Innovative approaches to the rehabilitation of upper extremity hemiparesis using virtual environments

Has your stroke hospital been innovative enough in 12.5 years to  bring this in? Or are they still in the dark ages when bloodletting was a stroke intervention?

We may as well go back to blood letting as a stroke prescription as discussed in the 1843 book, 'An Essay On The Nature and Treatment of Apoplexy'.

Ask your doctor what is the basis for their treatment of your stroke disabilities and why they moved away from bloodletting.  My doctor knew nothing and did nothing as proven by the writing of three E.T.(Evaluate and treat) prescriptions.

 

Innovative approaches to the rehabilitation of upper extremity hemiparesis using virtual environments

Eur J Phys Rehabil Med. Author manuscript; available in PMC 2017 Oct 19.

Published in final edited form as:

Eur J Phys Rehabil Med. 2009 Mar; 45(1): 123–133.

 

A. S. MERIANS,¹ E. TUNIK,^1,3 G. G. FLUET,¹ Q. QIU,² and S. V. ADAMOVICH^1,2

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Abstract

Aim

Upper-extremity interventions for hemiparesis are a challenging aspect of stroke rehabilitation. Purpose of this paper is to report the feasibility of using virtual environments (VEs) in combination with robotics to assist recovery of hand-arm function and to present preliminary data demonstrating the potential of using sensory manipulations in VE to drive activation in targeted neural regions.

Methods

We trained 8 subjects for 8 three hour sessions using a library of complex VE’s integrated with robots, comparing training arm and hand separately to training arm and hand together. Instrumented gloves and hand exoskeleton were used for hand tracking and haptic effects. Haptic Master robotic arm was used for arm tracking and generating three-dimensional haptic VEs. To investigate the use of manipulations in VE to drive neural activations, we created a “virtual mirror” that subjects used while performing a unimanual task. Cortical activation was measured with functional MRI (fMRI) and transcranial magnetic stimulation.

Results

Both groups showed improvement in kinematics and measures of real-world function. The group trained using their arm and hand together showed greater improvement. In a stroke subject, fMRI data suggested virtual mirror feedback could activate the sensorimotor cortex contralateral to the reflected hand (ipsilateral to the moving hand) thus recruiting the lesioned hemisphere.

Conclusion

Gaming simulations interfaced with robotic devices provide a training medium that can modify movement patterns. In addition to showing that our VE therapies can optimize behavioral performance, we show preliminary evidence to support the potential of using specific sensory manipulations to selectively recruit targeted neural circuits.

Keywords: Paresis, Robotics, Recovery of function, Arm, therapy, Stroke

Improvement in upper extremity post-stroke function has been recalcitrant to current therapeutic interventions with only 5% of all patients regaining full use of their upper extremity following intensive therapy. Stroke rehabilitation has focused on the facilitation of isolated movements through spasticity reduction, passive guidance and graded movement assistance. Current emphasis is on repetitive task practice and utilizing principles of motor learning such as regulating practice schedules and augmenting feedback. It is believed that these motor learning principles parallel the practice principles purported to effect neuroplasticity. Evidence that plasticity is “use-dependent” and intensive massed and repeated practice may be necessary to modify neural organization.^1–3

Virtual reality (VR) technology may be an appropriate means to provide these plasticity-mediated therapies using motor learning principles. The first generation of these computerized systems provided motivating environments in which tasks could be practiced repetitively. Training schedules, specificity and frequency of visual and auditory feedback could be objectively monitored and quantified. Currently treatment interventions are being developed to take advantage of technological advances such as the improvement in robotic design, the development of haptic interfaces, and the integration of these devices with virtual environments. Studies have shown that robotically-facilitated repetitive movement training might be an effective stimulus for normalizing upper extremity motor control in persons with moderate to severe impairments who have difficulties in performing unassisted movements.^4–6 Several authors have integrated VE with adaptive robotic systems to train the hemiparetic upper extremity.^7–10

Although considerable progress has been made in developing these devices, the clinical evidence demonstrating effectiveness of these systems has not yet reached the highest levels of evidence found in systematic reviews and randomized controlled studies. Many of the studies supporting the use of interactive robotics and virtual environments interfaced with movement tracking and sensing glove systems consist of case studies, small feasibility studies, or studies without control groups. Unfortunately, in fact, the assimilation of technology into rehabilitation has not been as fast or as extensive as in other branches of medicine.¹¹

If repetition and skill learning are important for motor learning and recovery of function, what do these technologies add over and above real-world task practice? This is an important question. What can training within an interactive virtual environment, either with or without robotic devices contribute to skill learning and improved motor control? Do gaming environments, augmented visual, auditory and haptic feedback provide added value to the learning process? Are these technological interventions able to model and incorporate accepted rehabilitation practices such as physical assistance and graded progression of tasks to adjust the kinematics of the movement during training? We believe that the combination of virtual environments and robotics can be effectively used both as a training tool and and as a test of hypotheses regarding the benefits of various rehabilitation approaches. These capabilities are afforded through the quantitative evaluation tools inherent to this technology.

We present an example of such a study that tests two different approaches to hand rehabilitation. The prevailing paradigm for upper extremity rehabilitation describes the need to develop proximal control and mobility of the shoulder prior to initiating training on the hand.¹² This has been the accepted rehabilitation method for many years. An increasing number of human and animal studies ^13–16 have reported that movement practice increases the area and density of motor cortex correlated with that movement, with the possibility that this expansion of motor territory influences representations occupying adjacent territory.¹⁶ It is not clear whether this expansion of cortical representations occurs through sharing of cortical tissue among representations ¹⁷ or through competition for cortical territory.^18–20 These findings prompt us to reconsider the rehabilitation strategy that encourages early shoulder activation post-stroke. In general, there is better return of upper arm function post-stroke than of the hand. ²¹ Does early motor activity of the upper arm and shoulder hinder recovery of hand function because of cortical competition facilitated through intensive motor activity? Several small studies exploring the concept of providing additional hand training during conventional therapy ¹⁶ or training the hand while the upper arm is deafferented and deefferented through regional anesthesia ²⁰ have shown positive changes in hand function.

The purpose of this paper is to report preliminary findings on the feasibility of using special designed virtual environments in combination with robotics to assist recovery of hand-arm function post-stroke. The first section presents preliminary findings that address the above mentioned competition hypothesis. Two groups of post-stroke patients were trained: one group used virtual reality training simulations to train the hand and arm together as a functional unit and one group trained hand and arm separately. We hypothesized that balancing and integrating the training of both proximal and distal components of the upper extremity will minimize over-representation of the upper arm.

In the second section, we report preliminary data that demonstrate the potential of sensory manipulations in VE to selectively drive activation in targeted neural regions. For this, we used a task, mirror visual feedback (MVF),²² which in smaller-scale studies has shown promise in aiding recovery of hand-arm function after stroke.^{23, 24} We simulated the MVF effect in VE by creating a “virtual mirror” as subjects performed a unimanual task. We simultaneously measured cortical activation with functional magnetic resonance imaging (fMRI) and, in a separate session, with transcranial magnetic stimulation (TMS). We hypothesized that the virtual mirror effect would be associated with activation of the motor cortex in the hemisphere ipsilateral to the moving hand (i.e. contralateral to the mirror-reflected hand).

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