You somehow expect that this complicated intervention will be implemented? Just write up an EXACT PROTOCOL ON ACTION OBSERVATION ALONE!
There's plenty of research on that already which your incompetent doctor has done nothing with! Competence is implementing new research as it comes out. NO EXCUSES!
Effects and mechanisms of synchronous virtual reality action observation and electrical stimulation on upper extremity motor function and activities of daily living in patients with stroke: a protocol for a randomized controlled trial
Yao Cui
Fang Cong1,2*
Ming Zeng
Jun Wang- 1Department of Physical Therapy, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
- 2School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- 3Department of Rehabilitation Medicine, The Second Affiliated Hospital of Jiaxing University, The Second Hospital of Jiaxing City, Jiaxing, Zhejiang, China
- 4Department of Physical Therapy, Hangzhou Geriatric Hospital, Hangzhou, Zhejiang, China
Background: Existing rehabilitation techniques are not satisfactory in improving motor function after stroke, resulting in heavy social burdens. With discovery of mirror neuron system (MNS), action observation (AO) has become a promising strategy to promote motor learning in rehabilitation. Based on MNS theory and virtual reality (VR) technology, we designed an innovative rehabilitative approach: synchronous 360° VR video AO (VRAO) and neuromuscular electrical stimulation (NMES). We hypothesized that VRAO+NMES could enhance MNS activation, thus to improve upper limb motor function and activities of daily living in stroke survivors.
Methods: To explore the efficacy and mechanism of VRAO+NMES, we designed this single center, evaluator blinded, prospective, two arm parallel group randomized controlled trial with 1:1 allocation ratio. The experiment group will receive VRAO+NMES, while the control group will receive VR landscape observation combined with NMES. The Fugl-Meyer Assessment for Upper Extremity is the primary outcome of this study, Brunstrom Recovery Stages for Upper Extremity, Manual Muscle Test, Range of Motion, Modified Barthel Index, and Functional Independence Measure are the secondary outcomes. In addition, functional near-infrared spectroscopy (fNIRS) and surface electromyography (sEMG) will be used to evaluate the activation of MNS brain regions and related muscles, respectively.
Discussion: Applying VR in AO therapy (AOT) has become popular, another study direction to improve AOT is to combine it with peripheral stimulations simultaneously. Due to its full immersive characteristic and multi-sensory input, 360° videos based VRAO+NMES could improve the motivation and engagement level of participants. In addition, fNIRS and sEMG test results may act as good biomarkers to predict rehabilitation outcomes, helping select suitable candidates for this new intervention.
Conclusion: The results of this study will provide evidence for the feasibility and potential clinical efficacy of VRAO+NMES in stroke rehabilitation, thus to promote the clinical applicability and generalize its use in hospital, community, and home rehabilitation settings.
Clinical trial registration: https://www.chictr.org.cn/showproj.html?proj=178276, Identifier [ChiCTR2200063552].
1 Introduction
Stroke is the second-leading cause of mortality and the third-leading cause of disability globally (1). The physical, cognitive, and emotional disorders caused by stroke influence the patients’ life comprehensively and dramatically; approximately half of stroke survivors are chronically disabled and need long-term rehabilitation (2). Promoting changes in brain structural plasticity and functional reorganization are critical to rehabilitation of motor function following stroke (3). In physiotherapy, motor learning and relearning have become important strategies to induce neuroplasticity (4). Recently, the discovery of mirror neuron system (MNS) has further advanced our understandings of the neuroscientific mechanisms underlying motor learning and brain functional reorganization (5). Mirror neurons are a special class of neuron that excites during both observation and execution of actions. It is, therefore, possible to activate the motor system by simply observing actions without actual motor outputs (6).
The motor system has the potential to learn new skills or to recover from injury by observing others’ actions through activation of MNS (7). Meta analysis results have showed that AO therapy (AOT) is helpful to improve stroke patients’ upper extremity and hand functions, walking ability, and activities of daily living (ADLs); it has been accepted as an effective method in neurorehabilitation (8–10).
With technological advances, two important study directions have recently emerged to further promote motor learning effects induced by activation of MNS. The first direction is to change the implementation methods and techniques of AOT to improve participants’ engagement. The second direction is to combine AOT with other rehabilitation techniques, thus to obtain synergistic effects and improve treatment efficacy (11).
In the first research direction, virtual reality (VR) technology has become increasingly important. As a new modality of rehabilitative approach, VR can offer multisensory integration, including visual, tactile, vestibular, proprioceptive, interoceptive, emotional, and somatosensory inputs, creating a favorable rehabilitation environment (12). According to immersion level, VR can be divided into immersive, semi-immersive, and non-immersive VR (13). There are several types of immersive VR, graphical computational three-dimensional (3D) animations VR and 180°/360° videos VR are the most common ones (14). Compared with watching two-dimensional (2D) videos on a computer screen, participants can change their point of view freely to watch the demonstration from different angles wearing a VR headset (15).
With advances in technology, 360° videos based fully immersive VR treatments are becoming more accessible and flexible, playing an important role in enhancing wellbeing (16). The immersive feelings facilitate engagement and motivation of participants; 360° VR videos are good choices to improve immersive feelings (17). With the highest levels of immersion and reality, the novelty of 360° VR videos will make AOT more interesting and motivating. Furthermore, by capturing or displaying a full spherical view, 360° VR provides a more authentic and immersive experience, closely resembling real-life perception (18). As the result, the enhanced immersive feelings will motivate participants to view the videos and try to imitate the actions (19, 20). In addition, the high frame rate (e.g., 100 fps) of the modern 360° camera allows users to capture slow motions of the observed actions, helping to show step-by-step details of daily life actions.
The second research direction involves obtaining synergistic effects through combination of AOT with other rehabilitation techniques. This is mainly based on the theory that central-peripheral synchronous stimulations have the potential to improve brain activity (21). To further evoke plasticity in human motor system, AOT has been reported to be combined with different treatments, including transcranial magnetic stimulation (TMS), electrical stimulation (ES), and rehabilitation robots (11). The most common peripheral stimulation is low-frequency ES, which is a kind of physiotherapy modality used to improve motor and sensory function, including neuromuscular electrical stimulation (NMES), functional electrical stimulation (FES), and peripheral nerve stimulation (PNS) (22). When applying AOT+PNS in healthy individuals, the PNS-generated afferent signals from the periphery induce neural plasticity in primary motor cortex (M1) (23). Seitz et al. (24) studied the immediate effect of concurrent applications of AO, motor imagery (MI), and PNS, showing that AO+MI+PNS can induce plasticity in M1.
Based on the above background, we designed a new kind of rehabilitative technique: concurrent VR-based AO combine with NMES (VRAO+NMES). By playing immersive 360° videos in a VR headset, we present visual information to participants. We have tested the validity of combination of AO and NMES in a previous study, using 2D video clips of hand extension movements as the modality of AOT. We tested brain activation patterns of left MNS during AO, action execution, and imitation combined with NMES in healthy participants, the results proved that MNS-based rehabilitation approaches may enhance cortical activation of MNS (21). In addition, we also confirmed that compared with action execution and 2D video based action imitation, the activation of MNS was enhanced when combing them with NMES (11). Here, we will further test the VRAO+NMES application in stroke rehabilitation.
Due to the effects of action visual stimulation on MNS and ES on motor units (MUs), VRAO+NMES may be helpful to accelerate the process of motor learning. In addition, the enhanced multisensory interactions generated by VRAO+NMES have potential to improve the alteration of body ownership and induce self-body recognition (23). To investigate the potential neuromuscular control mechanism underlying this new intervention, we will use functional near-infrared spectroscopy (fNIRS) and surface electromyography (sEMG) to evaluate the activation of brain regions and muscles, respectively. In addition, MNS network-based neuroplasticity changes have been confirmed recently, we will also explore the brain functional connection changes before and after the interventions (25).
We, therefore, aim to determine whether a concurrent application of VRAO and NMES would result in significant improvements in behavioral assessments and neurophysiological parameters, and to test whether the changes in motor function evaluated by clinical scales are related to the brain functional imaging results measured by fNIRS. We hypothesize that VRAO+NMES is superior in improving upper extremity and hand motor functions, ADLs, and MNS cortical activation levels compared to conventional therapy plus NMES. The underlying mechanism may be that the brain-muscle synchronous intervention enhances activation of the MNS and recruitment of MUs, thereby promoting brain plasticity changes, improving neuromuscular control function, and enhancing therapeutic effects.
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