Innovative technologies for rehabilitation and health promotion: what is the evidence?

Performing a shortened version of the Action Research Arm Test in immersive virtual reality to assess post-stroke upper limb activity

BACKGROUND

To plan treatment and measure post-stroke recovery, frequent and time-bounded functional assessments are recommended. With increasing needs for neurorehabilitation advances, new technology based methods, such as virtual reality (VR) have emerged. Here, we developed an immersive VR version of the Action Research Arm Test (ARAT-VR) to complement neurorehabilitation.

OBJECTIVE

This study aimed to assess the validity, usability and test-retest reliability of the ARAT-VR among individuals with stroke, healthcare professionals and healthy control subjects (HCS).

METHODS

Among the 19 items of the ARAT, 13 items were selected and developed in immersive VR. 11 healthcare professionals, 30 individuals with stroke, and 25 HCS were recruited. Content validity was assessed by asking healthcare professionals to rate the difficulty of performing each item of the ARAT-VR in comparison to the classical Action Research Arm Test (ARAT-19). Concurrent validity was first measured using correlation (Spearman tests) between the ARAT-VR and ARAT-19 scores for the individuals with stroke, and second through correlation and comparison between the scores of the ARAT-VR and the reduced version of the ARAT (ARAT-13) for both individuals with stroke and HCS (Wilcoxon signed rank tests and Bland-Altman plots). Usability was measured using the System Usability Scale. A part of individuals with stroke and HCS were re-tested following a convenient delay to measure test-retest reliability (Intra-class correlation and Wilcoxon tests).

RESULTS

Regarding the content validity, median difficulty of the 13 ARAT-VR items (0[0 to - 1] to 0[0-1]) evaluated by healthcare professionals was rated as equivalent to the classical ARAT for all tasks except those involving the marbles. For these, the difficulty was rated as superior to the real tasks (1[0-1] when pinching with the thumb-index and thumb-middle fingers, and 1[0-2] when pinching with thumb-ring finger). Regarding the concurrent validity, for paretic hand scores, there were strong correlations between the ARAT-VR and ARAT-13 (r = 0.84), and between the ARAT-VR and ARAT-19 (r = 0.83). Usability (SUS = 82.5[75-90]) and test-retest reliability (ICC = 0.99; p < 0.001) were excellent.

CONCLUSION

The ARAT-VR is a valid, usable and reliable tool that can be used to assess upper limb activity among individuals with stroke, providing potential to increase assessment frequency, remote evaluation, and improve neurorehabilitation. Trial registration https://clinicaltrials.gov/ct2/show/NCT04694833 ; Unique identifier: NCT04694833, Date of registration: 11/24/2020.

Current clinical practice in managing somatosensory impairments and the use of technology in stroke rehabilitation

Stroke-induced somatosensory impairments seem to be clinically overlooked, despite their prevalence and influence on motor recovery post-stroke. Interest in technology has been gaining traction over the past few decades as a promising method to facilitate stroke rehabilitation. This questionnaire-based cross-sectional study aimed to identify current clinical practice and perspectives on the management of somatosensory impairments post-stroke and the use of technology in assessing outcome measures and providing intervention. Participants were 132 physiotherapists and occupational therapists currently working with stroke patients in public hospitals and rehabilitation centres in Singapore. It was found that the majority (64.4%) of the therapists spent no more than half of the time per week on somatosensory interventions. Functional or task-specific training was the primary form of intervention applied to retrain somatosensory functions in stroke survivors. Standardised assessments (43.2%) were used less frequently than non-standardised assessments (97.7%) in clinical practice, with the sensory subscale of the Fugl-Meyer Assessment being the most popular outcome measure, followed by the Nottingham Sensory Assessment. While the adoption of technology for assessment was relatively scarce, most therapists (87.1%) reported that they have integrated technology into intervention. There was a common agreement that proprioception is an essential component in stroke rehabilitation, and that robotic technology combined with conventional therapy is effective in enhancing stroke rehabilitation, particularly for retraining proprioception. Most therapists identified price, technology usability, and lack of available space as some of the biggest barriers to integrating robotic technology in stroke rehabilitation. Standardised assessments and interventions targeting somatosensory functions should be more clearly delineated in clinical guidelines. Although therapists were positive about technology-based rehabilitation, obstacles that make technology integration challenging ought to be addressed.

New technologies promoting active upper limb rehabilitation after stroke: an overview and network meta-analysis

INTRODUCTION

The primary aim of this work was to summarize and compare the effects of active rehabilitation assisted by new technologies (virtual reality [VR], robot-assisted therapy [RAT] and telerehabilitation [TR)) on upper limb motor function and everyday living activity during the subacute and chronic phases of stroke. The secondary aims were to compare the effects of these technologies according to the intervention design (in addition to or in substitution of conventional therapy), the duration of active rehabilitation and the severity of patients' motor impairments.

EVIDENCE ACQUISITION

Several databases, namely PubMed, Scopus, Embase and Cochrane Library, were searched. Studies were included if they were meta-analyses with a moderate to high level of confidence (assessed with AMSTAR-2) that compared the effects of a new technology promoting active rehabilitation to that of a conventional therapy program among patients with stroke. Network meta-analyses were conducted to compare the effects of the new technologies.

EVIDENCE SYNTHESIS

Eighteen different meta-analyses were selected and fifteen included in the quantitative analysis. In total these 15 meta-analyses were based on 189 different randomized controlled trials. VR (SMD≥0.25; P<0.05), RAT (SMD≥0.29; P≤0.29) and TR (SMD≥-0.08; P≤0.64) were found to be at least as effective as conventional therapy. During the subacute phase, RAT's greatest effect was observed for patients with severe-moderate impairments whereas VR and TR's greatest effects were observed for patients with mild impairments. During the chronic phase, the highest effects were observed for patients with mild impairments, for all studies technologies. Network meta-analyses showed that VR and RAT were both significantly superior to TR in improving motor function during the chronic phase but revealed no significant difference between VR, RAT and TR effectiveness on both motor function (during the subacute phase) and activity (during both chronic and subacute phase).

CONCLUSIONS

This overview provides low-to-moderate evidence that rehabilitation assisted with technologies are at least as effective as conventional therapy for patients with stroke. While VR and RAT seem to be more efficient during the subacute phase, all technologies seem to be as efficient as one another in the chronic phase.

User perspectives on the design and setup of lower limb mirror therapy equipment after stroke: a technical report

OBJECTIVES

To co-design lower limb mirror therapy (MT) equipment and setup by working directly with stroke survivors and physiotherapists.

DESIGN

Co-design approach through focus groups.

PARTICIPANTS

Twenty-six participants. Sixteen stroke survivors and ten physiotherapists.

DATA COLLECTION AND ANALYSIS

Data were collected in an iterative process through two sets of focus groups. Firstly, prototype one of the MT equipment was presented to the participants. They were encouraged to use and comment on it. Then, the key requirements for ankle exercise with MT were presented, and participants discussed whether the prototype one was able to deliver these requirements. These findings informed iterations to the device, and a second prototype was produced and discussed in the second set of focus groups. The final prototype was then produced based on the participants' feedback. All focus groups were audio-recorded, followed by verbatim transcriptions and thematic analysis.

RESULTS

Main characteristics required of the lower limb MT device were found to be: the ability to produce MT ankle exercise from an upright sitting posture, an adjustable angle between 5 to 15 degree from the midline to allow clear lower limb reflection during seated exercise, and a lightweight device to enable easy use for stroke survivors.

CONCLUSION

This work produced an iteratively co-design lower limb MT to be used with stroke survivors.

Classification of Parkinson's disease and essential tremor based on balance and gait characteristics from wearable motion sensors via machine learning techniques: a data-driven approach

BACKGROUND

Parkinson's disease (PD) and essential tremor (ET) are movement disorders that can have similar clinical characteristics including tremor and gait difficulty. These disorders can be misdiagnosed leading to delay in appropriate treatment. The aim of the study was to determine whether balance and gait variables obtained with wearable inertial motion sensors can be utilized to differentiate between PD and ET using machine learning. Additionally, we compared classification performances of several machine learning models.

METHODS

This retrospective study included balance and gait variables collected during the instrumented stand and walk test from people with PD (n = 524) and with ET (n = 43). Performance of several machine learning techniques including neural networks, support vector machine, k-nearest neighbor, decision tree, random forest, and gradient boosting, were compared with a dummy model or logistic regression using F1-scores.

RESULTS

Machine learning models classified PD and ET based on balance and gait characteristics better than the dummy model (F1-score = 0.48) or logistic regression (F1-score = 0.53). The highest F1-score was 0.61 of neural network, followed by 0.59 of gradient boosting, 0.56 of random forest, 0.55 of support vector machine, 0.53 of decision tree, and 0.49 of k-nearest neighbor.

CONCLUSIONS

This study demonstrated the utility of machine learning models to classify different movement disorders based on balance and gait characteristics collected from wearable sensors. Future studies using a well-balanced data set are needed to confirm the potential clinical utility of machine learning models to discern between PD and ET.

Photobiomodulation therapy reduces acute pain and inflammation in mice

Photobiomodulation (PBM) is a therapy suggested for the treatment of pain and inflammation. Different mechanisms have been proposed to explain the analgesic and inflammatory effects of photobiomodulation, but there are still gaps on the mechanisms underlying. The objective was to investigate the analgesic and anti-inflammatory effect of red LED, as well as to investigate the possible mechanism of action in acute nociception models. Radiation was applied with red LED (660 nm, 215 mW, 84.64 mW/cm², 2.531 J/cm² (30s); 5.07 J/cm² (60s) 7.61 J/cm² (90s) and 10.15 J/cm² (120 s)). The red LED applied 60 s before the experiments, promoted reduction of the nociceptive neurogenic (1st phase) and inflammatory pain (2nd phase) induced by intraplantar (i.pl.) injection of formalin. This effect duration in the second phase was 180 min after pretreatment of the LED. Red LED also reduced nociception induced by intraperitoneal injection of acetic acid. Furthermore, red LED prevented nociception induced by i.pl. injection of cinnamaldehyde, capsaicin, menthol and acidified saline. It was demonstrate the involvement of glutamatergic system with the reduction the nociception induced by glutamate. The red LED was able to prevent nociception induced by intracellular signaling cascades activators, phorbol 12-myristate 13-acetate (PMA), bradykinin, forskolin and prostaglandin. In addition, red LED, respectively, from 30 to 90s demonstrated an antiedematogenic effect on ear edema and reduction the migration of inflammatory cells induced by single application of croton oil. Thus, the new findings in this study support some underlying mechanism by which red LED phototherapy reduces acute pain. However, need further clarification regarding analgesic and anti-inflammatory effect of the photobiomodulation in preclinical studies.

Physiotherapists' experiences with a blended osteoarthritis intervention: a mixed methods study

INTRODUCTION

E-Exercise is an effective 12-week blended intervention consisting of around five face-to-face physiotherapy sessions and a web-based application for patients with hip/knee osteoarthritis. In order to facilitate effective implementation of e-Exercise, this study aims to identify physiotherapists' experiences and determinants related to the usage of e-Exercise. Methods: An explanatory sequential mixed methods design embedded in a randomized controlled trial comparing e-Exercise with usual physiotherapy in patients with hip/knee osteoarthritis. Usage of e-Exercise was based on recruitment rates of 123 physiotherapists allocated to e-Exercise and objective web-based application usage data. Experiences and determinants related to e-Exercise usage were investigated with a questionnaire and clarified with semi-structured interviews. Results: Of the 123 physiotherapists allocated to e-Exercise, 54 recruited more than one eligible patient, of whom 10 physiotherapists continued using e-Exercise after the study period. Physiotherapists had mixed experiences with e-Exercise. Determinants related to intervention usage were appropriateness, added value, time, workload, professional autonomy, environmental factors, and financial consequences. Physiotherapists recommended to improve the ability to tailor e-Exercise to the individual needs of the patient patients' individual needs. Discussion: Determinants related to the usage of e-Exercise provided valuable information for the implementation of e-Exercise on broader scale. Most importantly, the flexibility of e-Exercise needs to be improved. Next, there is a need for education on how to integrate an online program within physiotherapy.

A Rehabilitation-Internet-of-Things in the Home to Augment Motor Skills and Exercise Training

Although motor learning theory has led to evidence-based practices, few trials have revealed the superiority of one theory-based therapy over another after stroke. Nor have improvements in skills been as clinically robust as one might hope. We review some possible explanations, then potential technology-enabled solutions. Over the Internet, the type, quantity, and quality of practice and exercise in the home and community can be monitored remotely and feedback provided to optimize training frequency, intensity, and progression at home. A theory-driven foundation of synergistic interventions for walking, reaching and grasping, strengthening, and fitness could be provided by a bundle of home-based Rehabilitation Internet-of-Things (RIoT) devices. A RIoT might include wearable, activity-recognition sensors and instrumented rehabilitation devices with radio transmission to a smartphone or tablet to continuously measure repetitions, speed, accuracy, forces, and temporal spatial features of movement. Using telerehabilitation resources, a therapist would interpret the data and provide behavioral training for self-management via goal setting and instruction to increase compliance and long-term carryover. On top of this user-friendly, safe, and conceptually sound foundation to support more opportunity for practice, experimental interventions could be tested or additions and replacements made, perhaps drawing from virtual reality and gaming programs or robots. RIoT devices continuously measure the actual amount of quality practice; improvements and plateaus over time in strength, fitness, and skills; and activity and participation in home and community settings. Investigators may gain more control over some of the confounders of their trials and patients will have access to inexpensive therapies.