If our hospitals can't even manage to buy survivors music for music therapy they will never buy virtual reality stuff.
They say nothing about full recovery, so I guess it was a failure at that. Once again using the tyranny of low expectations to declare success when survivors would consider it a failure.
Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial
Journal of NeuroEngineering and Rehabilitation volume 20, Article number: 38 (2023)
Abstract
Trial objective
To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.
Trial design
This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality–based therapy could be blinded to the intervention.
Participants
Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.
Intervention
Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).
Results
As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38–1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: − 35.5; 95% confidence interval: − 38.9 to − 32.0; wrist: effect size = 0.290; mean: − 5.6; 95% confidence interval: − 6.4 to − 4.8; hand: effect size = 0.299; mean: − -8.9; 95% confidence interval: − 10.1 to − 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: − 32.8; 95% confidence interval: − 40.1 to − 25.5).
Conclusion
The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.
Trials Registry: International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).
Introduction
Stroke is a leading cause of long-lasting disability. As many as 41.5 million new cases occur yearly in Europe, and 3.7 million survivors experience long-lasting impairments, whereas less than 15% of patients achieve full poststroke recovery [1].
It is estimated that 80% of stroke patients have upper-limb deficits and have decreased activity and use of the paretic hand in daily life [2]; the involvement of the more affected hand in activities of daily living (ADLs) depends on the severity of the deterioration and is associated with a decrease in health-related quality of life (HRQoL) and restrictions on social participation [3, 4].
Most of the functional recovery after diagnosis occurs in the first three months, although neural repair processes and behavioral improvements continue to show slight plasticity in later phases of the rehabilitation process [5, 6]. Therefore, it is crucial that hand rehabilitation begin early; treatment should start within this window of opportunity for functional recovery, when the brain is especially receptive to sensorimotor interaction [7,8,9].
Rehabilitative treatment of the upper limb is recognized by consensus among survivors, caregivers and health professionals as one of the top ten research priorities for poststroke recovery [10, 11]. In addition to the rehabilitation of the upper limb, other priorities should also be taken into account for the development of neurorehabilitation programs and the design of the corresponding studies, such as minimizing patients’ mobility disability, poststroke fatigue and difficulty in fulfilling responsibilities in the family and work environments; improving patients’ response to the demands of society; and ensuring exhaustive, well-structured monitoring of their clinical evolution after treatment.
During poststroke hand treatment, special attention must be paid to restoring the different biomechanical movements and curvature of the hand in order to provide a stable base and correct alignment as a prerequisite for dexterity training and modulation of reaching movements [12,13,14]. It is crucial to remember that restoring the selective voluntary movements of the upper limb in stroke patients also relies on the postural control that is necessary for reaching movements—scapula stabilization, shoulder stability more broadly, and selective muscle recruitment [15,16,17,18,19,20].
Various therapies based on a conventional approach have been demonstrated to be useful, achieving good results in terms of hand rehabilitation: motor imagery training seems to improve the precision and accuracy of movement, as well as the reception of sensory signals, by fostering activation of dormant synapses and accelerating reperfusion of the ischemic penumbra [21]. Mirror therapy can reduce asymmetric hemisphere activation, stimulate the primary motor cortex in both the lesioned (ipsilateral) hemisphere and the opposite (contralateral) hemisphere, widely activate the mirror neuron system and induce partial pathways for motor neurons on the side affected by stroke, which facilitates the remodeling of brain function [22, 23]. Constraint-induced movement therapy focuses on intensive, gradual training of the paretic upper limb to improve its use in specific tasks, limit the use of the less affected upper limb, and, in the context of behavior-changing methods for improving adherence, transfer the clinical achievements into the patient’s real life [24] by relating the therapeutic intervention components to the improvement of motor function and the use and skill of the paretic hand in daily life [25]. Forced use, which is meant to maximize daily use of the paretic hand, seems to yield improvements in motor function after intervention, and these improvements persist for three months after poststroke intervention [26]. Last but not least, active sensory therapies focus on active sensory training in the context of practice with goals involving multiple areas of the brain; pursuing neural reorganization in this manner enhances the motor recovery of the paretic upper limb (e.g., practicing nonvisual identification of common objects increases stereognosis) [27].
Another important aspect of hand-focused therapy programs is the use of a generous dose of intense repetition [28]. Lang et al. [27] determined by means of meta-regression that from 24 to 57 h, the effect size increased by 0.034 for every ten extra hours of therapy, independent of the specific poststroke intervention. In a conventional therapy session at an ordinary hospital rehabilitation unit, a patient can achieve 30 repetitions of an exercise involving the upper limbs, whereas specific technological systems allow more than 300 repetitions in 34 min of action per session [29, 30].
Recent years have witnessed an increased use of technology-based and especially virtual reality–based neurorehabilitation approaches, which have allowed the creation of effective simulated environments and provided multimodal, controllable and customizable stimulation [31]. The re-creation of objects in virtual form maximizes visual feedback [32]. In addition, high intensity and a large number of repetitions are key factors influencing neuroplasticity and functional improvement in patients [33]. Rehabilitation based on virtual reality offers the possibility of addressing individual treatment needs and simultaneously standardizing evaluation and training protocols [34, 35].
There are two major types of virtual reality-based systems used in neurorehabilitation: nonspecific virtual reality (N-SVR) systems and specific virtual reality (SVR) systems. These two classes differ in that systems of the former type use game consoles and video games designed by the entertainment industry. Such consoles (Wii, Xbox, PlayStation, etc.) run games that are not designed for adults suffering from a neurological pathology and do not allow monitoring of movement or other motor or functional variables of the affected body segments. Thus, N-SVR systems are not designed for the neurophysiological recovery of the brain, and they do not focus on the neuronal connections necessary for the recovery of hand function after stroke. In contrast, SVR systems are specifically designed to promote motor learning and recovery, optimizing the acquisition, retention and generalization of motor skills. SVR systems incorporate key features of virtual reality and add objective, quantitative movement monitoring and exergames to facilitate the motor recovery of the hand (regular voluntary movement, arches of hand curvature, grasping, pinch grips and gross manipulation). In addition, SVR systems comply with the principles of neurorehabilitation: mass practice (repetitive training), high dosing (intensive training), structured practice, task-specific practice (ADL-relevant skills training), variable practice, multisensory stimulation (training in which the feedback is not limited to the visual modality), increasing difficulty (individualized training), explicit feedback (training that provides knowledge about the results), implicit feedback (training that provides task-relevant implicit signals), avatar representation (immersive training) and encouragement of the use of the paretic limb (training that counteracts compensation) [36].
In this sense, neurorehabilitation SVR systems allow rehabilitation work to proceed in a functional way and with specific intervention objectives, and these systems can easily evaluate and document progress during sessions [37]. Taking advantage of these characteristics, several authors have used virtual reality-based therapy (VRBT) to restore motor function after stroke [38,39,40]. Immersion, presence, and interactivity are three key features of virtual reality [41, 42]. In the course of our study, the exergames of the HandTutor© glove software made it possible for the user to become the main character (immersion); users perceived the connection to the virtual environment through movement (interactivity) and acted inside it as they received input and responded to the challenges posed by the exergame (presence).
In this regard, Laver et al. [40] analyzed studies that compared N-SVR-based therapies with an alternative intervention or no intervention. In 2017, they updated their review by adding 35 new studies of N-SVR-based therapies, the majority of which used commercial games on the Nintendo Wii console. They concluded that virtual reality alone did not offer statistically significant improvements, in contrast to conventional treatment. However, when virtual reality was applied as a complement to common treatment, this combined treatment outperformed the conventional treatment alone. In these studies, the experimental group was given more time for treatment than the control group [41].
Choosing the appropriate neurorehabilitation strategies to maximize clinical results in stroke patients takes priority. In this sense, a combination of more traditional neurophysiological approaches and motion-based therapies, delivered at a high intensity and in a large dose in motivating game-related environments where motion can be made, offers an important advantage in restoring the motor function of the upper limb [29, 31].
Our clinical trial differs from the studies included in the review as follows: (1) it adds SVR technology (HandTutor© glove), designed for hand motor rehabilitation; (2) it offers the same amount of time for intervention in both groups (control vs. experimental); and (3) it combines SVR with conventional treatment (experimental group). Additionally, many of the studies included in the review focused on adult patients with chronic stroke (a period of recovery equal to or greater than six months after diagnosis).
Ikbali and collaborators [39] used the Kinect sensor and the Xbox 360 console from Microsoft Inc.© to train active movement of the upper limb, focusing on shoulder abduction and adduction and wrist flexion and extension exercises.
The Kinect sensor, independent of any specific software for rehabilitation after stroke, is able to capture gross movement of the upper limb, but it cannot identify hand motion and does not include exergames designed for hand motor rehabilitation.
Programs incorporating SVR technology to train distal motor function after cerebrovascular accident remain little known [43, 44], in contrast to programs focusing on proximal motor function [45], robot-assisted hand treatment [30, 46] or improving balance and walking [47, 48]. Therefore, the aim of the present study is to test whether conventional rehabilitation combined with SVR is more effective than conventional therapy alone in restoring the motor function and muscle tone of the hand after stroke.
It was hypothesized that, compared to control group (CG) participants, adults randomized to the experimental group (EG) would achieve an increased degree of hand motor function improvement and have superior results on the Fugl-Meyer Assessment, Ashworth Scale, and Action Research Arm Test.
More at link.
No comments:
Post a Comment