1
|
Feitosa JA, Casseb RF, Camargo A, Brandao AF, Li LM, Castellano G. Graph analysis of cortical reorganization after virtual reality-based rehabilitation following stroke: a pilot randomized study. Front Neurol 2023; 14:1241639. [PMID: 37869147 PMCID: PMC10587561 DOI: 10.3389/fneur.2023.1241639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Stroke is the leading cause of functional disability worldwide. With the increase of the global population, motor rehabilitation of stroke survivors is of ever-increasing importance. In the last decade, virtual reality (VR) technologies for rehabilitation have been extensively studied, to be used instead of or together with conventional treatments such as physiotherapy or occupational therapy. The aim of this work was to evaluate the GestureCollection VR-based rehabilitation tool in terms of the brain changes and clinical outcomes of the patients. Methods Two groups of chronic patients underwent a rehabilitation treatment with (experimental) or without (control) complementation with GestureCollection. Functional magnetic resonance imaging exams and clinical assessments were performed before and after the treatment. A functional connectivity graph-based analysis was used to assess differences between the connections and in the network parameters strength and clustering coefficient. Results Patients in both groups showed improvement in clinical scales, but there were more increases in functional connectivity in the experimental group than in the control group. Discussion The experimental group presented changes in the connections between the frontoparietal and the somatomotor networks, associative cerebellum and basal ganglia, which are regions associated with reward-based motor learning. On the other hand, the control group also had results in the somatomotor network, in its ipsilateral connections with the thalamus and with the motor cerebellum, which are regions more related to a purely mechanical activity. Thus, the use of the GestureCollection system was successfully shown to promote neuroplasticity in several motor-related areas.
Collapse
Affiliation(s)
- Jamille Almeida Feitosa
- Gleb Wataghin Institute of Physics, University of Campinas – UNICAMP, Campinas, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology – BRAINN, Campinas, Brazil
| | - Raphael Fernandes Casseb
- Brazilian Institute of Neuroscience and Neurotechnology – BRAINN, Campinas, Brazil
- Neuroimaging Laboratory, Department of Neurology, University of Campinas – UNICAMP, Campinas, Brazil
| | - Alline Camargo
- Neuroimaging Laboratory, Department of Neurology, University of Campinas – UNICAMP, Campinas, Brazil
| | - Alexandre Fonseca Brandao
- Gleb Wataghin Institute of Physics, University of Campinas – UNICAMP, Campinas, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology – BRAINN, Campinas, Brazil
| | - Li Min Li
- Brazilian Institute of Neuroscience and Neurotechnology – BRAINN, Campinas, Brazil
- Neuroimaging Laboratory, Department of Neurology, University of Campinas – UNICAMP, Campinas, Brazil
| | - Gabriela Castellano
- Gleb Wataghin Institute of Physics, University of Campinas – UNICAMP, Campinas, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology – BRAINN, Campinas, Brazil
| |
Collapse
|
2
|
Marek K, Zubrycki I, Miller E. Immersion Therapy with Head-Mounted Display for Rehabilitation of the Upper Limb after Stroke-Review. SENSORS (BASEL, SWITZERLAND) 2022; 22:9962. [PMID: 36560328 PMCID: PMC9785384 DOI: 10.3390/s22249962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
Immersive virtual therapy technology is a new method that uses head-mounted displays for rehabilitation purposes. It offers a realistic experience that puts the user in a virtual reality. This new type of therapy is used in the rehabilitation of stroke patients. Many patients after this disease have complications related to the upper extremities that limit independence in their everyday life, which affects the functioning of society. Conventional neurological rehabilitation can be supplemented by the use of immersive virtual therapy. The system allows patients with upper limb dysfunction to perform a motor and task-oriented training in virtual reality that is individually tailored to their performance. The complete immersion therapy itself is researched and evaluated by medical teams to determine the suitability for rehabilitation of the upper limb after a stroke. The purpose of this article is to provide an overview of the latest research (2019-2022) on immersive virtual reality with head-mounted displays using in rehabilitation of the upper extremities of stroke patients.
Collapse
Affiliation(s)
- Klaudia Marek
- Department of Neurological Rehabilitation, Medical University of Lodz, Milionowa 14, 93-113 Lodz, Poland
| | - Igor Zubrycki
- Institute of Automatic Control, Lodz University of Technology, Stefanowskiego 18, 90-537 Lodz, Poland
| | - Elżbieta Miller
- Department of Neurological Rehabilitation, Medical University of Lodz, Milionowa 14, 93-113 Lodz, Poland
| |
Collapse
|
3
|
Consideration-of-concept of EvolvRehab-Body for upper limb virtual rehabilitation at home for people late after stroke. Physiotherapy 2022; 116:97-107. [DOI: 10.1016/j.physio.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/16/2022] [Accepted: 03/26/2022] [Indexed: 11/18/2022]
|
4
|
Feitosa JA, Fernandes CA, Casseb RF, Castellano G. Effects of virtual reality-based motor rehabilitation: a systematic review of fMRI studies. J Neural Eng 2021; 19. [PMID: 34933281 DOI: 10.1088/1741-2552/ac456e] [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] [Received: 06/29/2021] [Accepted: 12/21/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND The use of virtual reality (VR) as a rehabilitation tool has been shown to induce motor and cognitive improvements in different populations. Functional magnetic resonance imaging (fMRI) has been used to investigate neuroplasticity resulting from these treatments. We hypothesize that VR rehabilitation induces functional improvement and brain changes that can be detected by fMRI. OBJECTIVE To systematically review the effects of VR intervention on the cortical reorganization measured by fMRI and associated with functional improvement. METHODS We performed a systematic review of studies published between 2005 and 2021. Papers were retrieved from six databases using the following keywords: "motor rehabilitation", "fMRI" and "virtual reality". Case studies, pre-post studies, cross-sectional studies, and randomized controlled trials published were included. Manuscripts were assessed by The NIH Study Quality Assessment Tools to determine their quality. RESULTS Twenty-three articles met our eligibility criteria: 18 about VR rehabilitation in stroke and five on other clinical conditions (older adults, cerebral palsy, and Parkinson's disease). Changes in neural patterns of activation and reorganization were revealed in both the ipsilesional and the contralesional hemispheres. Results were located mainly in the primary motor cortex, sensorimotor cortex and supplementary motor area in post-stroke patients in the acute, subacute, and chronic rehabilitation phases, and were associated with functional improvement after VR intervention. Similar effects were observed in older adults and in patients with other neurological diseases with improved performance. CONCLUSION Most stroke-related studies showed either restoration to normal or increase of activation patterns or relateralization at/to the ipsilesional hemisphere, with some also reporting a decrease in activity or extent of activation after VR therapy. In general, VR intervention demonstrated evidence of efficacy both in neurological rehabilitation and in performance improvement of older adults, accompanied by fMRI evidence of brain reorganization.
Collapse
Affiliation(s)
- Jamille A Feitosa
- University of Campinas, Institute of Physics Gleb Wataghin, R. Sérgio Buarque de Holanda, nº 777, Campinas, SP, 13083-872, BRAZIL
| | - Corina A Fernandes
- University of Campinas, Institute of Physics Gleb Wataghin, R. Sérgio Buarque de Holanda, nº 777, Campinas, SP, 13083-872, BRAZIL
| | - Raphael F Casseb
- University of Campinas, Neuroimaging Laboratory - Rua Vital Brasil, 251, Cidade Universitaria "Zeferino Vaz", Campinas, SP, Brazil, Campinas, 13083-888, BRAZIL
| | - Gabriela Castellano
- Department of Cosmic Rays and Chronology, University of Campinas - UNICAMP, Institute of Physics Gleb Wataghin, R. Sérgio Buarque de Holanda, nº 777, Cidade Universitária, Campinas, SP, 13083-859, BRAZIL
| |
Collapse
|
5
|
Hao J, Xie H, Harp K, Chen Z, Siu KC. Effects of virtual reality intervention on neural plasticity in stroke rehabilitation: a systematic review. Arch Phys Med Rehabil 2021; 103:523-541. [PMID: 34352269 DOI: 10.1016/j.apmr.2021.06.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To systematically review and examine the current literature regarding the effects of Virtual Reality (VR)-based rehabilitation on neural plasticity changes in stroke survivors. DATA SOURCES Six bioscience and engineering databases were searched, including Medline via Ebsco, Embase, PsycINFO, IEEE Explore, Cumulative Index of Nursing and Allied Health, and Scopus. STUDY SELECTION Studies reporting on the pre-post assessment of a VR intervention with neural plasticity measures published between 2000-2021 were included. DATA EXTRACTION Two independent reviewers conducted study selection, data extraction and quality assessment. Methodological quality of controlled trials was assessed using the Physiotherapy Evidence Database scale. Risk of bias of pre-post intervention and case studies was evaluated using the National Institutes of Health Quality Assessment Tool. DATA SYNTHESIS Twenty-seven studies (Total n=232) were included. Seven randomized controlled trials were rated as good quality while the two clinical controlled trials were moderate. Based on the risk of bias assessment, one pre-post study and one case study were graded as good quality, one pre-post study and one case study were poor, the other 14 studies were all at fair. After the VR intervention, main neurophysiological findings across studies include: (1) improved interhemispheric balance, (2) enhanced cortical connectivity, (3) increased cortical mapping of the affected limb muscles, (4) the improved neural plasticity measures were correlated to the enhanced behavior outcomes, (5) increased activation of regions in frontal cortex and (6) the mirror neuron system may be involved. CONCLUSIONS Virtual reality induced changes in neural plasticity for stroke survivors. Positive correlations between the neural plasticity changes and functional recovery elucidates the mechanisms of VR's therapeutic effects in stroke rehabilitation. This review prompts systematic understanding of the neurophysiological mechanisms of VR-based stroke rehabilitation and summarizes the emerging evidence for ongoing innovation of VR systems and application in stroke rehabilitation.
Collapse
Affiliation(s)
- Jie Hao
- Division of Physical Therapy Education, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, United States
| | - Haoyu Xie
- Division of Physical Therapy Education, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, United States
| | - Kimberly Harp
- Leon S. McGoogan Health Sciences Library, University of Nebraska Medical Center, Omaha, United States
| | - Zhen Chen
- Department of Neurorehabilitation, The First Rehabilitation Hospital of Shanghai, Shanghai, China
| | - Ka-Chun Siu
- Division of Physical Therapy Education, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, United States.
| |
Collapse
|
6
|
Choi S, Pyun SB. Repetitive Transcranial Magnetic Stimulation on the Supplementary Motor Area Changes Brain Connectivity in Functional Dysphagia. Brain Connect 2021; 11:368-379. [PMID: 33781085 DOI: 10.1089/brain.2020.0818] [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: 11/13/2022] Open
Abstract
Background: Previous studies arguing that functional dysphagia could be explained by underlying neurobiological mechanisms are insufficient to explain brain regions that functionally interact in patients with functional dysphagia. Therefore, we investigated functional connectivity changes associated with functional dysphagia after applying facilitatory repetitive transcranial magnetic stimulation (rTMS) on the supplementary motor area (SMA). Materials and Methods: A patient with severe long-lasting functional dysphagia and 15 healthy controls participated in this study. A facilitatory 5 Hz rTMS protocol was applied to the patient's SMA. We performed functional magnetic resonance imaging (fMRI) using volitional swallowing tasks to investigate neural network changes before rTMS (pre-rTMS), immediately after rTMS, and 3 months later. Results: The pre-rTMS fMRI results of the patient showed extensive overactivation in the left-lateralized regions related to volitional swallowing compared with the healthy controls. Following rTMS, dysphagia symptoms partially improved. The patient showed positive connectivity with the bilateral cerebellum in the bilateral SMA seeds before rTMS treatment. Furthermore, left-lateralized overactivation was washed out immediately after completion of rTMS, and connectivity between the left SMA and left precentral gyrus recovered 3 months after rTMS treatment. Conclusion: Our findings confirm that functional dysphagia might be a neurobiological manifestation caused by maladaptive functional connectivity changes in brain structures related to swallowing. Furthermore, noninvasive brain modulation with rTMS over the SMA may facilitate functional connectivity changes between the cortical and subcortical regions. Accordingly, these changes will allow control of the movements related to swallowing and may lead to improved clinical symptoms.
Collapse
Affiliation(s)
- Sunyoung Choi
- Clinical Research Division, Korean Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Sung-Bom Pyun
- BK21 Graduate Program, Department of Biomedical Sciences and Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Republic of Korea.,Brain Convergence Research Center, Korea University, Seoul, Republic of Korea
| |
Collapse
|
7
|
Wang Z, Liao M, Li Q, Zhang Y, Liu H, Fan Z, Bu L. Effects of three different rehabilitation games' interaction on brain activation using functional near-infrared spectroscopy. Physiol Meas 2020; 41:125005. [PMID: 33227728 DOI: 10.1088/1361-6579/abcd1f] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study reveals the changes in brain activation due to different game interaction states based on functional near-infrared spectroscopy signals and discusses their significance for stroke rehabilitation. APPROACH The oxygenated hemoglobin concentration (Delta [HbO2]) signals and the deoxygenated hemoglobin (Delta [HbR]) signals were recorded from the prefrontal cortex (PFC), the motor cortex (MC), the occipital lobe (OL) and the temporal lobe of 21 subjects (mean age: 24.6 ± 1.9 years old) in three game interaction states: physical, motion-sensing, and button-push training. The subjects were also asked to complete user-satisfaction survey scales after the experiment. MAIN RESULTS Compared with the button-training state, several channels in the PFC and MC region of the physical-training state were significantly altered as were several channels in the RMC region of the motion-sensing training state (P < 0.05 after adjustment). The motion-sensing state of the PFC had a significant correlation with that of the MC and the OL. The subjective scale results show that the acceptability of the physical and motion-sensing states was greater than the acceptability of the button-push training state. SIGNIFICANCE The results show that the brain regions responded more strongly when activated by the physical and motion-sensing states compared with the button-push training state, and the physical and motion-sensing states are more conducive to the rehabilitation of the nervous system. The design of rehabilitation products for stroke patients is discussed and valuable insights are offered to support the selection of better interactive training methods.
Collapse
Affiliation(s)
- Zilin Wang
- School of Mechanical Engineering, Shandong University, Jinan, 250061, People's Republic of China
| | | | | | | | | | | | | |
Collapse
|
8
|
Subramaniam S, Bhatt T. Dance-based exergaming for upper extremity rehabilitation and reducing fall-risk in community-dwelling individuals with chronic stroke. A preliminary study. Top Stroke Rehabil 2019; 26:565-575. [PMID: 31576774 DOI: 10.1080/10749357.2019.1625545] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Post-stroke, individuals demonstrate persistent upper extremity (UE) motor impairments that impact functional movements and change-in-support strategies essential for recovery from postural instability. OBJECTIVES: This study primarily aims to quantify the effect of dance-based exergaming (DBExG) intervention on improving paretic UE movement control. The secondary aim is to assess if these improvements in UE movement control if observed, could partially account for improved fall-risk.Methods: Thirteen adults with chronic stroke received DBExG training using the commercially available Kinect dance gaming "Just Dance 3". Surface electromyography of shoulder muscle activity during the stand-reaching task and UE shoulder kinematics for a dance trial were recorded. Changes in balance control were determined using the Activities-specific Balance Confidence scale [ABC] and Timed-Up-and-Go test [TUG].Results: Post-training, participants demonstrated improvements in shoulder muscle activity in the form of performance (reaction time, burst duration, and movement time) and production outcomes (peak acceleration) (p < .05). There was also a post-training increase in shoulder joint excursion (Ex) and peak joint angles (∠) during dance trials (p < .05). Participants exhibited positive post-intervention correlations between ABC and shoulder joint Ex [R2 of 0.43 (p < .05)] and between TUG and peak joint ∠ [R2 of 0.51 (p < .05)]. CONCLUSION: Findings demonstrated the beneficial effect of DBExG for improving UE movement and the training-induced gains were also positively correlated with improvements in fall-risk measures in people with chronic stroke. Thus, DBEx training could be used as a meaningful clinical application for this population group.
Collapse
Affiliation(s)
- Savitha Subramaniam
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
| | - Tanvi Bhatt
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
9
|
Aramaki AL, Sampaio RF, Reis ACS, Cavalcanti A, Dutra FCMSE. Virtual reality in the rehabilitation of patients with stroke: an integrative review. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:268-278. [DOI: 10.1590/0004-282x20190025] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/10/2018] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective: To describe the intervention protocols to using commercial video games as virtual reality (VR) in rehabilitation of patients with stroke. Methods: Integrative review using the descriptors “rehabilitation”, “virtual reality exposure therapy” and “videogames” in the LILACS and PUBMED databases. Articles published from 2011 to 2018 were selected. Results: We found 1,396 articles, 1,383 were excluded and 13 were selected. Most of the articles were randomized clinical trials published in 2014 or later. The sample size varied from 5–47 adults, or adults and elders, with chronic stroke. The Nintendo Wii® was the most used video game system. The intervention happened two or three times a week, each session lasting from 30 to 60 minutes, over 2–12 weeks. Balance, upper limb motor functions, quality of life and daily living activities were the most common evaluated outcomes. The Fugl-Meyer Assessment, Berg Balance Scale, Timed Up and Go test, Barthel Scale and SF-36 were the most common outcome measurement tools. Conclusions: The studies indicated improvement in dynamic balance, upper limb motor function and quality of life after rehabilitation using VR. The VR was more effective than conventional treatments for the outcome of dynamic balance. Two studies did not find any changes in static balance and daily living activities. Physical aspects and quality of life were the outcomes most evaluated by the researchers; as were the population with chronic strokes and protocols of long duration and low intensity. Few studies targeted immediate VR effects, performance in daily living activities and social participation.
Collapse
Affiliation(s)
- Alberto Luiz Aramaki
- Universidade Federal do Triângulo Mineiro, Brasil; NETRAS - Núcleo de Estudos e Pesquisas em Trabalho, Participação Social e Saúde, Brasil
| | | | - Ana Caroline Silva Reis
- NETRAS - Núcleo de Estudos e Pesquisas em Trabalho, Participação Social e Saúde, Brasil; Universidade Federal do Triângulo Mineiro, Brasil
| | | | - Fabiana Caetano Martins Silva e Dutra
- Universidade Federal do Triângulo Mineiro, Brasil; NETRAS - Núcleo de Estudos e Pesquisas em Trabalho, Participação Social e Saúde, Brasil; Universidade Federal do Triângulo Mineiro, Brasil
| |
Collapse
|
10
|
Schuster-Amft C, Eng K, Suica Z, Thaler I, Signer S, Lehmann I, Schmid L, McCaskey MA, Hawkins M, Verra ML, Kiper D. Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial. PLoS One 2018; 13:e0204455. [PMID: 30356229 PMCID: PMC6200191 DOI: 10.1371/journal.pone.0204455] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/20/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery. OBJECTIVE The aim of this study was to directly compare virtual reality-based training with conventional therapy. METHODS In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16x45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects. Blinded assessors tested patients twice before, once during, and twice after the intervention up to 2-month follow-up for dexterity (primary outcome: Box and Block Test), bimanual upper limb function (Chedoke-McMaster Arm and Hand Activity Inventory), and subjective perceived changes (Stroke Impact Scale). RESULTS 54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20-81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences. CONCLUSIONS Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01774669.
Collapse
Affiliation(s)
- Corina Schuster-Amft
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Institute for Rehabilitation and Performance Technology, Bern University of Applied Sciences, Burgdorf, Switzerland
| | - Kynan Eng
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Zorica Suica
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Irene Thaler
- Department of Physiotherapy, Insel Group, Bern University Hospital, Berne, Switzerland
| | - Sandra Signer
- Physiotherapy Department, Buergerspital Solothurn, Solothurn, Switzerland
| | - Isabelle Lehmann
- Department of Physiotherapy, Insel Group, Bern University Hospital, Berne, Switzerland
| | - Ludwig Schmid
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Physiotherapy Department, Zurcher RehaZentrum Lengg, Zurich, Switzerland
| | - Michael A. McCaskey
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Institute of Human Movement Sciences, ETH Zurich, Zurich, Switzerland
| | - Miura Hawkins
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Martin L. Verra
- Department of Physiotherapy, Insel Group, Bern University Hospital, Berne, Switzerland
| | - Daniel Kiper
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
| |
Collapse
|
11
|
Darbois N, Guillaud A, Pinsault N. Do Robotics and Virtual Reality Add Real Progress to Mirror Therapy Rehabilitation? A Scoping Review. Rehabil Res Pract 2018; 2018:6412318. [PMID: 30210873 PMCID: PMC6120256 DOI: 10.1155/2018/6412318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Mirror therapy has been used in rehabilitation for multiple indications since the 1990s. Current evidence supports some of these indications, particularly for cerebrovascular accidents in adults and cerebral palsy in children. Since 2000s, computerized or robotic mirror therapy has been developed and marketed. OBJECTIVES To map the extent, nature, and rationale of research activity in robotic or computerized mirror therapy and the type of evidence available for any indication. To investigate the relevance of conducting a systematic review and meta-analysis on these therapies. METHOD Systematic scoping review. Searches were conducted (up to May 2018) in the Cochrane Library, Google Scholar, IEEE Xplore, Medline, Physiotherapy Evidence Database, and PsycINFO databases. References from identified studies were examined. RESULTS In sum, 75 articles met the inclusion criteria. Most studies were publicly funded (57% of studies; n = 43), without disclosure of conflict of interest (59% of studies; n = 44). The main outcomes assessed were pain, satisfaction on the device, and body function and activity, mainly for stroke and amputees patients and healthy participants. Most design studies were case reports (67% of studies; n = 50), with only 12 randomized controlled trials with 5 comparing standard mirror therapy versus virtual mirror therapy, 5 comparing second-generation mirror therapy versus conventional rehabilitation, and 2 comparing other interventions. CONCLUSION Much of the research on second-generation mirror therapy is of very low quality. Evidence-based rationale to conduct such studies is missing. It is not relevant to recommend investment by rehabilitation professionals and institutions in such devices.
Collapse
Affiliation(s)
- Nelly Darbois
- Critical Thinking Research Federation FED 4276, University Grenoble-Alpes, Grenoble, France
- Cortecs team, Grenoble, France
- School of Physiotherapy, Grenoble-Alpes University Hospital, Grenoble, France
| | - Albin Guillaud
- Critical Thinking Research Federation FED 4276, University Grenoble-Alpes, Grenoble, France
- Cortecs team, Grenoble, France
- ThEMAS team, TIMC-IMAG Laboratory, UMR CNRS-UGA 5525, Grenoble, France
| | - Nicolas Pinsault
- Critical Thinking Research Federation FED 4276, University Grenoble-Alpes, Grenoble, France
- School of Physiotherapy, Grenoble-Alpes University Hospital, Grenoble, France
- ThEMAS team, TIMC-IMAG Laboratory, UMR CNRS-UGA 5525, Grenoble, France
| |
Collapse
|
12
|
Demers M, Chan Chun Kong D, Levin MF. Feasibility of incorporating functionally relevant virtual rehabilitation in sub-acute stroke care: perception of patients and clinicians. Disabil Rehabil Assist Technol 2018. [PMID: 29526122 DOI: 10.1080/17483107.2018.1449019] [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] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine user satisfaction and safety of incorporating a low-cost virtual rehabilitation intervention as an adjunctive therapeutic option for cognitive-motor upper limb rehabilitation in individuals with sub-acute stroke. METHODS A low-cost upper limb virtual rehabilitation application incorporating realistic functionally-relevant unimanual and bimanual tasks, specifically designed for cognitive-motor rehabilitation was developed for patients with sub-acute stroke. Clinicians and individuals with stroke interacted with the intervention for 15-20 or 20-45 minutes, respectively. The study had a mixed-methods convergent parallel design that included a focus group interview with clinicians working in a stroke program and semi-structured interviews and standardized assessments (Borg Perceived Exertion Scale, Short Feedback Questionnaire) for participants with sub-acute stroke undergoing rehabilitation. The occurrence of adverse events was also noted. RESULTS Three main themes emerged from the clinician focus group and patient interviews: Perceived usefulness in rehabilitation, satisfaction with the virtual reality intervention and aspects to improve. All clinicians and the majority of participants with stroke were highly satisfied with the intervention and perceived its usefulness to decrease arm motor impairment during functional tasks. No participants experienced major adverse events. CONCLUSIONS Incorporation of this type of functional activity game-based virtual reality intervention in the sub-acute phase of rehabilitation represents a way to transfer skills learned early in the clinical setting to real world situations. This type of intervention may lead to better integration of the upper limb into everyday activities. Implications for Rehabilitation • Use of a cognitive-motor low-cost virtual reality intervention designed to remediate arm motor impairments in sub-acute stroke is feasible, safe and perceived as useful by therapists and patients for stroke rehabilitation. • Input from end-users (therapists and individuals with stroke) is critical for the development and implementation of a virtual reality intervention.
Collapse
Affiliation(s)
- Marika Demers
- a School of Physical and Occupational Therapy, McGill University , Montreal , Canada.,b Feil and Oberfeld Research Center, Jewish Rehabilitation Hospital, Center for Interdisciplinary Research in Rehabilitation of Greater Montreal , Montreal , Canada
| | - Daniel Chan Chun Kong
- a School of Physical and Occupational Therapy, McGill University , Montreal , Canada.,b Feil and Oberfeld Research Center, Jewish Rehabilitation Hospital, Center for Interdisciplinary Research in Rehabilitation of Greater Montreal , Montreal , Canada
| | - Mindy F Levin
- a School of Physical and Occupational Therapy, McGill University , Montreal , Canada.,b Feil and Oberfeld Research Center, Jewish Rehabilitation Hospital, Center for Interdisciplinary Research in Rehabilitation of Greater Montreal , Montreal , Canada
| |
Collapse
|
13
|
Cerebral Reorganization in Subacute Stroke Survivors after Virtual Reality-Based Training: A Preliminary Study. Behav Neurol 2017; 2017:6261479. [PMID: 28720981 PMCID: PMC5506482 DOI: 10.1155/2017/6261479] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/12/2017] [Accepted: 05/31/2017] [Indexed: 11/17/2022] Open
Abstract
Background Functional magnetic resonance imaging (fMRI) is a promising method for quantifying brain recovery and investigating the intervention-induced changes in corticomotor excitability after stroke. This study aimed to evaluate cortical reorganization subsequent to virtual reality-enhanced treadmill (VRET) training in subacute stroke survivors. Methods Eight participants with ischemic stroke underwent VRET for 5 sections per week and for 3 weeks. fMRI was conducted to quantify the activity of selected brain regions when the subject performed ankle dorsiflexion. Gait speed and clinical scales were also measured before and after intervention. Results Increased activation in the primary sensorimotor cortex of the lesioned hemisphere and supplementary motor areas of both sides for the paretic foot (p < 0.01) was observed postintervention. Statistically significant improvements were observed in gait velocity (p < 0.05). The change in voxel counts in the primary sensorimotor cortex of the lesioned hemisphere is significantly correlated with improvement of 10 m walk time after VRET (r = −0.719). Conclusions We observed improved walking and increased activation in cortical regions of stroke survivors after VRET training. Moreover, the cortical recruitment was associated with better walking function. Our study suggests that cortical networks could be a site of plasticity, and their recruitment may be one mechanism of training-induced recovery of gait function in stroke. This trial is registered with ChiCTR-IOC-15006064.
Collapse
|
14
|
A Mixed Methods Small Pilot Study to Describe the Effects of Upper Limb Training Using a Virtual Reality Gaming System in People with Chronic Stroke. Rehabil Res Pract 2017; 2017:9569178. [PMID: 28197341 PMCID: PMC5286463 DOI: 10.1155/2017/9569178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 12/20/2016] [Accepted: 12/25/2016] [Indexed: 12/22/2022] Open
Abstract
Introduction. This small pilot study aimed to examine the feasibility of an upper limb rehabilitation system (the YouGrabber) in a community rehabilitation centre, qualitatively explore participant experiences, and describe changes after using it. Methods and Material. Chronic stroke participants attending a community rehabilitation centre in the UK were randomised to either a YouGrabber or a gym group and completed 18 training sessions over 12 weeks. The motor activity log, box and block, and fatigue severity score were administered by a blinded assessor before and after the intervention. Semistructured interviews were used to ascertain participants' views about using the YouGrabber. Results. Twelve participants (6 females) with chronic stroke were recruited. All adhered to the intervention. There were no adverse events, dropouts, or withdrawal. There were no significant differences between the YouGrabber and gym groups although there were significant within group improvements on the motor activity log (median change: 0.59, range: 0.2–1.25; p < 0.05) within the YouGrabber group. Participants reported that the YouGrabber was motivational but they expressed frustration with technical challenges. Conclusions. The YouGrabber appeared practical and may improve upper limb activities in people several months after stroke. Future work could examine cognition, cost effectiveness, and different training intensities.
Collapse
|
15
|
House G, Burdea G, Polistico K, Roll D, Kim J, Grampurohit N, Damiani F, Keeler S, Hundal J, Pollack S. Integrative rehabilitation of residents chronic post-stroke in skilled nursing facilities: the design and evaluation of the BrightArm Duo. Disabil Rehabil Assist Technol 2016; 11:683-94. [PMID: 26218427 DOI: 10.3109/17483107.2015.1068384] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/29/2015] [Indexed: 11/13/2022]
Abstract
PURPOSE To describe the novel BrightArm Duo bimanual upper extremity (UE) rehabilitation system; to determine its technology acceptance and clinical benefit for older hemiplegic participants. METHODS The system table tilted to adjust arm gravity loading. Participants wore arm supports that sensed grasp strength and wrist position on the table. Wrist weights further increased shoulder exertion. Games were designed to improve UE strength, motor function, cognition and emotive state and adapted automatically to each participant. The system underwent feasibility trials spanning 8 weeks in two skilled nursing facilities (SNFs). Participants were evaluated pre-therapy and post-therapy using standardized clinical measures. Computerized measures of supported arm reach, table tilt and number of arm repetitions were stored on a remote server. OUTCOMES Seven participants had significant improvements in their active range of shoulder movement, supported arm reach, shoulder strength, grasp strength and their ability to focus. The group demonstrated higher arm function measured with FMA (p = 0.01) and CAHAI (p = 0.05), and had an improvement in depression (Becks Depression Inventory, II). BrightArm Duo technology was well accepted by participants with a rating of 4.4 out of 5 points. CONCLUSIONS Given these findings, it will be beneficial to evaluate the BrightArm Duo application in SNF maintenance programs. Implications for Rehabilitation Integrative rehabilitation that addresses both physical and cognitive domains is promising for post-stroke maintenance in skilled nursing facilities. Simultaneous bilateral arm exercise may improve arm function in older hemiplegic patients several years after stroke. Virtual reality games that adapt to the patient can increase attention and working memory while decreasing depression in elderly.
Collapse
Affiliation(s)
- G House
- a Bright Cloud International Corp , Highland Park , NJ , USA
| | - G Burdea
- a Bright Cloud International Corp , Highland Park , NJ , USA
| | - K Polistico
- a Bright Cloud International Corp , Highland Park , NJ , USA
| | - D Roll
- a Bright Cloud International Corp , Highland Park , NJ , USA
| | - J Kim
- a Bright Cloud International Corp , Highland Park , NJ , USA
| | - N Grampurohit
- a Bright Cloud International Corp , Highland Park , NJ , USA
| | - F Damiani
- b Roosevelt Care Center , Edison , NJ , USA
| | - S Keeler
- c JFK Hartwyck at Edison Estates , Edison , NJ , USA
| | - J Hundal
- d Hundal Neuropsychology Group , Watchung , NJ , USA
| | - S Pollack
- e Data Driven Innovation , Westhampton , NY , USA , and
- f Computer Information Systems and Decision Sciences, St. John's University , Queens , NY , USA
| |
Collapse
|
16
|
Hartman K, Altschuler EL. Mirror Therapy for Hemiparesis Following Stroke: A Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0131-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
17
|
Colomer C, Llorens R, Noé E, Alcañiz M. Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke. J Neuroeng Rehabil 2016; 13:45. [PMID: 27169462 PMCID: PMC4864937 DOI: 10.1186/s12984-016-0153-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 05/03/2016] [Indexed: 11/24/2022] Open
Abstract
Background Virtual and mixed reality systems have been suggested to promote motor recovery after stroke. Basing on the existing evidence on motor learning, we have developed a portable and low-cost mixed reality tabletop system that transforms a conventional table in a virtual environment for upper limb rehabilitation. The system allows intensive and customized training of a wide range of arm, hand, and finger movements and enables interaction with tangible objects, while providing audiovisual feedback of the participants’ performance in gamified tasks. This study evaluates the clinical effectiveness and the acceptance of an experimental intervention with the system in chronic stroke survivors. Methods Thirty individuals with stroke were included in a reversal (A-B-A) study. Phase A consisted of 30 sessions of conventional physical therapy. Phase B consisted of 30 training sessions with the experimental system. Both interventions involved flexion and extension of the elbow, wrist, and fingers, and grasping of different objects. Sessions were 45-min long and were administered three to five days a week. The body structures (Modified Ashworth Scale), functions (Motricity Index, Fugl-Meyer Assessment Scale), activities (Manual Function Test, Wolf Motor Function Test, Box and Blocks Test, Nine Hole Peg Test), and participation (Motor Activity Log) were assessed before and after each phase. Acceptance of the system was also assessed after phase B (System Usability Scale, Intrinsic Motivation Inventory). Results Significant improvement was detected after the intervention with the system in the activity, both in arm function measured by the Wolf Motor Function Test (p < 0.01) and finger dexterity measured by the Box and Blocks Test (p < 0.01) and the Nine Hole Peg Test (p < 0.01); and participation (p < 0.01), which was maintained to the end of the study. The experimental system was reported as highly usable, enjoyable, and motivating. Conclusions Our results support the clinical effectiveness of mixed reality interventions that satisfy the motor learning principles for upper limb rehabilitation in chronic stroke survivors. This characteristic, together with the low cost of the system, its portability, and its acceptance could promote the integration of these systems in the clinical practice as an alternative to more expensive systems, such as robotic instruments. Electronic supplementary material The online version of this article (doi:10.1186/s12984-016-0153-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Carolina Colomer
- Servicio de Neurorrehabilitación y Daño Cerebral de los Hospitales NISA. Fundación Hospitales NISA, Valencia, Spain
| | - Roberto Llorens
- Servicio de Neurorrehabilitación y Daño Cerebral de los Hospitales NISA. Fundación Hospitales NISA, Valencia, Spain. .,Instituto Interuniversitario de Investigación en Bioingeniería y Tecnología Orientada al Ser Humano, Universitat Politècnica de València, Camino de Vera s/n, Valencia, 46022, Spain.
| | - Enrique Noé
- Servicio de Neurorrehabilitación y Daño Cerebral de los Hospitales NISA. Fundación Hospitales NISA, Valencia, Spain
| | - Mariano Alcañiz
- Instituto Interuniversitario de Investigación en Bioingeniería y Tecnología Orientada al Ser Humano, Universitat Politècnica de València, Camino de Vera s/n, Valencia, 46022, Spain.,Ciber, Fisiopatología Obesidad y Nutrición, CB06/03 Instituto de Salud Carlos III, Av. Sos Baynat s/n, Univesity of Jaume I, Castellón, 12071, Spain
| |
Collapse
|
18
|
Guo F, Xu Q, Abo Salem HM, Yao Y, Lou J, Huang X. The neuronal correlates of mirror therapy: A functional magnetic resonance imaging study on mirror-induced visual illusions of ankle movements. Brain Res 2016; 1639:186-93. [DOI: 10.1016/j.brainres.2016.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/27/2016] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
|
19
|
Gerber CN, Kunz B, van Hedel HJA. Preparing a neuropediatric upper limb exergame rehabilitation system for home-use: a feasibility study. J Neuroeng Rehabil 2016; 13:33. [PMID: 27008504 PMCID: PMC4806437 DOI: 10.1186/s12984-016-0141-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/17/2016] [Indexed: 12/11/2022] Open
Abstract
Background Home-based, computer-enhanced therapy of hand and arm function can complement conventional interventions and increase the amount and intensity of training, without interfering too much with family routines. The objective of the present study was to investigate the feasibility and usability of the new portable version of the YouGrabber® system (YouRehab AG, Zurich, Switzerland) in the home setting. Methods Fifteen families of children (7 girls, mean age: 11.3y) with neuromotor disorders and affected upper limbs participated. They received instructions and took the system home to train for 2 weeks. After returning it, they answered questions about usability, motivation, and their general opinion of the system (Visual Analogue Scale; 0 indicating worst score, 100 indicating best score; ≤30 not satisfied, 31–69 average, ≥70 satisfied). Furthermore, total pure playtime and number of training sessions were quantified. To prove the usability of the system, number and sort of support requests were logged. Results The usability of the system was considered average to satisfying (mean 60.1–93.1). The lowest score was given for the occurrence of technical errors. Parents had to motivate their children to start (mean 66.5) and continue (mean 68.5) with the training. But in general, parents estimated the therapeutic benefit as high (mean 73.1) and the whole system as very good (mean 87.4). Children played on average 7 times during the 2 weeks; total pure playtime was 185 ± 45 min. Especially at the beginning of the trial, systems were very error-prone. Fortunately, we, or the company, solved most problems before the patients took the systems home. Nevertheless, 10 of 15 families contacted us at least once because of technical problems. Conclusions Despite that the YouGrabber® is a promising and highly accepted training tool for home-use, currently, it is still error-prone, and the requested support exceeds the support that can be provided by clinical therapists. A technically more robust system, combined with additional attractive games, likely results in higher patient motivation and better compliance. This would reduce the need for parents to motivate their children extrinsically and allow for clinical trials to investigate the effectiveness of the system. Trial registration ClinicalTrials.gov NCT02368223 Electronic supplementary material The online version of this article (doi:10.1186/s12984-016-0141-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Corinna N Gerber
- Pediatric Rehab Research Group, Rehabilitation Center for Children and Adolescents, Mühlebergstrasse 104, CH-8910, Affoltern am Albis, Switzerland. .,Department of Health Sciences and Technology, ETH Zurich, Rämistrasse 101, CH-8092, Zurich, Switzerland. .,Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032, Zürich, Switzerland.
| | - Bettina Kunz
- Pediatric Rehab Research Group, Rehabilitation Center for Children and Adolescents, Mühlebergstrasse 104, CH-8910, Affoltern am Albis, Switzerland.,Department of Health Sciences and Technology, ETH Zurich, Rämistrasse 101, CH-8092, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032, Zürich, Switzerland
| | - Hubertus J A van Hedel
- Pediatric Rehab Research Group, Rehabilitation Center for Children and Adolescents, Mühlebergstrasse 104, CH-8910, Affoltern am Albis, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032, Zürich, Switzerland
| |
Collapse
|
20
|
Ellington A, Adams R, White M, Diamond P. Behavioral intention to use a virtual instrumental activities of daily living system among people with stroke. Am J Occup Ther 2015; 69:6903290030p1-8. [PMID: 25871604 PMCID: PMC4453041 DOI: 10.5014/ajot.2015.014373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the behavioral intention to use (BIU) regarding a virtual system for practicing instrumental activities of daily living (IADLs) among people with stroke. METHOD Fourteen people who had sustained a stroke used a virtual world-based system over four sessions to participate in virtual occupations of preparing meals and putting away groceries. To investigate intention to use the technology, participants responded to a questionnaire based on the Technology Acceptance Model and were interviewed about the experience. RESULTS Analysis of questionnaire responses revealed favorable attitudes toward the technology and statistically significant correlations between these attitudes and positive BIU. Analysis of qualitative data revealed four themes to support system use: Use of the affected arm increased, the virtual practice was enjoyable, the technology was user-friendly, and the system reflected real-life activities. CONCLUSION This study shows that participants reported a positive BIU for the virtual system for practicing IADLs.
Collapse
Affiliation(s)
- Allison Ellington
- Allison Ellington, MS, OTR/L, is Director of Clinical Education, Department of Occupational Therapy, Murphy Deming College of Health Sciences, Mary Baldwin College, Staunton, VA, and occupational therapist, University of Virginia HealthSouth Rehabilitation Hospital, Charlottesville;
| | - Richard Adams
- Richard Adams, PhD, is Principal Research Scientist, Barron Associates, Charlottesville, VA
| | - Marga White
- Marga White, MS, OTL, is Occupational Therapist, University of Virginia HealthSouth Rehabilitation Hospital, Charlottesville
| | - Paul Diamond
- Paul Diamond, MD, is Director of Neurorehabilitation and Associate Professor, Physical Medicine and Rehabilitation Department, University of Virginia School of Medicine, Charlottesville
| |
Collapse
|