartz
- 2Department of Neurology and Neurological Sciences and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California
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12
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Powell ES, Westgate PM, Goldstein LB, Sawaki L. Absence of Motor-Evoked Potentials Does Not Predict Poor Recovery in Patients With Severe-Moderate Stroke: An Exploratory Analysis. Arch Rehabil Res Clin Transl 2019; 1:100023. [PMID: 33543054 PMCID: PMC7853378 DOI: 10.1016/j.arrct.2019.100023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective To better understand the role of the presence or absence of motor-evoked potentials (MEPs) in predicting functional outcomes following a severe-moderate stroke. Design Retrospective exploratory analysis. We compared the effects of the stimulation condition (active or sham), MEP status (+ or −), and a combination of stimulation condition and MEP status on outcome. Within-group and between-group changes were assessed with longitudinal repeated measures analysis of variance and longitudinal repeated measures analysis of covariance, respectively. The proportions of participants who achieved minimal clinically important differences (MCIDs) for the main outcome measures were calculated. Setting University research laboratory within a rehabilitation hospital. Participants A total of 129 subjects with severe-moderate stroke-related motor impairments who participated in previous studies combining neuromodulation and motor training Interventions Neuromodulation (active or sham) and motor training. Main Outcome Measures Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT). Results When participants were grouped by stimulation condition or MEP status, all groups improved from baseline to immediate postintervention and follow-up evaluations (all P<.05). Analysis by stimulation condition and MEP status found that the MEP−/active group improved by 4.2 points on FMA (P<.0001) and 1.8 on ARAT (P=.003) post intervention. The MEP+/active group improved by 5.7 points on FMA (P<.0001) and 3.9 points on ARAT (P<.0001) post intervention. There were no between-group differences (P>.05). Regarding MCIDs, in the MEP−/active group, 14.5% of individuals reached MCID on FMA and 8.3% on ARAT post intervention. In the MEP+/active group, 33.3% of individuals reached MCID on FMA and 27.3% on ARAT post intervention. Conclusion As expected, the MEP+ group had the greatest improvement in motor function. However, it was shown that individuals without MEPs can also achieve meaningful changes, as reflected by MCID, when neuromodulation is paired with motor training. To our knowledge, this is the first study to differentiate the effects of neuromodulation by MEP status.
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Affiliation(s)
- Elizabeth S Powell
- Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, Kentucky
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Lumy Sawaki
- Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, Kentucky
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13
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Fors U, Kamwesiga JT, Eriksson GM, von Koch L, Guidetti S. User evaluation of a novel SMS-based reminder system for supporting post-stroke rehabilitation. BMC Med Inform Decis Mak 2019; 19:122. [PMID: 31269946 PMCID: PMC6610841 DOI: 10.1186/s12911-019-0847-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 06/20/2019] [Indexed: 11/26/2022] Open
Abstract
Background According to WHO stroke is a growing societal challenge and the third leading cause of global disease-burden estimated using disability-adjusted life years. Rehabilitation after stroke is an area of mutual interest for health care in many countries. Within the health care sector there is a growing emphasis on ICT services to provide clients with easier access to information, self-evaluation, and self-management. ICT-supported care programs possible to use in clients’ home environments are also recommended when there are long distances to the health care specialists. The aim of this study was to evaluate the technical usability of a SMS-based reminder system as well as user opinions when using such a system to assist clients to remember to perform daily rehabilitation activities, to rate their performance and to allow Occupational therapists (OT’s) to track and follow-up clients’ results over time. Methods Fifteen persons with stroke were invited to participate in the study and volunteered to receive daily SMS-based reminders regarding three activities to perform on a daily basis as well as answer daily SMS-based questions about their success rate during eight weeks. Clients, a number of family members, as well as OTs were interviewed to evaluate their opinions of using the reminder system. Results All clients were positive to the reminder system and felt that it helped them to regain their abilities. Their OTs agreed that the reminder and follow-up system was of benefit in the rehabilitation process. However, some technical and other issues were limiting the use of the system for some clients. The issues were mostly linked to the fact that the SMS system was based on a Swedish phone number, so that all messages needed to be sent internationally. Conclusion In conclusion, it seems that this type of SMS-based reminder systems could be of good use in the rehabilitation process after stroke, even in low income counties where few clients have access to Internet or smart phones, and where access to healthcare services is limited. However, since the results are based on clients’, OTs’ and family members’ expressed beliefs, we suggest that future research objectively investigate the intervention’s beneficial effects on the clients’ physical and cognitive health. Electronic supplementary material The online version of this article (10.1186/s12911-019-0847-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Uno Fors
- Department of Computer and Systems Sciences (DSV), Stockholm University, Stockholm, Sweden.
| | - Julius T Kamwesiga
- Uganda Allied Health Examinations Board, Kampala, Uganda.,Division of Occupational Therapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Gunilla M Eriksson
- Division of Occupational Therapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Uppsala, Sweden
| | - Lena von Koch
- Division of Occupational Therapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - Susanne Guidetti
- Division of Occupational Therapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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14
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Mugler EM, Tomic G, Singh A, Hameed S, Lindberg EW, Gaide J, Alqadi M, Robinson E, Dalzotto K, Limoli C, Jacobson T, Lee J, Slutzky MW. Myoelectric Computer Interface Training for Reducing Co-Activation and Enhancing Arm Movement in Chronic Stroke Survivors: A Randomized Trial. Neurorehabil Neural Repair 2019; 33:284-295. [PMID: 30888251 DOI: 10.1177/1545968319834903] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Abnormal muscle co-activation contributes to impairment after stroke. We developed a myoelectric computer interface (MyoCI) training paradigm to reduce abnormal co-activation. MyoCI provides intuitive feedback about muscle activation patterns, enabling decoupling of these muscles. OBJECTIVE To investigate tolerability and effects of MyoCI training of 3 muscle pairs on arm motor recovery after stroke, including effects of training dose and isometric versus movement-based training. METHODS We randomized chronic stroke survivors with moderate-to-severe arm impairment to 3 groups. Two groups tested different doses of isometric MyoCI (60 vs 90 minutes), and one group tested MyoCI without arm restraint (90 minutes), over 6 weeks. Primary outcome was arm impairment (Fugl-Meyer Assessment). Secondary outcomes included function, spasticity, and elbow range-of-motion at weeks 6 and 10. RESULTS Over all 32 subjects, MyoCI training of 3 muscle pairs significantly reduced impairment (Fugl-Meyer Assessment) by 3.3 ± 0.6 and 3.1 ± 0.7 ( P < 10-4) at weeks 6 and 10, respectively. Each group improved significantly from baseline; no significant differences were seen between groups. Participants' lab-based and home-based function also improved at weeks 6 and 10 ( P ≤ .01). Spasticity also decreased over all subjects, and elbow range-of-motion improved. Both moderately and severely impaired patients showed significant improvement. No participants had training-related adverse events. MyoCI reduced abnormal co-activation, which appeared to transfer to reaching in the movement group. CONCLUSIONS MyoCI is a well-tolerated, novel rehabilitation tool that enables stroke survivors to reduce abnormal co-activation. It may reduce impairment and spasticity and improve arm function, even in severely impaired patients.
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Affiliation(s)
| | | | | | | | | | - Jon Gaide
- 1 Northwestern University, Chicago, IL, USA
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15
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Semrau JA, Herter TM, Scott SH, Dukelow SP. Vision of the upper limb fails to compensate for kinesthetic impairments in subacute stroke. Cortex 2018; 109:245-259. [PMID: 30391879 DOI: 10.1016/j.cortex.2018.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/08/2018] [Accepted: 09/29/2018] [Indexed: 11/25/2022]
Abstract
Kinesthesia is an essential component of proprioception allowing for perception of movement. Due to neural injury, such as stroke, kinesthesia can be significantly impaired. Throughout neurorehabilitation, clinicians may encourage use of vision to guide limb movement to retrain impaired kinesthesia. However, little evidence exists that vision improves kinesthetic performance after stroke. We examined behavioral and neuroanatomical characteristics of kinesthesia post-stroke to determine if these impairments improve with vision. Stroke subjects (N = 281) performed a robotic kinesthetic matching task (KIN) without and with vision at ∼10 days post-stroke. A robotic exoskeleton moved the stroke-affected arm while subjects mirror-matched the movement with the opposite arm. Performance was compared to 160 controls. Spatial and temporal parameters were used to quantify kinesthetic performance. A Kinesthetic Task Score was calculated to determine overall performance on KIN without and with vision. Acute stroke imaging (N = 236) was collected to determine commonalities in lesion characteristics amongst kinesthetic impairment groups. Forty-eight percent (N = 135) of subjects had post-stroke impairment in kinesthesia both without and with vision. Only 19% (N = 52) improved to control-level performance with vision. Of the 48% of subjects that failed to improve with vision, many (N = 77, 57%) had neglect and/or field deficits. Notably 58 subjects (43%) did not have these deficits and still failed to improve with vision. Subjects who failed to improve with vision often had lesions affecting corticospinal tracts, insula, and parietal cortex, specifically the supramarginal gyrus and inferior parietal lobule. Many individuals could not use vision of the limb to correct for impaired kinesthesia after stroke. Subjects that failed to improve kinesthesia with vision had lesions affecting known sensorimotor integration areas. Our results suggest that integration of spatial information is impaired in many individuals post-stroke, particularly after parietal cortex damage. The result is a disconnect between kinesthetic and visuomotor processing necessary for visual limb guidance.
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Affiliation(s)
- Jennifer A Semrau
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Troy M Herter
- Department of Exercise Science, University of South Carolina, Columbia, SC, USA
| | - Stephen H Scott
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Sean P Dukelow
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
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16
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Zou D, Liu C, Zhang Q, Li X, Qin G, Huang Q, Meng Y, Chen L, Wei J. Association between polymorphisms in microRNAs and ischemic stroke in an Asian population: evidence based on 6,083 cases and 7,248 controls. Clin Interv Aging 2018; 13:1709-1726. [PMID: 30254431 PMCID: PMC6140750 DOI: 10.2147/cia.s174000] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Polymorphisms in miR-146a (rs2910164), miR-196a2 (rs11614913), miR-149 (rs2292832) and miR-499 (rs3746444) have been associated with ischemic stroke (IS), but studies have given inconsistent results. Methods This meta-analysis investigated the possible association between IS risk and the four polymorphisms. A total of 14 case-control studies from Asian populations involving 6,083 cases and 7,248 controls for the four polymorphisms were included. Results Results showed that the GG genotype of miR-146a (rs2910164) may be associated with increased IS risk according to the recessive model (OR=1.20, 95% CI=1.02–1.42, P=0.03). Similarly, the CC genotype of miR-149 (rs2292832) may be associated with increased IS risk according to the recessive model (OR=1.28, 95% CI=1.08–1.52, P=0.005) and the homozygous model (OR=1.31, 95% CI=1.09–1.58, P=0.004). In contrast, miR-196a2 (rs11614913) and miR-499 (rs3746444) polymorphisms did not show significant association with IS risk in any of the five genetic models. Conclusion These results indicate that the GG genotype of miR-146a (rs2910164) and CC genotype of miR-149 (rs2292832) may confer increased susceptibility to IS, while miR-196a2 (rs11614913) and miR-499 (rs3746444) polymorphisms may not be associated with IS risk in Asian populations. These conclusions should be verified in large and well-designed studies.
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Affiliation(s)
- Donghua Zou
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Chunbin Liu
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Qian Zhang
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Xianfeng Li
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Gang Qin
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Qi Huang
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Youshi Meng
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Li Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
| | - Jinru Wei
- Department of Stroke Center, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China,
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17
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Palermo E, Hayes DR, Russo EF, Calabrò RS, Pacilli A, Filoni S. Translational effects of robot-mediated therapy in subacute stroke patients: an experimental evaluation of upper limb motor recovery. PeerJ 2018; 6:e5544. [PMID: 30202655 PMCID: PMC6128258 DOI: 10.7717/peerj.5544] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/09/2018] [Indexed: 11/20/2022] Open
Abstract
Robot-mediated therapies enhance the recovery of post-stroke patients with motor deficits. Repetitive and repeatable exercises are essential for rehabilitation following brain damage or other disorders that impact the central nervous system, as plasticity permits to reorganize its neural structure, fostering motor relearning. Despite the fact that so many studies claim the validity of robot-mediated therapy in post-stroke patient rehabilitation, it is still difficult to assess to what extent its adoption improves the efficacy of traditional therapy in daily life, and also because most of the studies involved planar robots. In this paper, we report the effects of a 20-session-rehabilitation project involving the Armeo Power robot, an assistive exoskeleton to perform 3D upper limb movements, in addition to conventional rehabilitation therapy, on 10 subacute stroke survivors. Patients were evaluated through clinical scales and a kinematic assessment of the upper limbs, both pre- and post-treatment. A set of indices based on the patients' 3D kinematic data, gathered from an optoelectronic system, was calculated. Statistical analysis showed a remarkable difference in most parameters between pre- and post-treatment. Significant correlations between the kinematic parameters and clinical scales were found. Our findings suggest that 3D robot-mediated rehabilitation, in addition to conventional therapy, could represent an effective means for the recovery of upper limb disability. Kinematic assessment may represent a valid tool for objectively evaluating the efficacy of the rehabilitation treatment.
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Affiliation(s)
- Eduardo Palermo
- Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Rome, Italy
| | - Darren Richard Hayes
- Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Rome, Italy
- Seidenberg School of Computer Science and Information Systems, Pace University, New York, NY, USA
| | | | | | - Alessandra Pacilli
- Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Rome, Italy
| | - Serena Filoni
- Fondazione Centri di Riabilitazione Padre Pio Onlus, San Giovanni Rotondo, Italy
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18
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Dinon T, Caimmi M, Chiavenna A, Malosio M, Prini A, Scano A, Molinari Tosatti L, Currò C, Lenzi B, Megale V. DUALarm: An open-source and 3D-printable device for upper limb neurorehabilitation. J Rehabil Assist Technol Eng 2018; 5:2055668317749989. [PMID: 31191920 PMCID: PMC6453029 DOI: 10.1177/2055668317749989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 11/22/2017] [Indexed: 11/16/2022] Open
Abstract
Positively advocating that low-cost additive 3D-printing technologies and open-source licensed software/hardware platforms represent an optimal solution to realize low-cost equipment, a mechanical and 3D-printable device for bilateral upper-limb rehabilitation is presented. The design and manufacturing process of this wheel-geared mechanism, enabling in-phase and anti-phase movements, will be openly provided online with the aim of making a set of customizable devices for neurorehabilitation exploitable all over the world even by people/countries with limited economical and technological resources. In order to characterize the interaction with the device, preliminary trials with EMG and kinematics recordings were performed on healthy subjects.
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Affiliation(s)
- Tito Dinon
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
| | - Marco Caimmi
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
| | - Andrea Chiavenna
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
| | - Matteo Malosio
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
| | - Alessio Prini
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
| | - Alessandro Scano
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
| | - Lorenzo Molinari Tosatti
- 1Institute of Industrial Technologies and Automation, National Research Council of Italy, Milan, Italy
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19
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Beed AT, Peduzzi P, Guarino P, Wininger M. A Partitioning Algorithm for Extracting Movement Epochs from Robot-Derived Kinematic Data. Front Robot AI 2017. [DOI: 10.3389/frobt.2017.00057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Effect of Transcranial Direct Current Stimulation on Severely Affected Arm-Hand Motor Function in Patients After an Acute Ischemic Stroke. Am J Phys Med Rehabil 2017; 96:S178-S184. [DOI: 10.1097/phm.0000000000000823] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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21
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Wittenberg GF, Richards LG, Jones-Lush LM, Roys SR, Gullapalli RP, Yang S, Guarino PD, Lo AC. Predictors and brain connectivity changes associated with arm motor function improvement from intensive practice in chronic stroke. F1000Res 2016; 5:2119. [PMID: 28357039 PMCID: PMC5345776 DOI: 10.12688/f1000research.8603.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose: The brain changes that underlie therapy-induced improvement in motor function after stroke remain obscure. This study sought to demonstrate the feasibility and utility of measuring motor system physiology in a clinical trial of intensive upper extremity rehabilitation in chronic stroke-related hemiparesis.
Methods: This was a substudy of two multi-center clinical trials of intensive robotic and intensive conventional therapy arm therapy in chronic, significantly hemiparetic, stroke patients. Transcranial magnetic stimulation was used to measure motor cortical output to the biceps and extensor digitorum communus muscles. Magnetic resonance imaging (MRI) was used to determine the cortical anatomy, as well as to measure fractional anisotropy, and blood oxygenation (BOLD) during an eyes-closed rest state. Region-of-interest time-series correlation analysis was performed on the BOLD signal to determine interregional connectivity. Functional status was measured with the upper extremity Fugl-Meyer and Wolf Motor Function Test.
Results: Motor evoked potential (MEP) presence was associated with better functional outcomes, but the effect was not significant when considering baseline impairment. Affected side internal capsule fractional anisotropy was associated with better function at baseline. Affected side primary motor cortex (M1) activity became more correlated with other frontal motor regions after treatment. Resting state connectivity between affected hemisphere M1 and dorsal premotor area (PMAd) predicted recovery.
Conclusions: Presence of motor evoked potentials in the affected motor cortex and its functional connectivity with PMAd may be useful in predicting recovery. Functional connectivity in the motor network shows a trends towards increasing after intensive robotic or non-robotic arm therapy. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00372411 \& NCT00333983.
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Affiliation(s)
- George F Wittenberg
- Department of Veterans Affairs (VA) Maryland Health Care System, Geriatrics Research, Education and Clinical Center, and Maryland Exercise & Robotics Center of Excellence, Baltimore, MD, 21201, USA; Departments of Neurology, Physical Therapy and Rehabilitation Science, Internal Medicine, Older Americans Independence Center, University of Maryland, Baltimore, MD, 21201, USA
| | - Lorie G Richards
- North Florida/South Georgia Veterans Health System, Gainesville, FL, 32611, USA; University of Florida, Gainesville, FL, 32608, USA
| | - Lauren M Jones-Lush
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, 21201, USA
| | - Steven R Roys
- Department of Radiology, University of Maryland, Baltimore, MD, 21201, USA
| | - Rao P Gullapalli
- Department of Radiology, University of Maryland, Baltimore, MD, 21201, USA
| | - Suzy Yang
- VA Cooperative Studies Program Coordinating Center, West Haven, CT, 06516, USA
| | - Peter D Guarino
- VA Cooperative Studies Program Coordinating Center, West Haven, CT, 06516, USA
| | - Albert C Lo
- Providence VA Medical Center and VA Research and Development Center of Excellence, Center for Restorative and Regenerative Medicine, Brown University, Providence, RI, 02908, USA
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22
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Steinberg GK, Kondziolka D, Wechsler LR, Lunsford LD, Coburn ML, Billigen JB, Kim AS, Johnson JN, Bates D, King B, Case C, McGrogan M, Yankee EW, Schwartz NE. Clinical Outcomes of Transplanted Modified Bone Marrow-Derived Mesenchymal Stem Cells in Stroke: A Phase 1/2a Study. Stroke 2016; 47:1817-24. [PMID: 27256670 DOI: 10.1161/strokeaha.116.012995] [Citation(s) in RCA: 284] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/25/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Preclinical data suggest that cell-based therapies have the potential to improve stroke outcomes. METHODS Eighteen patients with stable, chronic stroke were enrolled in a 2-year, open-label, single-arm study to evaluate the safety and clinical outcomes of surgical transplantation of modified bone marrow-derived mesenchymal stem cells (SB623). RESULTS All patients in the safety population (N=18) experienced at least 1 treatment-emergent adverse event. Six patients experienced 6 serious treatment-emergent adverse events; 2 were probably or definitely related to surgical procedure; none were related to cell treatment. All serious treatment-emergent adverse events resolved without sequelae. There were no dose-limiting toxicities or deaths. Sixteen patients completed 12 months of follow-up at the time of this analysis. Significant improvement from baseline (mean) was reported for: (1) European Stroke Scale: mean increase 6.88 (95% confidence interval, 3.5-10.3; P<0.001), (2) National Institutes of Health Stroke Scale: mean decrease 2.00 (95% confidence interval, -2.7 to -1.3; P<0.001), (3) Fugl-Meyer total score: mean increase 19.20 (95% confidence interval, 11.4-27.0; P<0.001), and (4) Fugl-Meyer motor function total score: mean increase 11.40 (95% confidence interval, 4.6-18.2; P<0.001). No changes were observed in modified Rankin Scale. The area of magnetic resonance T2 fluid-attenuated inversion recovery signal change in the ipsilateral cortex 1 week after implantation significantly correlated with clinical improvement at 12 months (P<0.001 for European Stroke Scale). CONCLUSIONS In this interim report, SB623 cells were safe and associated with improvement in clinical outcome end points at 12 months. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01287936.
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Affiliation(s)
- Gary K Steinberg
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.).
| | - Douglas Kondziolka
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Lawrence R Wechsler
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - L Dade Lunsford
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Maria L Coburn
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Julia B Billigen
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Anthony S Kim
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Jeremiah N Johnson
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Damien Bates
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Bill King
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Casey Case
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Michael McGrogan
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Ernest W Yankee
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
| | - Neil E Schwartz
- From the Department of Neurosurgery (G.K.S., M.L.C., J.N.J.) and Department of Neurology and Neurological Sciences (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; Department of Neurosurgery, New York University and NYU Langone Medical Center, NY (D.K.); Department of Neurosurgery (L.D.L.) and Department of Neurology (L.R.W., J.B.B.), University of Pittsburgh Medical School and University of Pittsburgh Medical Center, PA; Department of Neurology, University of California, San Francisco (A.S.K.); SanBio, Inc, Mountain View, CA (D.B., C.C., M.M., E.W.Y.); and Western Statistical Consulting, LLC, Phoenix, AZ (B.K.)
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Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:e98-e169. [PMID: 27145936 DOI: 10.1161/str.0000000000000098] [Citation(s) in RCA: 1571] [Impact Index Per Article: 196.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. CONCLUSIONS As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).
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Semrau JA, Herter TM, Scott SH, Dukelow SP. Examining Differences in Patterns of Sensory and Motor Recovery After Stroke With Robotics. Stroke 2015; 46:3459-69. [PMID: 26542695 DOI: 10.1161/strokeaha.115.010750] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/16/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Developing a better understanding of the trajectory and timing of stroke recovery is critical for developing patient-centered rehabilitation approaches. Here, we quantified proprioceptive and motor deficits using robotic technology during the first 6 months post stroke to characterize timing and patterns in recovery. We also make comparisons of robotic assessments to traditional clinical measures. METHODS One hundred sixteen subjects with unilateral stroke were studied at 4 time points: 1, 6, 12, and 26 weeks post stroke. Subjects performed robotic assessments of proprioceptive (position sense and kinesthesia) and motor function (unilateral reaching task and bimanual object hit task), as well as several clinical measures (Functional Independence Measure, Purdue Pegboard, and Chedoke-McMaster Stroke Assessment). RESULTS One week post stroke, many subjects displayed proprioceptive (48% position sense and 68% kinesthesia) and motor impairments (80% unilateral reaching and 85% bilateral movement). Interindividual recovery on robotic measures was highly variable. However, we characterized recovery as early (normal by 6 weeks post stroke), late (normal by 26 weeks post stroke), or incomplete (impaired at 26 weeks post stroke). Proprioceptive and motor recovery often followed different timelines. Across all time points, robotic measures were correlated with clinical measures. CONCLUSIONS These results highlight the need for more sensitive, targeted identification of sensory and motor deficits to optimize rehabilitation after stroke. Furthermore, the trajectory of recovery for some individuals with mild to moderate stroke may be much longer than previously considered.
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Affiliation(s)
- Jennifer A Semrau
- From the Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (J.A.S., S.P.D.); Department of Exercise Science, University of South Carolina, Columbia (T.M.H.); and Department of Biomedical and Molecular Sciences, Centre for Neuroscience Studies, School of Medicine, Queen's University, Kingston, Ontario, Canada (S.H.S.)
| | - Troy M Herter
- From the Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (J.A.S., S.P.D.); Department of Exercise Science, University of South Carolina, Columbia (T.M.H.); and Department of Biomedical and Molecular Sciences, Centre for Neuroscience Studies, School of Medicine, Queen's University, Kingston, Ontario, Canada (S.H.S.)
| | - Stephen H Scott
- From the Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (J.A.S., S.P.D.); Department of Exercise Science, University of South Carolina, Columbia (T.M.H.); and Department of Biomedical and Molecular Sciences, Centre for Neuroscience Studies, School of Medicine, Queen's University, Kingston, Ontario, Canada (S.H.S.)
| | - Sean P Dukelow
- From the Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (J.A.S., S.P.D.); Department of Exercise Science, University of South Carolina, Columbia (T.M.H.); and Department of Biomedical and Molecular Sciences, Centre for Neuroscience Studies, School of Medicine, Queen's University, Kingston, Ontario, Canada (S.H.S.).
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Wu X, Guarino P, Lo AC, Peduzzi P, Wininger M. Long-term Effectiveness of Intensive Therapy in Chronic Stroke. Neurorehabil Neural Repair 2015; 30:583-90. [PMID: 26450442 DOI: 10.1177/1545968315608448] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background While recent clinical trials involving robot-assisted therapy have failed to show clinically significant improvement versus conventional therapy, it is possible that a broader strategy of intensive therapy-to include robot-assisted rehabilitation-may yield clinically meaningful outcomes. Objective To test the immediate and sustained effects of intensive therapy (robot-assisted therapy plus intensive conventional therapy) on outcomes in a chronic stroke population. Methods A multivariate mixed-effects model adjusted for important covariates was established to measure the effect of intensive therapy versus usual care. A total of 127 chronic stroke patients from 4 Veterans Affairs medical centers were randomized to either robot-assisted therapy (n = 49), intensive comparison therapy (n = 50), or usual care (n = 28), in the VA-ROBOTICS randomized clinical trial. Patients were at least 6 months poststroke, of moderate-to-severe upper limb impairment. The primary outcome measure was the Fugl-Meyer Assessment at 12 and 36 weeks. Results There was significant benefit of intensive therapy over usual care on the Fugl-Meyer Assessment at 12 weeks with a mean difference of 4.0 points (95% CI = 1.3-6.7); P = .005; however, by 36 weeks, the benefit was attenuated (mean difference 3.4; 95% CI = -0.02 to 6.9; P = .05). Subgroup analyses showed significant interactions between treatment and age, treatment and time since stroke. Conclusions Motor benefits from intensive therapy compared with usual care were observed at 12 and 36 weeks posttherapy; however, this difference was attenuated at 36 weeks. Subgroups analysis showed that younger age, and a shorter time since stroke were associated with greater immediate and long-term improvement of motor function.
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Affiliation(s)
- Xiaotian Wu
- Yale University, New Haven, CT, USA VA Connecticut Healthcare System, West Haven, CT, USA
| | - Peter Guarino
- Yale University, New Haven, CT, USA VA Connecticut Healthcare System, West Haven, CT, USA
| | - Albert C Lo
- VA RRD Center of Excellence for Neurorestoration and Neurotechnology, Providence, RI, USA Brown University, Providence, RI, USA
| | - Peter Peduzzi
- Yale University, New Haven, CT, USA VA Connecticut Healthcare System, West Haven, CT, USA
| | - Michael Wininger
- Yale University, New Haven, CT, USA VA Connecticut Healthcare System, West Haven, CT, USA University of Hartford, West Hartford, CT, USA
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Choe YK, Foster T, Asselin A, LeVander M, Baird J. Cognitive-linguistic effort in multidisciplinary stroke rehabilitation: Decreasing vs. increasing cues for word retrieval. Neuropsychol Rehabil 2015; 27:318-348. [PMID: 26366476 DOI: 10.1080/09602011.2015.1078820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Approximately 24% of stroke survivors experience co-occurring aphasia and hemiparesis. These individuals typically attend back-to-back therapy sessions. However, sequentially scheduled therapy may trigger physical and mental fatigue and have an adverse impact on treatment outcomes. The current study tested a hypothesis that exerting less effort during a therapy session would reduce overall fatigue and enhance functional recovery. Two stroke survivors chronically challenged by non-fluent aphasia and right hemiparesis sequentially completed verbal naming and upper-limb tasks on their home computers. The level of cognitive-linguistic effort in speech/language practice was manipulated by presenting verbal naming tasks in two conditions: Decreasing cues (i.e., most-to-least support for word retrieval), and Increasing cues (i.e., least-to-most support). The participants completed the same upper-limb exercises throughout the study periods. Both individuals showed a statistically significant advantage of decreasing cues over increasing cues in word retrieval during the practice period, but not at the end of the practice period or thereafter. The participant with moderate aphasia and hemiparesis achieved clinically meaningful gains in upper-limb functions following the decreasing cues condition, but not after the increasing cues condition. Preliminary findings from the current study suggest a positive impact of decreasing cues in the context of multidisciplinary stroke rehabilitation.
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Affiliation(s)
- Yu-Kyong Choe
- a Department of Communication Disorders , University of Massachusetts Amherst , Amherst , MA , USA
| | - Tammie Foster
- b Cooley Dickinson Hospital , Northampton , MA , USA
| | - Abigail Asselin
- a Department of Communication Disorders , University of Massachusetts Amherst , Amherst , MA , USA
| | - Meagan LeVander
- a Department of Communication Disorders , University of Massachusetts Amherst , Amherst , MA , USA
| | - Jennifer Baird
- c Department of Physical Therapy , St. Ambrose University , Davenport , IA , USA
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McCabe J, Monkiewicz M, Holcomb J, Pundik S, Daly JJ. Comparison of Robotics, Functional Electrical Stimulation, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction After Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil 2015; 96:981-90. [DOI: 10.1016/j.apmr.2014.10.022] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/17/2014] [Accepted: 10/29/2014] [Indexed: 10/24/2022]
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Germanotta M, Vasco G, Petrarca M, Rossi S, Carniel S, Bertini E, Cappa P, Castelli E. Robotic and clinical evaluation of upper limb motor performance in patients with Friedreich's Ataxia: an observational study. J Neuroeng Rehabil 2015; 12:41. [PMID: 25900021 PMCID: PMC4448881 DOI: 10.1186/s12984-015-0032-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Friedreich's ataxia (FRDA) is the most common hereditary autosomal recessive form of ataxia. In this disease there is early manifestation of gait ataxia, and dysmetria of the arms and legs which causes impairment in daily activities that require fine manual dexterity. To date there is no cure for this disease. Some novel therapeutic approaches are ongoing in different steps of clinical trial. Development of sensitive outcome measures is crucial to prove therapeutic effectiveness. The aim of the study was to assess the reliability and sensitivity of quantitative and objective assessment of upper limb performance computed by means of the robotic device and to evaluate the correlation with clinical and functional markers of the disease severity. METHODS Here we assess upper limb performances by means of the InMotion Arm Robot, a robot designed for clinical neurological applications, in a cohort of 14 children and young adults affected by FRDA, matched for age and gender with 18 healthy subjects. We focused on the analysis of kinematics, accuracy, smoothness, and submovements of the upper limb while reaching movements were performed. The robotic evaluation of upper limb performance consisted of planar reaching movements performed with the robotic system. The motors of the robot were turned off, so that the device worked as a measurement tool. The status of the disease was scored using the Scale for the Assessment and Rating of Ataxia (SARA). Relationships between robotic indices and a range of clinical and disease characteristics were examined. RESULTS All our robotic indices were significantly different between the two cohorts except for two, and were highly and reliably discriminative between healthy and subjects with FRDA. In particular, subjects with FRDA exhibited slower movements as well as loss of accuracy and smoothness, which are typical of the disease. Duration of Movement, Normalized Jerk, and Number of Submovements were the best discriminative indices, as they were directly and easily measurable and correlated with the status of the disease, as measured by SARA. CONCLUSIONS Our results suggest that outcome measures obtained by means of robotic devices can improve the sensitivity of clinical evaluations of patients' dexterity and can accurately and efficiently quantify changes over time in clinical trials, particularly when functional scales appear to be no longer sensitive.
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Affiliation(s)
- Marco Germanotta
- Don Carlo Gnocchi Onlus Foundation, Piazzale Morandi 6, 20121, Milan, Italy.
| | - Gessica Vasco
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Units, IRCCS Bambino Gesù Children's Hospital, Via Torre di Palidoro, 00050, Passoscuro (Fiumicino), Rome, Italy. .,Unit of Neuromuscular and Neurodegenerative Disorders, Laboratory of Molecular Medicine, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Maurizio Petrarca
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Units, IRCCS Bambino Gesù Children's Hospital, Via Torre di Palidoro, 00050, Passoscuro (Fiumicino), Rome, Italy.
| | - Stefano Rossi
- Department of Economics and Management - Industrial Engineering (DEIM), University of Tuscia, Via del Paradiso 47, 01100, Viterbo, Italy.
| | - Sacha Carniel
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Units, IRCCS Bambino Gesù Children's Hospital, Via Torre di Palidoro, 00050, Passoscuro (Fiumicino), Rome, Italy.
| | - Enrico Bertini
- Unit of Neuromuscular and Neurodegenerative Disorders, Laboratory of Molecular Medicine, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Paolo Cappa
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Units, IRCCS Bambino Gesù Children's Hospital, Via Torre di Palidoro, 00050, Passoscuro (Fiumicino), Rome, Italy. .,Department of Mechanical and Aerospace Engineering, "Sapienza", University of Rome, Via Eudossiana 18, 00184, Roma, Italy.
| | - Enrico Castelli
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Units, IRCCS Bambino Gesù Children's Hospital, Via Torre di Palidoro, 00050, Passoscuro (Fiumicino), Rome, Italy.
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Daly JJ, Huggins JE. Brain-computer interface: current and emerging rehabilitation applications. Arch Phys Med Rehabil 2015; 96:S1-7. [PMID: 25721542 PMCID: PMC4383183 DOI: 10.1016/j.apmr.2015.01.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/07/2015] [Accepted: 01/07/2015] [Indexed: 11/19/2022]
Abstract
A formal definition of brain-computer interface (BCI) is as follows: a system that acquires brain signal activity and translates it into an output that can replace, restore, enhance, supplement, or improve the existing brain signal, which can, in turn, modify or change ongoing interactions between the brain and its internal or external environment. More simply, a BCI can be defined as a system that translates "brain signals into new kinds of outputs." After brain signal acquisition, the BCI evaluates the brain signal and extracts signal features that have proven useful for task performance. There are 2 broad categories of BCIs: implantable and noninvasive, distinguished by invasively and noninvasively acquired brain signals, respectively. For this supplement, we will focus on BCIs that use noninvasively acquired brain signals.
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Affiliation(s)
- Janis J Daly
- Brain Rehabilitation Research Program, McKnight Brain Institute, University of Florida, Gainesville, FL; Department of Neurology, College of Medicine, University of Florida, Gainesville, FL; Brain Rehabilitation Research Center of Excellence, Gainesville, FL; North Florida/South Georgia Veterans Affairs Medical Center, Gainesville, FL.
| | - Jane E Huggins
- Department of Physical Medicine and Rehabilitation, Department of Biomedical Engineering, and Program of Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI
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Babaiasl M, Mahdioun SH, Jaryani P, Yazdani M. A review of technological and clinical aspects of robot-aided rehabilitation of upper-extremity after stroke. Disabil Rehabil Assist Technol 2015; 11:263-80. [PMID: 25600057 DOI: 10.3109/17483107.2014.1002539] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cerebrovascular accident (CVA) or stroke is one of the leading causes of disability and loss of motor function. Millions of people around the world are effected by it each year. Stroke results in disabled arm function. Restoration of arm function is essential to regaining activities of daily living (ADL). Along with traditional rehabilitation methods, robot-aided therapy has emerged in recent years. Robot-aided rehabilitation is more intensive, of longer duration and more repetitive. Using robots, repetitive dull exercises can turn into a more challenging and motivating tasks such as games. Besides, robots can provide a quantitative measure of the rehabilitation progress. This article overviews the terms used in robot-aided upper-limb rehabilitation. It continues by investigating the requirements for rehabilitation robots. Then the most outstanding works in robot-aided upper-limb rehabilitation and their control schemes have been investigated. The clinical outcomes of the built robots are also given that demonstrates the usability of these robots in real-life applications and their acceptance. This article summarizes a review done along with a research on the design, simulation and control of a robot for use in upper-limb rehabilitation after stroke. Implications for Rehabilitation Reviewing common terms in rehabilitation of upper limb using robots Reviewing rehabilitation robots built up to date Reviewing clinical outcomes of the mentioned rehabilitation robots.
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Affiliation(s)
- Mahdieh Babaiasl
- a School of Engineering Emerging Technologies , University of Tabriz , Tabriz , Iran
| | - Seyyed Hamed Mahdioun
- a School of Engineering Emerging Technologies , University of Tabriz , Tabriz , Iran
| | - Poorya Jaryani
- b Department of Mechanical Engineering, Islamshahr Branch , Islamic Azad University , Islamshahr , Iran , and
| | - Mojtaba Yazdani
- c Control Department, Electronics Faculty , Semnan University , Semnan , Iran
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Merians AS, Fluet G, Tunik E, Qiu Q, Saleh S, Adamovich S. Movement rehabilitation in virtual reality from then to now: how are we doing? INTERNATIONAL JOURNAL ON DISABILITY AND HUMAN DEVELOPMENT : IJDHD 2014; 13:311-317. [PMID: 29057195 PMCID: PMC5648340 DOI: 10.1515/ijdhd-2014-0321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
During the past decade, there has been a continuous exploration of how virtual environments can be used to facilitate motor recovery and relearning after neurological impairment. There are two goals for using virtual environments: to improve patients' rehabilitation outcomes beyond our current capabilities or to supplement labor-intensive and time consuming therapies with technology-based interventions. After over a decade of investigation, it seems appropriate to determine whether we are succeeding in meeting such goals.
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Affiliation(s)
- Alma S. Merians
- Department of Rehabilitation and Movement Sciences, University of Medicine
and Dentistry of New Jersey, 65 Bergen Street, Newark, NJ 07107, USA
| | - Gerard Fluet
- Department of Rehabilitation and Movement Sciences, University of Medicine
and Dentistry of New Jersey, Newark, NJ, USA
| | - Eugene Tunik
- Department of Rehabilitation and Movement Sciences, University of Medicine
and Dentistry of New Jersey, Newark, NJ, USA
| | - Q. Qiu
- Department of Rehabilitation and Movement Sciences, University of Medicine
and Dentistry of New Jersey, Newark, NJ, USA
| | - Soha Saleh
- Department of Rehabilitation and Movement Sciences, University of Medicine
and Dentistry of New Jersey, Newark, NJ, USA
| | - Sergei Adamovich
- Department of Rehabilitation and Movement Sciences, University of Medicine
and Dentistry of New Jersey, Newark, NJ, USA; and New Jersey Institute of Technology,
Department of Biomedical Engineering, Newark, NJ, USA
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Byl NN, Abrams GM, Pitsch E, Fedulow I, Kim H, Simkins M, Nagarajan S, Rosen J. Chronic stroke survivors achieve comparable outcomes following virtual task specific repetitive training guided by a wearable robotic orthosis (UL-EXO7) and actual task specific repetitive training guided by a physical therapist. J Hand Ther 2014; 26:343-52; quiz 352. [PMID: 23911077 DOI: 10.1016/j.jht.2013.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 05/23/2013] [Accepted: 06/03/2013] [Indexed: 02/03/2023]
Abstract
Survivors post stroke commonly have upper limb impairments. Patients can drive neural reorganization, brain recovery and return of function with task specific repetitive training (TSRT). Fifteen community independent stroke survivors (25-75 years, >6 months post stroke, Upper Limb Fugl Meyer [ULFM] scores 16-39) participated in this randomized feasibility study to compare outcomes of upper limb TSRT guided by a robotic orthosis (bilateral or unilateral) or a physical therapist. After 6 weeks of training (18 h), across all subjects, there were significant improvements in depression, flexibility, strength, tone, pain and voluntary movement (ULFM) (p < 0.05; effect sizes 0.49-3.53). Each training group significantly improved ULFM scores and range of motion without significant group differences. Virtual or actual TSRT performed with a robotic orthosis or a physical therapist significantly reduced arm impairments around the shoulder and elbow without significant gains in fine motor hand control, activities of daily living or independence.
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Affiliation(s)
- Nancy N Byl
- Department of Physical Therapy and Rehabilitation Medicine, School of Medicine, University of California, San Francisco, USA.
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Wang TC, Tsai AC, Wang JY, Lin YT, Lin KL, Chen JJ, Lin BY, Lin TC. Caregiver-Mediated Intervention Can Improve Physical Functional Recovery of Patients With Chronic Stroke. Neurorehabil Neural Repair 2014; 29:3-12. [DOI: 10.1177/1545968314532030] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Purpose. Patients with chronic stroke may benefit from continuing rehabilitation training after hospital discharge. This study examined whether caregiver-mediated, home-based intervention (CHI) could improve physical functioning and social participation in these patients. Methods. A single-blind, randomized, controlled 12-week trial conducted with 51 patients from 3 hospitals in Taiwan who had chronic stroke (>6 months; Brunnstrom recovery stages III-V). Patients and their caregivers in the intervention arm (n = 25) were given weekly personalized CHI trainings designed by a physical therapist. Patients in the control arm (n = 26) received visits from the therapist without intervention. All were evaluated for physical recovery through the Stroke Impact Scale, Berg Balance Scale, 10-Meter Walk Test, 6-Minute Walk Test, and Barthel Index at baseline and endpoint. Caregivers were evaluated with the Caregiver Burden Scale. Results were analyzed through Mann-Whitney U test. Results. CHI significantly improved scores of the Stroke Impact Scale: strength (control vs intervention, respectively: 1.4 vs 15.5; P = .002), mobility (–0.5 vs 13.7; P < .001), composite physical (–0.7 vs 11.2; P < .001), and general recovery domain (0.2 vs 17.4; P < .001). CHI also significantly improved free-walking velocity (–1.4 vs 7.5 cm/s; P = .006), 6-minute walk distance (–10.5 vs 15.8 m; P = .003), Berg Balance Scale score (–0.8 vs 4.5; P = .006), and Barthel Index score (0.6 vs 7.2; P = .008). CHI did not significantly increase caregiver burden at endpoint. Conclusion. CHI can improve physical functional recovery and, possibly, social participation in patients with chronic stroke.
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Affiliation(s)
- Tzu-Chi Wang
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
- Department of Physical Therapy, Tzu Hui Institute of Technology, Pingtung, Taiwan
| | - Alan C. Tsai
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
- Department of Health Services Management, School of Public Health, China Medical University, Taichung, Taiwan
| | - Jiun-Yi Wang
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Yu-Te Lin
- Section of Neurology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ko-Long Lin
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jiun Jiang Chen
- Department of Rehabilitation, Kaohsiung Municipal Min-sheng Hospital, Kaohsiung, Taiwan
| | - Bei Yi Lin
- Department of Rehabilitation, Yuan’s General Hospital, Kaohsiung, Taiwan
| | - Tai Ching Lin
- Department of Rehabilitation, St Joseph Hospital, Kaohsiung, Taiwan
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Ambrosio F, Boninger ML, Brubaker CE, Delitto A, Wagner WR, Shields RK, Wolf SL, Rando TA. Guest editorial: emergent themes from second annual symposium on regenerative rehabilitation, Pittsburgh, Pennsylvania. ACTA ACUST UNITED AC 2014; 50:vii-xiv. [PMID: 23881770 DOI: 10.1682/jrrd.2013.04.0081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Grossman AW, Broderick JP. Advances and challenges in treatment and prevention of ischemic stroke. Ann Neurol 2013; 74:363-72. [PMID: 23929628 DOI: 10.1002/ana.23993] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/07/2013] [Accepted: 07/29/2013] [Indexed: 11/05/2022]
Abstract
We review recent advances in the treatment and prevention of acute ischemic stroke, including the current state of endovascular therapy, in light of 5 randomized controlled trials published this past year. Although no benefit of endovascular therapy over intravenous (IV) recombinant tissue plasminogen activator (rt-PA) has been demonstrated, endovascular therapy is an appropriate treatment for acute ischemic stroke patients within the t-PA window who are ineligible for IV t-PA but have a large vascular occlusion. These trials reveal promises and current limitations of endovascular therapy, and comparison of reperfusion therapies remains an important area of research. One common theme is the strong association between a faster time to reperfusion, improved outcome, and reduced mortality. Primary and secondary stroke prevention trials emphasize the importance of aggressive management of medical risk factors as part of any preventative strategy. New oral anticoagulants, for example, offer cost-effective risk reduction in patients with atrial fibrillation, and may represent an opportunity for those with cryptogenic stroke. We highlight areas of unmet need and promising research in stroke, including the need to deliver proven therapies to more patients, and the need to recruit patients into clinical trials that better define the role of endovascular and other stroke therapies. Finally, improvement in strategies to recover speech, cognition, and motor function has the potential to benefit far more stroke patients than any acute stroke therapy, and represents the greatest opportunity for research in the coming century.
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Affiliation(s)
- Aaron W Grossman
- Department of Neurology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH
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Semrau JA, Herter TM, Scott SH, Dukelow SP. Robotic Identification of Kinesthetic Deficits After Stroke. Stroke 2013; 44:3414-21. [PMID: 24193800 DOI: 10.1161/strokeaha.113.002058] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jennifer A. Semrau
- From the Hotchkiss Brain Institute (J.A.S., T.M.H., S.P.D.), and Department of Clinical Neurosciences (J.A.S., T.M.H., S.P.D.), University of Calgary, Alberta, Canada; Centre for Neuroscience Studies (T.M.H., S.H.S.), Department of Anatomy and Cell Biology (S.H.S.), and School of Medicine (S.H.S.), Queen’s University, Kingston, Ontario, Canada; and Department of Exercise Science, University of South Carolina, Columbia (T.M.H.)
| | - Troy M. Herter
- From the Hotchkiss Brain Institute (J.A.S., T.M.H., S.P.D.), and Department of Clinical Neurosciences (J.A.S., T.M.H., S.P.D.), University of Calgary, Alberta, Canada; Centre for Neuroscience Studies (T.M.H., S.H.S.), Department of Anatomy and Cell Biology (S.H.S.), and School of Medicine (S.H.S.), Queen’s University, Kingston, Ontario, Canada; and Department of Exercise Science, University of South Carolina, Columbia (T.M.H.)
| | - Stephen H. Scott
- From the Hotchkiss Brain Institute (J.A.S., T.M.H., S.P.D.), and Department of Clinical Neurosciences (J.A.S., T.M.H., S.P.D.), University of Calgary, Alberta, Canada; Centre for Neuroscience Studies (T.M.H., S.H.S.), Department of Anatomy and Cell Biology (S.H.S.), and School of Medicine (S.H.S.), Queen’s University, Kingston, Ontario, Canada; and Department of Exercise Science, University of South Carolina, Columbia (T.M.H.)
| | - Sean P. Dukelow
- From the Hotchkiss Brain Institute (J.A.S., T.M.H., S.P.D.), and Department of Clinical Neurosciences (J.A.S., T.M.H., S.P.D.), University of Calgary, Alberta, Canada; Centre for Neuroscience Studies (T.M.H., S.H.S.), Department of Anatomy and Cell Biology (S.H.S.), and School of Medicine (S.H.S.), Queen’s University, Kingston, Ontario, Canada; and Department of Exercise Science, University of South Carolina, Columbia (T.M.H.)
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Doucet BM, Griffin L. High-versus low-frequency stimulation effects on fine motor control in chronic hemiplegia: a pilot study. Top Stroke Rehabil 2013; 20:299-307. [PMID: 23893829 DOI: 10.1310/tsr2004-299] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The optimal parameters of neuromuscular electrical stimulation (NMES) for recovery of hand function after stroke are not known. This clinical pilot study examined whether higher or lower frequencies are more effective for improving fine motor control of the hand in a chronic poststroke population. METHODS A 1-month, 4 times per week, in-home regimen of either a high-frequency (40 Hz) or low-frequency (20 Hz) NMES program was applied to the hemiplegic thenar muscles of 16 persons with chronic stroke. Participants were identified a priori as having a low level of function (LF) or a high level of function (HF). Outcome measures of strength, dexterity, and endurance were measured before and after participation in the regimen. RESULTS LF subjects showed no significant changes with either the high- or the low-frequency NMES regimen. HF subjects showed significant changes in strength, dexterity, and endurance. Within this group, higher frequencies of stimulation yielded strength gains and increased motor activation; lower frequencies affected dexterity and endurance. CONCLUSIONS The results suggest that higher frequencies of stimulation could be more effective in improving strength and motor activation properties and that lower frequencies may affect coordination and endurance changes. Results also indicate that persons with a higher functional level of recovery may respond more favorably to NMES regimens, but further study with larger patient groups is warranted.
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Affiliation(s)
- Barbara M Doucet
- Division of Rehabilitation Sciences, University of Texas Medical Branch in Galveston, Galveston, TX, USA
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Abstract
Stroke is the major cause of long-term disability worldwide, with impaired manual dexterity being a common feature. In the past few years, noninvasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have been investigated as adjuvant strategies to neurorehabilitative interventions. These NIBS techniques can be used to modulate cortical excitability during and for several minutes after the end of the stimulation period. Depending on the stimulation parameters, cortical excitability can be reduced (inhibition) or enhanced (facilitation). Differential modulation of cortical excitability in the affected and unaffected hemisphere of patients with stroke may induce plastic changes within neural networks active during functional recovery. The aims of this chapter are to describe results from these proof-of-principle trials and discuss possible putative mechanisms underlying such effects. Neurophysiological and neuroimaging changes induced by application of NIBS are reviewed briefly.
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40
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Jaberzadeh S, Zoghi M. Non-invasive brain stimulation for enhancement of corticospinal excitability and motor performance. Basic Clin Neurosci 2013; 4:257-65. [PMID: 25337355 PMCID: PMC4202565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 06/24/2013] [Accepted: 06/25/2013] [Indexed: 11/29/2022] Open
Abstract
During the past 20 years, non-invasive brain stimulation has become an emerging field in clinical neuroscience due to its capability to transiently modulate corticospinal excitability, motor and cognitive functions. Whereas transcranial magnetic stimulation has been used extensively since more than two decades ago as a potential "neuromodulator", transcranial current stimulation (tCS) has more recently gathered increased scientific interests. The primary aim of this narrative review is to describe characteristics of different tCS paradigms. tCS is an umbrella term for a number of brain modulating paradigms such as transcranial direct current stimulation (tDCS), transcranial alternative current stimulation (tACS), and transcranial random noise stimulation (tRNS). Their efficacy is dependent on two current parameters: intensity and length of application. Unlike tACS and tRNS, tDCS is polarity dependent. These techniques could be used as stand-alone techniques or can be used to prime the effects of other movement trainings. The review also summarises safety issues, the mechanisms of tDCS-induced neuroplasticity, limitations of current state of knowledge in the literature, tool that could be used to understand brain plasticity effects in motor regions and tool that could be used to understand motor learning effects.
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Affiliation(s)
- Shapour Jaberzadeh
- Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Maryam Zoghi
- Melbourne Medical School, the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne
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Duff M, Chen Y, Cheng L, Liu SM, Blake P, Wolf SL, Rikakis T. Adaptive Mixed Reality Rehabilitation Improves Quality of Reaching Movements More Than Traditional Reaching Therapy Following Stroke. Neurorehabil Neural Repair 2012; 27:306-15. [DOI: 10.1177/1545968312465195] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Adaptive mixed reality rehabilitation (AMRR) is a novel integration of motion capture technology and high-level media computing that provides precise kinematic measurements and engaging multimodal feedback for self-assessment during a therapeutic task. Objective. We describe the first proof-of-concept study to compare outcomes of AMRR and traditional upper-extremity physical therapy. Methods. Two groups of participants with chronic stroke received either a month of AMRR therapy (n = 11) or matched dosing of traditional repetitive task therapy (n = 10). Participants were right handed, between 35 and 85 years old, and could independently reach to and at least partially grasp an object in front of them. Upper-extremity clinical scale scores and kinematic performances were measured before and after treatment. Results. Both groups showed increased function after therapy, demonstrated by statistically significant improvements in Wolf Motor Function Test and upper-extremity Fugl-Meyer Assessment (FMA) scores, with the traditional therapy group improving significantly more on the FMA. However, only participants who received AMRR therapy showed a consistent improvement in kinematic measurements, both for the trained task of reaching to grasp a cone and the untrained task of reaching to push a lighted button. Conclusions. AMRR may be useful in improving both functionality and the kinematics of reaching. Further study is needed to determine if AMRR therapy induces long-term changes in movement quality that foster better functional recovery.
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Affiliation(s)
| | | | - Long Cheng
- Arizona State University, Tempe, AZ, USA
| | - Sheng-Min Liu
- John J. Rhodes Rehabilitation Institute, Banner Baywood Medical Center, Mesa, AZ, USA
| | - Paul Blake
- John J. Rhodes Rehabilitation Institute, Banner Baywood Medical Center, Mesa, AZ, USA
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Dobkin BH, Dorsch A. The promise of mHealth: daily activity monitoring and outcome assessments by wearable sensors. Neurorehabil Neural Repair 2012; 25:788-98. [PMID: 21989632 DOI: 10.1177/1545968311425908] [Citation(s) in RCA: 222] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mobile health tools that enable clinicians and researchers to monitor the type, quantity, and quality of everyday activities of patients and trial participants have long been needed to improve daily care, design more clinically meaningful randomized trials of interventions, and establish cost-effective, evidence-based practices. Inexpensive, unobtrusive wireless sensors, including accelerometers, gyroscopes, and pressure-sensitive textiles, combined with Internet-based communications and machine-learning algorithms trained to recognize upper- and lower-extremity movements, have begun to fulfill this need. Continuous data from ankle triaxial accelerometers, for example, can be transmitted from the home and community via WiFi or a smartphone to a remote data analysis server. Reports can include the walking speed and duration of every bout of ambulation, spatiotemporal symmetries between the legs, and the type, duration, and energy used during exercise. For daily care, this readily accessible flow of real-world information allows clinicians to monitor the amount and quality of exercise for risk factor management and compliance in the practice of skills. Feedback may motivate better self-management as well as serve home-based rehabilitation efforts. Monitoring patients with chronic diseases and after hospitalization or the start of new medications for a decline in daily activity may help detect medical complications before rehospitalization becomes necessary. For clinical trials, repeated laboratory-quality assessments of key activities in the community, rather than by clinic testing, self-report, and ordinal scales, may reduce the cost and burden of travel, improve recruitment and retention, and capture more reliable, valid, and responsive ratio-scaled outcome measures that are not mere surrogates for changes in daily impairment, disability, and functioning.
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Affiliation(s)
- Bruce H Dobkin
- Department of Neurology, Geffen UCLA School of Medicine, Los Angeles, CA, USA.
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Coupar F, Pollock A, Legg LA, Sackley C, van Vliet P. Home-based therapy programmes for upper limb functional recovery following stroke. Cochrane Database Syst Rev 2012; 2012:CD006755. [PMID: 22592715 PMCID: PMC6464926 DOI: 10.1002/14651858.cd006755.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND With an increased focus on home-based stroke services and the undertaking of programmes, targeted at upper limb recovery within clinical practice, a systematic review of home-based therapy programmes for individuals with upper limb impairment following stroke was required. OBJECTIVES To determine the effects of home-based therapy programmes for upper limb recovery in patients with upper limb impairment following stroke. SEARCH METHODS We searched the Cochrane Stroke Group's Specialised Trials Register (May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to May 2011), EMBASE (1980 to May 2011), AMED (1985 to May 2011) and six additional databases. We also searched reference lists and trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) in adults after stroke, where the intervention was a home-based therapy programme targeted at the upper limb, compared with placebo, or no intervention or usual care. PRIMARY OUTCOMES were performance in activities of daily living (ADL) and functional movement of the upper limb. SECONDARY OUTCOMES were performance in extended ADL and motor impairment of the arm. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts, extracted data and appraised trials. We undertook assessment of risk of bias in terms of method of randomisation and allocation concealment (selection bias), blinding of outcome assessment (detection bias), whether all the randomised patients were accounted for in the analysis (attrition bias) and the presence of selective outcome reporting. MAIN RESULTS We included four studies with 166 participants. No studies compared the effects of home-based upper limb therapy programmes with placebo or no intervention. Three studies compared the effects of home-based upper limb therapy programmes with usual care. PRIMARY OUTCOMES we found no statistically significant result for performance of ADL (mean difference (MD) 2.85; 95% confidence interval (CI) -1.43 to 7.14) or functional movement of the upper limb (MD 2.25; 95% CI -0.24 to 4.73)). SECONDARY OUTCOMES no statistically significant results for extended ADL (MD 0.83; 95% CI -0.51 to 2.17)) or upper limb motor impairment (MD 1.46; 95% CI -0.58 to 3.51). One study compared the effects of a home-based upper limb programme with the same upper limb programme based in hospital, measuring upper limb motor impairment only; we found no statistically significant difference between groups (MD 0.60; 95% CI -8.94 to 10.14). AUTHORS' CONCLUSIONS There is insufficient good quality evidence to make recommendations about the relative effect of home-based therapy programmes compared with placebo, no intervention or usual care.
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Affiliation(s)
- Fiona Coupar
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK.
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Caurin GAP, Siqueira AAG, Andrade KO, Joaquim RC, Krebs HI. Adaptive strategy for multi-user robotic rehabilitation games. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2011:1395-8. [PMID: 22254578 DOI: 10.1109/iembs.2011.6090328] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In this paper, we discuss a strategy for the adaptation of the "difficulty level" in games intended to include motor planning during robotic rehabilitation. We consider concurrently the motivation of the user and his/her performance in a Pong game. User motivation is classified in three levels (not motivated, well motivated and overloaded). User performance is measured as a combination of knowledge of results--achieved goals and score points in the game--and knowledge of performance--joint displacement, speed, aiming, user work, etc. Initial results of a pilot test with unimpaired healthy young volunteers are also presented showing a tendency for individualization of the parameter values.
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Affiliation(s)
- Glauco A P Caurin
- Massachusetts Institute of Technology, Mechanical Engineering Department, Cambridge, MA 02139, USA
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Tanaka S, Sandrini M, Cohen LG. Modulation of motor learning and memory formation by non-invasive cortical stimulation of the primary motor cortex. Neuropsychol Rehabil 2011; 21:650-75. [PMID: 21942897 DOI: 10.1080/09602011.2011.605589] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Transcranial magnetic (TMS) and direct current (tDCS) stimulation are non-invasive brain stimulation techniques that allow researchers to purposefully modulate cortical excitability in focal areas of the brain. Recent work has provided preclinical evidence indicating that TMS and tDCS can facilitate motor performance, motor memory formation, and motor skill learning in healthy subjects and possibly in patients with brain lesions. Although the optimal stimulation parameters to accomplish these goals remain to be determined, and controlled multicentre clinical studies are lacking, these findings suggest that cortical stimulation techniques could become in the future adjuvant strategies in the rehabilitation of motor deficits. The aim of this article is to critically review these findings and to discuss future directions regarding the possibility of combining these techniques with other interventions in neurorehabilitation.
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Affiliation(s)
- Satoshi Tanaka
- Division of Cerebral Integration, National Institute for Physiological Sciences, Okazaki, Japan
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46
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Liao WW, Wu CY, Hsieh YW, Lin KC, Chang WY. Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial. Clin Rehabil 2011; 26:111-20. [PMID: 21840917 DOI: 10.1177/0269215511416383] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients. DESIGN Prospective, randomized, controlled trial. SETTING Stroke units in three medical centres. SUBJECTS Twenty patients post stroke for a mean of 22 months. INTERVENTION Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90-105 minutes each day, 5 days per week, for four weeks. MAIN MEASURES Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire. RESULTS The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43). CONCLUSIONS Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.
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Affiliation(s)
- Wan-Wen Liao
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
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47
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Wagner TH, Lo AC, Peduzzi P, Bravata DM, Huang GD, Krebs HI, Ringer RJ, Federman DG, Richards LG, Haselkorn JK, Wittenberg GF, Volpe BT, Bever CT, Duncan PW, Siroka A, Guarino PD. An economic analysis of robot-assisted therapy for long-term upper-limb impairment after stroke. Stroke 2011; 42:2630-2. [PMID: 21757677 DOI: 10.1161/strokeaha.110.606442] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is a leading cause of disability. Rehabilitation robotics have been developed to aid in recovery after a stroke. This study determined the additional cost of robot-assisted therapy and tested its cost-effectiveness. METHODS We estimated the intervention costs and tracked participants' healthcare costs. We collected quality of life using the Stroke Impact Scale and the Health Utilities Index. We analyzed the cost data at 36 weeks postrandomization using multivariate regression models controlling for site, presence of a prior stroke, and Veterans Affairs costs in the year before randomization. RESULTS A total of 127 participants were randomized to usual care plus robot therapy (n=49), usual care plus intensive comparison therapy (n=50), or usual care alone (n=28). The average cost of delivering robot therapy and intensive comparison therapy was $5152 and $7382, respectively (P<0.001), and both were significantly more expensive than usual care alone (no additional intervention costs). At 36 weeks postrandomization, the total costs were comparable for the 3 groups ($17 831 for robot therapy, $19 746 for intensive comparison therapy, and $19 098 for usual care). Changes in quality of life were modest and not statistically different. CONCLUSIONS The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group. However, uncertainty remains about the cost-effectiveness of robotic-assisted rehabilitation compared with traditional rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00372411.
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Affiliation(s)
- Todd H Wagner
- VA Palo Alto Health Economics Resource Center & Department of Health Research and Policy, Stanford University, 795 Willow Road, 152-MPD, Menlo Park, CA 94025, USA.
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Hsieh YW, Wu CY, Liao WW, Lin KC, Wu KY, Lee CY. Effects of Treatment Intensity in Upper Limb Robot-Assisted Therapy for Chronic Stroke. Neurorehabil Neural Repair 2011; 25:503-11. [DOI: 10.1177/1545968310394871] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Objectives. Robot-assisted therapy (RT) is a current promising intervention in stroke rehabilitation, but more research is warranted for examining its efficacy and the dose–benefit relation. The authors investigated the effects of higher intensity versus lower intensity RT on movements of forearm pronation–supination and wrist flexion–extension relative to conventional rehabilitation (CR) in patients poststroke for a mean of 21 months. Methods. In this pilot study, 18 patients with initial mean Fugl-Meyer Assessment (FMA) of 37 to 44 for the upper extremity were randomized to higher intensity RT, lower intensity RT, or CR intervention for 4 weeks. The dose of the higher intensity RT was twice the number of repetitions in the lower intensity RT. Outcome measures at pretreatment and posttreatment were administered to patients to evaluate beneficial and adverse effects of interventions. Primary outcomes were the FMA and Medical Research Council scale. Results. There were significant differences in motor function ( P = .04) and daily performance ( P = .03) among the 3 groups. The higher intensity RT group showed better improvement in motor function, muscle strength, performance of daily activities, and bimanual ability than the other 2 groups. The intensive RT intervention did not induce higher levels of an oxidative DNA biomarker. Conclusions. Higher intensity of RT that assists forearm and wrist movements may lead to greater improvement in motor ability and functional performance in stroke patients. A sample size of only 20 to 25 in each arm of a larger randomized controlled trial is needed to confirm the findings for similar subjects.
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Affiliation(s)
| | | | | | - Keh-chung Lin
- National Taiwan University, Taipei, Taiwan
- National Taiwan University Hospital, Taipei, Taiwan
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Kowalczewski J, Chong SL, Galea M, Prochazka A. In-home tele-rehabilitation improves tetraplegic hand function. Neurorehabil Neural Repair 2011; 25:412-22. [PMID: 21372246 DOI: 10.1177/1545968310394869] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) survivors with tetraplegia have great difficulty performing activities of daily living (ADLs). Functional electrical stimulation (FES) combined with exercise therapy (ET) can improve hand function, but delivering the treatment is problematic. OBJECTIVE To compare 2 ET treatments delivered by in-home tele-therapy (IHT). METHODS Each treatment involved ET, tele-supervised 1 h/d, 5 d/wk for 6 weeks. Treatment 1: "conventional ET" comprised strength training, computer games played with a trackball, and therapeutic electrical stimulation (TES). Treatment 2: "ReJoyce ET" comprised FES-ET on a workstation, the Rehabilitation Joystick for Computerized Exercise (ReJoyce) with which participants played computer games associated with ADLs. Participants were block-randomized into group 1 receiving conventional ET first, followed by 1-month washout, and then ReJoyce ET and group 2 in reverse order. In all, 13 participants took part, 5 completing the study with both hands, such that both groups had a sample size of 9. PRIMARY OUTCOME MEASURE Action Research Arm Test (ARAT). SECONDARY OUTCOME MEASURES grasp and pinch forces and the ReJoyce automated hand function test (RAHFT). RESULTS ARAT scores improved more after ReJoyce ET (13.0% ± 9.8%) than after conventional ET (4.0% ± 9.6%; F = 10.6, P < .01). RAHFT scores also improved more after ReJoyce ET (16.9% ± 8.6%) than conventional ET (3.3% ± 10.2%; F = 20.4, P < .01). CONCLUSIONS FES-ET on a workstation, supervised over the Internet, is feasible and may be effective for patients who can meet the residual motor function requirements of our study.
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Affiliation(s)
- Jan Kowalczewski
- Center for Neuroscience, University of Alberta, Edmonton, Alberta, Canada
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Peduzzi P, Kyriakides T, O'Connor TZ, Guarino P, Warren SR, Huang GD. Methodological issues in comparative effectiveness research: clinical trials. Am J Med 2010; 123:e8-15. [PMID: 21184867 DOI: 10.1016/j.amjmed.2010.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The US Department of Veterans Affairs (VA) Cooperative Studies Program has been conducting comparative effectiveness clinical trials for nearly 4 decades in many disease areas, including cardiovascular disease/surgery, diabetes mellitus, mental health, neurologic disorders, cancer, infectious diseases, and rheumatoid arthritis. The features that have made this program advantageous for conducting comparative effectiveness clinical trials are described along with methodological considerations for future trials based on lessons learned from its experience conducting these types of studies. Some of the lessons learned involve managing risk factors, clinical equipoise, patient preferences, evolving technology, the use of usual care as a comparator and pharmaceutical issues related to study drug blinding. These issues are not unique to the VA but can play an important role in enabling valid comparisons between treatments that may have differences in delivery or mechanisms of action and could affect the execution and feasibility of conducting a clinical trial with a comparative effectiveness aim. We also outline some future directions for comparative effectiveness clinical trials.
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Affiliation(s)
- Peter Peduzzi
- VA Cooperative Studies Program Coordinating Center, US Department of Veterans Affairs, West Haven, Connecticut, USA.
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