Feasibility and preliminary efficacy of a combined virtual reality, robotics and electrical stimulation intervention in upper extremity stroke rehabilitation

 Well then, write this up as a preliminary protocol and create a distribution method to get it to all 10 million yearly stroke survivors  now and into the future.  Your responsibility since our fucking failures of stroke associations have completely failed at that job. This has to go to the survivors, not the hospitals or therapists, survivors are the only ones who will ensure the protocols are used correctly. And it even covers severe impairments.

Feasibility and preliminary efficacy of a combined virtual reality, robotics and electrical stimulation intervention in upper extremity stroke rehabilitation

• Nahid Norouzi-Gheidari,
• Philippe S. Archambault,
• Katia Monte-Silva,
• Dahlia Kairy,
• Heidi Sveistrup,
• Michael Trivino,
• Mindy F. Levin &
• Marie-Hélène Milot 

Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 61 (2021) Cite this article

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Abstract

Background

Approximately 80% of individuals with chronic stroke present with long lasting upper extremity (UE) impairments. We designed the perSonalized UPper Extremity Rehabilitation (SUPER) intervention, which combines robotics, virtual reality activities, and neuromuscular electrical stimulation (NMES). The objectives of our study were to determine the feasibility and the preliminary efficacy of the SUPER intervention in individuals with moderate/severe stroke.

Methods

Stroke participants (n = 28) received a 4-week intervention (3 × per week), tailored to their functional level. The functional integrity of the corticospinal tract was assessed using the Predict Recovery Potential algorithm, involving measurements of motor evoked potentials and manual muscle testing. Those with low potential for hand recovery (shoulder group; n = 18) received a robotic-rehabilitation intervention focusing on elbow and shoulder movements only. Those with a good potential for hand recovery (hand group; n = 10) received EMG-triggered NMES, in addition to robot therapy. The primary outcomes were the Fugl-Meyer UE assessment and the ABILHAND assessment. Secondary outcomes included the Motor Activity Log and the Stroke Impact Scale.

Results

Eighteen participants (64%), in either the hand or the shoulder group, showed changes in the Fugl-Meyer UE or in the ABILHAND assessment superior to the minimal clinically important difference.

Conclusions

This indicates that our personalized approach is feasible and may be beneficial in improving UE function in individuals with moderate to severe impairments due to stroke.

Trial registration

ClinicalTrials.gov NCT03903770. Registered 4 April 2019. Registered retrospectively.

Introduction

Approximately 80% of individuals with stroke experience hemiparesis of the upper extremity (UE) [1] leading to chronic impairments such as weakness, loss of motor control, edema, pain and spasticity. These have important consequences for quality of life as impairments in hand and arm function limit participation in activities of daily living [2, 3]. Accordingly, recovery of UE function is seen as highly important by individuals with chronic stroke, caregivers and rehabilitation professionals [4].

According to the Canadian Stroke Best Practices [5], UE rehabilitation should involve the affected limb in “training that is meaningful, engaging, repetitive, progressively adapted, task-specific and goal-oriented”. Advances in rehabilitation technology, in particular robotics, virtual reality (VR) and neuromuscular electrical stimulation (NMES), have been shown to be individually effective for improving UE function of individuals with stroke, through the provision of such repetitive and task-oriented training. Robotic devices can be used to assist individuals who are unable to complete arm movements by themselves [6]. Robotic rehabilitation has demonstrated functional gains in individuals with mild and moderate stroke impairments [7,8,9]. Likewise, some of our recent work [10] has shown that individuals with severe, chronic stroke can improve their arm range of motion and clinical scores after ten sessions of robotic therapy. However, it should be noted that functional gains in robotic therapy are not greater than those obtained with similar intensity conventional therapy [8]. While the intensity of practice is a determining factor in stroke recovery, higher improvements might have been achieved by robotic therapy if its focus was not only on shoulder and elbow movements, but also on hand function. This may be possible by integrating robotic therapy in a rehabilitation program that also includes other modalities that better target hand function.

VR activities constitute another approach to UE stroke rehabilitation, where patients typically perform movements without physical assistance. Reviews examining the use of VR for the improvement of UE function show promising results [11, 12]. In our view, VR could consolidate the UE functional gains obtained through robotic rehabilitation. While most VR activities typically focus on shoulder and elbow movements, some recent technical advances now allow the inclusion of hand movements as well. Specifically, the Microsoft Kinect version 2, used to track movements in VR, can detect hand opening and closing in addition to shoulder, elbow and wrist movements. These capabilities have been included in a new rehabilitation application, targeting UE reaching and grasping movements [13], which was part of our rehabilitation approach.

Electromyographically (EMG)-triggered NMES is a muscle stimulation modality that has been used to facilitate motor recovery of the hand after stroke [14]. The individual with stroke needs to activate the muscle(s) volitionally to trigger the NMES [15]. Thus, EMG-triggered NMES provides wrist and/or finger extension time-locked to the cognitive movement intent to actively extend the wrist and open the hand, making the training ecological and functionally relevant. EMG-triggered NMES has been shown to improve voluntary activation of isolated muscles, particularly in task-specific patterns [16].

While advances in robotics, VR and NMES have led to new treatment modalities targeting UE function post-stroke, further progress is needed for these technologies to have a true impact. Despite numerous studies attempting to identify the most effective rehabilitation interventions, post-stroke UE recovery remains disappointing [17] with sensorimotor deficits persisting in a large proportion of stroke survivors for more than 6 months (up to 62% [18]). Improvements in clinical scores have been small and often fail to meet the criteria for minimal clinically important differences (MCID) [19]. While most of the recent clinical trials have failed to demonstrate improvements on UE function that favour new interventions such as robotics or VR, over conventional, dose-matched therapy [20], combination of different modalities may have a greater impact on stroke recovery than each individual modality alone [21]. Thus, there is a need to look beyond the ‘one-size-fits-all’ approach, where a single UE modality is applied to a group of post-stroke individuals. Another possible reason for the relatively small gains in UE function, and in particular the low gains in hand function [17], is that an individual’s potential for recovery is not always considered [20]. In clinical practice, therapists typically prescribe UE exercises to their clients based on initial clinical measures, which turn out to be poor predictors of future UE function [22]. However, assessing the integrity of the affected corticospinal tract (CST), by means of motor evoked potentials (MEPs) elicited by non-invasive transcranial magnetic stimulation (TMS), was found to strongly predict the changes in UE function that could be elicited by rehabilitation [23]. In particular, the work by Milot et al. [24] showed that amongst several brain measures (e.g., magnetic resonance imaging, diffusion tensor imaging), baseline MEP amplitude was the best predictor of the response to robotic training of the affected UE in chronic stroke survivors. The presence of a MEP indicates that the CST, linking the motor areas of the brain to the hand musculature, is at least partially preserved.

Considering that (1) an individualized intervention to post stroke UE rehabilitation is desirable, (2) CST integrity is a strong predictor of hand function recovery, and (3) combination of different modalities may have a greater impact on stroke recovery than each individual modality alone, our proposed approach was to combine multiple modalities in an individualized intervention, tailored to each stroke participant’s functional status and recovery potential. Recovery may be enhanced by first assessing CST integrity in order to determine the potential for recuperating hand function, and then combining multiple purposefully selected combinations of modalities to target motor deficits of each individual. Specifically, our perSonalized UPper Extremity Rehabilitation (SUPER) program included: (1) robotic activities to work on physically assisted UE reaching movements; (2) VR activities to work on unassisted reaching and grasping movements; and (3) NMES to facilitate hand opening and closing movements. The frequency of incorporation of each modality during the intervention was determined according to the individual’s potential for hand recovery. Our objectives were to determine the feasibility and the treatment effect of the SUPER program in individuals with moderate/severe chronic stroke. Our hypotheses were that (1) the SUPER program would be feasible in terms of process, resources, management and safety indicators and (2) stroke participants with a low potential for hand recovery would benefit from a shoulder/elbow-centered intervention, while those with a high potential would benefit from an intervention involving the whole arm.

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