Additional, Mechanized Upper Limb Self-Rehabilitation in Patients With Subacute Stroke: The REM-AVC Randomized Trial

 Their conclusion is godawful.

Additional, Mechanized Upper Limb Self-Rehabilitation in Patients With Subacute Stroke: The REM-AVC Randomized Trial

Olivier Rémy-Néris

,

Anaïs Le Jeannic

,

Angelina Dion

,

Béatrice Médée

,

Emmanuel Nowak

,

Élodie Poiroux

,

Isabelle Durand-Zaleski

,

and on behalf of the REM Investigative Team*

Originally published29 Apr 2021https://doi.org/10.1161/STROKEAHA.120.032545Stroke. 2021;52:1938–1947

• This article is commented on by the following:

Abstract

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Background and Purpose:

Additional therapy may improve poststroke outcomes. Self-rehabilitation is a useful means to increase rehabilitation time. Mechanized systems are usual means to extend time for motor training. The primary aim was to compare the effects of self-rehabilitation using a mechanized device with control self-exercises on upper extremity impairment in patients with stroke.

Methods:

Phase III, parallel, concealed allocation, randomized controlled, multicenter trial, with 12-month follow-up. Patients aged 18 to 80 years, 3 weeks to 3 months poststroke with a Fugl-Meyer Assessment score of 10 to 40 points, were randomized to the Exo or control groups. All undertook two 30-minute self-rehabilitation sessions/day, 5 days/wk for 4 weeks in addition to usual rehabilitation. The Exo group performed games-based exercises using a gravity-supported mechanical exoskeleton (Armeo Spring). The control group performed stretching plus basic active exercises. Primary outcome was change in upper extremity Fugl-Meyer Assessment score at 4 weeks.

Results:

Two hundred fifteen participants were randomly allocated to the Exo group (107) or the control group (108). Mean age (SD), 58.3 (13.6) years; mean time poststroke, 54.8 (22.1) days; and mean baseline Fugl-Meyer Assessment score, 26.1 (9.5). There was no between-group difference in mean change in Fugl-Meyer Assessment score following the intervention: 13.3 (9.0) in the Exo group and 11.8 (8.8) in the control group (P=0.22). There were no significant between-group differences in changes for any of the other outcomes at any time point (except for perception of the self-rehabilitation). There was no between-group difference in cost utility at 12 months.

Conclusions:

In patients with moderate-to-severe impairment in the subacute phase of stroke, the purchase and use of complex devices to provide additional upper limb training may not be necessary: simply educating patients to regularly move and stretch their limbs appears sufficient.(Really? Survivors can get to 100% recovery  that way? Your tyranny of low expectations is godawful.)

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01383512.

 

Influence of New Technologies on Post-Stroke Rehabilitation: A Comparison of Armeo Spring to the Kinect System

I see nothing here that would suggest that the comparison was valid.  No matching of objective damage in both groups, so you have no clue if you are comparing minimal damage to maximum damage; pea sized dead area to baseball dead area. Lousy research.  My god, do a lot of mentors and senior researchers need to be fired.

Influence of New Technologies on Post-Stroke Rehabilitation: A Comparison of Armeo Spring  to the Kinect System

Aušra Adomavičienė 1,*, Kristina Daunoravičienė 2, Raimondas Kubilius 3, Lina Varžaitytė 3  and Juozas Raistenskis 1 1 Department of Rehabilitation, Physical and Sports Medicine, Faculty of Medicine, Vilnius University, Santariskiu g.2, LT-08661 Vilnius, Lithuania; ausra.adomaviciene@gmail.com (A.A.); juozas.raistenskis@santa.lt (J.R.) 2 Department of Biomechanical Engineering, Vilnius Gediminas Technical University, J. Basanavičiaus g. 28, 03224 Vilnius, Lithuania; kristina.daunoraviciene@vgtu.lt 3 Rehabilitation Department, Lithuanian University of Health Sciences, Eiveniu g. 2, LT-50161 Kaunas, Lithuania; raimondas.kubilius@kaunoklinikos.lt (R.K.); lina.varzaityte@gmail.com (L.V.) * Correspondence: ausra.adomaviciene@gmail.com; Tel.: +370-65646379 Received: 22 November 2018; Accepted: 3 April 2019; Published: 9 April 2019

Abstract: 

Background: New technologies to improve post-stroke rehabilitation outcomes are of great interest and have a positive impact on functional, motor, and cognitive recovery. Identifying the most effective rehabilitation intervention is a recognized priority for stroke research and provides an opportunity to achieve a more desirable effect.
Objective: The objective is to verify the effect of new technologies on motor outcomes of the upper limbs, functional state, and cognitive functions in post-stroke rehabilitation.
Methods: Forty two post-stroke patients (8.69 ± 4.27 weeks after stroke onset) were involved in the experimental study during inpatient rehabilitation. Patients were randomly divided into two groups: conventional programs were combined with the Armeo Spring robot-assisted trainer (Armeo group; n = 17) and the Kinect-based system (Kinect group; n = 25). The duration of sessions with the new technological devices was 45 min/day (10 sessions in total). Functional recovery was compared among groups using the Functional Independence Measure (FIM), and upper limbs’ motor function recovery was compared using the Fugl–Meyer Assessment Upper Extremity (FMA-UE), Modified Ashworth Scale (MAS), Hand grip strength (dynamometry), Hand Tapping test (HTT), Box and Block Test (BBT), and kinematic measures (active Range Of Motion (ROM)), while cognitive functions were assessed by the MMSE (Mini-Mental State Examination), ACE-R (Addenbrooke’s Cognitive Examination-Revised), and HAD (Hospital Anxiety and Depression Scale) scores.
Results: Functional independence did not show meaningful differences in scores between technologies (p > 0.05), though abilities of self-care were significantly higher after Kinect-based training (p < 0.05). The upper limbs’ kinematics demonstrated higher functional recovery after robot training: decreased muscle tone, improved shoulder and elbow ROMs, hand dexterity, and grip strength (p < 0.05). Besides, virtual reality games involve more arm rotation and performing wider movements. Both new technologies caused an increase in overall global cognitive changes, but visual constructive abilities (attention, memory, visuospatial abilities, and complex commands) were statistically higher after robotic therapy. Furthermore, decreased anxiety level was observed after virtual reality therapy (p < 0.05).
Conclusions: Our study displays that even a short-term, two-week training program with new technologies had a positive effect and significantly recovered post-strokes functional level in self-care, upper limb motor ability (dexterity and movements, grip strength, kinematic data), visual constructive abilities (attention, memory, visuospatial abilities, and complex commands) and decreased anxiety level. (You can't come to any valid conclusions at all.)

Armeo Senso

One of my readers did more research on ArmeoSenso. Thanks Geoff,
 Remember I'm not medically trained to be able to give you advice. Don't do this on your own.
I loved using their Lokomat. The Armeo Boom could probably be simply replaced with simple cane weight bearing exercises.

My original post on it is here:

Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system

Dean: I did a search of “Armeo Senso” and found these related websites:
1. Game demo video by the guy that created the game
https://www.youtube.com/watch?v=ae-Rk58jZ7c
2. Company website (most products by this company are really expensive)
https://www.hocoma.com/world/en/products/armeo/
3. University of Zurich website on their organization (Note Hocoma is listed on the organizational chart)
http://www.neuro-rehab.uzh.ch/en/Organization3.html
4. University of Zurich website on their research on reward systems for stroke patients
http://www.neuro-rehab.uzh.ch/en/Research/Group1.html (
These guys are on the right track. Developing a system with 2-4 sensors (wrist, elbow, torso) that interact with a well-crafted computer game, just cannot be that expensive. Especially, if initial development cost is spread out to the hundreds of thousands (millions?) of people with upper limb hemiplegia from brain injury that could benefit from its use. A fun & even addicting game like this that helps the patients move with intention as many times as possible should be available to all stroke survivors that can move at all. Of course, this is still “experimental” and our providers & insurance companies (and Medicare) do not want to go there without a gazillion dollar double blind study done over several years proving it works.

Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system

What the hell will this take to get it written up as a stroke protocol so survivors can DEMAND they get this from their therapists? Our fucking failures of stroke associations most certainly will not do it. That would require some brains and initiative instead of all the incompetence displayed by our stroke associations.
Full article here if you want to do this on your own since your complete medical staff will do nothing on this: 

Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system

Abstract here:
http://www.ncbi.nlm.nih.gov/pubmed/27515583

Wittmann F¹, Held JP², Lambercy O¹, Starkey ML³, Curt A³, Höver R⁴, Gassert R¹, Luft AR^5,6, Gonzenbach RR⁵.

Author information

Abstract

BACKGROUND:

The effect of rehabilitative training after stroke is dose-dependent. Out-patient rehabilitation training is often limited by transport logistics, financial resources and a lack of motivation/compliance. We studied the feasibility of an unsupervised arm therapy for self-directed rehabilitation therapy in patients' homes.

METHODS:

An open-label, single group study involving eleven patients with hemiparesis due to stroke (27 ± 31.5 months post-stroke) was conducted. The patients trained with an inertial measurement unit (IMU)-based virtual reality system (ArmeoSenso) in their homes for six weeks. The self-selected dose of training with ArmeoSenso was the principal outcome measure whereas the Fugl-Meyer Assessment of the upper extremity (FMA-UE), the Wolf Motor Function Test (WMFT) and IMU-derived kinematic metrics were used to assess arm function, training intensity and trunk movement. Repeated measures one-way ANOVAs were used to assess differences in training duration and clinical scores over time.

RESULTS:

All subjects were able to use the system independently in their homes and no safety issues were reported. Patients trained on 26.5 ± 11.5 days out of 42 days for a duration of 137 ± 120 min per week. The weekly training duration did not change over the course of six weeks (p = 0.146). The arm function of these patients improved significantly by 4.1 points (p = 0.003) in the FMA-UE. Changes in the WMFT were not significant (p = 0.552). ArmeoSenso based metrics showed an improvement in arm function, a high number of reaching movements (387 per session), and minimal compensatory movements of the trunk while training.

CONCLUSIONS:

Self-directed home therapy with an IMU-based home therapy system is safe and can provide a high dose of rehabilitative therapy. The assessments integrated into the system allow daily therapy monitoring, difficulty adaptation and detection of maladaptive motor patterns such as trunk movements during reaching.

TRIAL REGISTRATION:

Unique identifier: NCT02098135 .

KEYWORDS:

Arm; Feasibility; Rehabilitation; Stroke; Video games; Virtual reality therapy

PMID:

27515583

DOI:

10.1186/s12984-016-0182-1

Game doubles as stroke app using iPhone’s Force Touch & robotics to deliver rehab

All these positive statements but yet I never see any publicly published protocols on any of these. Because we have NO stroke leadership or strategy anywhere in stroke. If we had a great stroke association we would have cutting edge interviews asking where are the protocols and when will it be delivered to stroke departments?  This won't occur in your lifetime, your childrens' lifetime or even your grandchildrens' lifetime. We are all fucking screwed basically forever.

I still prefer the cockroach stomping game.

Game doubles as stroke app using iPhone’s Force Touch & robotics to deliver rehab

A team of physicians, developers, artists, and programmers are developing and testing a gaming app, Bandit’s Shark Showdown, to both improve recovery in stroke patients and maybe even make it fun.
There are a lot of stroke apps out there, from aids to help patients recognizing potential stroke signs to decision support tools for diagnosis. Featured in a recent profile in The New Yorker, neurologist Dr. John Krakauer expressed his frustration with the limitations of traditional post-stroke rehabilitation and hopes to unlock the potential of robotic therapy combined with cutting-edge interactive entertainment. He has helped found the “Brain, Learning, Animation, Movement lab”(BLAM), a “Pixar-grade” team of engineers, designers, artists and programmers that work with clinicians to use the best of art and science further research on the brain.

One of their studies involves investigating motor recovery as part of stroke rehabilitation. This is done through utilizing a combination of the game, Bandit’s Shark Showdown, with a robotic arm, the Hocoma ArmeoPower, to encourage intensive game-based therapy. Instead of traditional rehabilitation where the focus is often task-based, the focus here is simply on movement in a virtual environment, directing a dolphin through various challenges like battling dangerous sharks and other enemies.
Three members of BLAM, who also own an indie gaming company called Max and Haley, designed Bandit’s Shark Showdown. In fact, it wasn’t really designed as a medical app. Rather, they had already been in the business of designing apps based on animal movements and were working with the National Aquarium in Baltimore to design a game based on dolphin movements.
They’re also testing the use of Force Touch in the game according to an interview in the Verge. Players (patients recovering from strokes) have to apply varying levels of pressure to control their dolphin as it goes after sharks. They hope that this can help users work on balancing force and dexterity, offering yet another tool for recovery.
After a cerebral vascular accident, several mechanisms have been traditionally postulated to allow to motor recovery. These include neural plasticity with periinfact reorganization (undamaged regions of the brain taking over for damaged regions), diaschisis (regions remote from infarcted location are initially deactivated but later recover), and ipsilateral/contralateral hemisphere activity (inhibition and excitability) ¹. The majority of motor recovery after a stroke is thought to occur within the first 3 months. This is an ideal time for Acute Rehabilitation, where a team consisting of a rehabilitation physician, therapists (physical, occupational, and speech), neuropsychologist, nursing, social workers and more attempt to maximize functional outcomes for post-stroke survivors.
Current approaches to therapy during this time include increasing attention to the affected paretic region, while in the past having focused on compensatory strategies. Techniques such as Constraint-induced movement therapy (CIMT) have been utilized, supported by recently published clinical trials.
However, as noted by Dr. Krakauer, the ability to provide enough high-intensity and frequency of such therapy may be limited in some post-stroke care environments. Apps offer an opportunity here and while there are many available, the quality of these stroke apps has been found to be lacking. Robotics offer an intriguing avenue to increase the frequency of such therapy and combining this with an immersive game, such as Bandit’s Shark Showdown, may offer even more benefits. The upcoming clinical trial of this technology through BLAM, with stroke patients at Columbia University and a clinic in Zurich, is certainly exciting and is one to follow for all interested in neuro-rehabilitation.
Check out Bandit’s Shark Showdown on iTunes

Using a brain-machine interface to control a hybrid upper limb exoskeleton during rehabilitation of patients with neurological conditions

Maybe your grandchildren will be able to use this. With NO stroke strategy or stroke leadership this will take at least 50 years to get to clinical use. Unless you are rich and can pay for your own research.
http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-015-0082-9

• Enrique Hortal†Email author,
• Daniel Planelles†,
• Francisco Resquin,
• José M. Climent,
• José M. Azorín and
• José L. Pons

†Contributed equally

Journal of NeuroEngineering and Rehabilitation201512:92

DOI: 10.1186/s12984-015-0082-9

©  Hortal et al. 2015

Received: 31 March 2015

Accepted: 8 October 2015

Published: 17 October 2015

Abstract

Background

As a consequence of the increase of cerebro-vascular accidents, the number of people suffering from motor disabilities is raising. Exoskeletons, Functional Electrical Stimulation (FES) devices and Brain-Machine Interfaces (BMIs) could be combined for rehabilitation purposes in order to improve therapy outcomes.

Methods

In this work, a system based on a hybrid upper limb exoskeleton is used for neurological rehabilitation. Reaching movements are supported by the passive exoskeleton ArmeoSpring and FES. The movement execution is triggered by an EEG-based BMI. The BMI uses two different methods to interact with the exoskeleton from the user’s brain activity. The first method relies on motor imagery tasks classification, whilst the second one is based on movement intention detection.

Results

Three healthy users and five patients with neurological conditions participated in the experiments to verify the usability of the system. Using the BMI based on motor imagery, healthy volunteers obtained an average accuracy of 82.9 ± 14.5 %, and patients obtained an accuracy of 65.3 ± 9.0 %, with a low False Positives rate (FP) (19.2 ± 10.4 % and 15.0 ± 8.4 %, respectively). On the other hand, by using the BMI based on detecting the arm movement intention, the average accuracy was 76.7 ± 13.2 % for healthy users and 71.6 ± 15.8 % for patients, with 28.7 ± 19.9 % and 21.2 ± 13.3 % of FP rate (healthy users and patients, respectively).

Conclusions

The accuracy of the results shows that the combined use of a hybrid upper limb exoskeleton and a BMI could be used for rehabilitation therapies. The advantage of this system is that the user is an active part of the rehabilitation procedure. The next step will be to verify what are the clinical benefits for the patients using this new rehabilitation procedure.

Keywords

BMI EEG Rehabilitation Neurological condition Exoskeleton Functional electrical stimulation Motor imagery Arm movement intention detection

Background

Currently, the number of people suffering from motor disabilities or reduced mobility is increasing. Cerebro-Vascular Accidents (CVAs), i.e. strokes, are ones of the main causes of these problems. The number of people with probability of suffering a CVA is growing worldwide mainly due to the aging population [1]. This value is expected to reach in 2030 an increase of 24.9 % compared to 2010 levels [2]. According to the Spanish Society of Neurology, the number of stroke patients at Spanish hospitals has increased by 40 % over the last 15 years [3]. As reported by the World Health Organization (WHO), 15 million people suffer stroke worldwide each year, and around 5 million of them are permanently disabled [4]. All these facts evidence the necessity of improving not only prevention mechanisms but also rehabilitation procedures for people with these conditions.

Due to certain shortcomings of conventional therapy, rehabilitation systems applied after a CVA have experimented an important improvement in recent years. After conventional therapies, motor impairments as paralysis persist in a large percentage of stroke population. Recovery of motor skills is commonly very low after stroke [5] and, compared to lower limb, improvements of upper limb motor function are even lower [6]. By these facts, novel rehabilitation approach, as robot-aided rehabilitation and functional electrical stimulation (FES) were introduced, with the aim to improve effectiveness of therapy.

Several publications have showed improvements in upper limb motor function after rehabilitation therapies based on robotic devices [7, 8] and FES [9, 10]. Furthermore, the combined use of both technologies has shown promising results in terms of motor recovery after stroke [11, 12]. The main advantage of using the hybrid approach is that, individual limitations are overcome, generating in this way a more robust concept [13]. Robotic devices generally apply external mechanical forces to drive joint movements, while FES-based therapy facilitates exercise execution leaded by the participant’s own muscles. This last approach yields several benefits considering motor recovery, such as muscle strength [14] and cortical excitability [15]. Further, even when stroke participant does not contribute to voluntary movement these advantages are still present. However, the use of FES elicits the fast occurrence of muscle fatigue due to non-physiological recruitment (unnatural) of the motor units. Muscle fatigue decreases the efficacy of therapy and also entails other drawbacks, that is why, effort are always targeted to prolong the appearance of its effects. Moreover, the nonlinear and time variant behavior of the muscles during FES generate a less accurate motor control response. This problem can be addressed by using an exoskeleton, in order to cooperatively aid the movements. The inclusion of robotic device avoids stimulate arm’s muscles to overcome gravity effects, and hence, release the system from patients discomfort generated when arm muscles are constantly stimulated for this purpose. So, the main idea begins the hybrid approach based on reaching movement rehabilitation is that the exoskeleton compensate again gravity and FES assists the patient for movements execution.

Besides physical rehabilitation [16], an important question arises from the neurological level due to the neuroplasticity [17]. In this regard, multiple works focused on this kind of rehabilitation are being developed [18–20]. Brain-Machine Interfaces (BMIs) are conceived as a powerful tool for rehabilitation of CVA patients. By using these interfaces, patients are an active part of the process because the control commands are generated directly from their brain activity. Thus, not only would the rehabilitation improve from the physical point of view, but also from the neurological perspective [21]. With this system, patients are actively involved in their rehabilitation process.

To achieve a greater involvement of the patients, the use of a BMI can represent an important improvement. Several studies based on BMIs have demonstrated that people with disabilities are able to control properly systems such as a wheelchair [22], robots [23] or other devices such as a PC mouse [24] or a web browser [25]. The main objective in these works was to provide a new way to interact with the environment and facilitate daily life activities. However, these systems were not designed to restore the affected capacities of the users. Other works used brain signals to command systems that provide aid in physical and neurological rehabilitation as in [26].

Thanks to neuroscience, it is well known that many brain cognitive processes are located around the cortex. When BMIs are used in motor rehabilitation, parietal and frontal lobes are more interesting than others because they take part in intention, planning and decision of making a movement [27]. Therefore, signals acquired from these lobes can provide more information about the will to imagine or perform a movement. By using their brain signals, patients in rehabilitation could command a device to provide them some voluntary mobility. It is demonstrated that a FES therapy triggered by Electromyography (EMG) has advantages as it integrates the concept of sensorimotor feedback [9]. Using electroencephalography (EEG), follows the same approach, FES simulates normal operation of neural connections, taking the cortical level signals instead of peripheral signals (EMG) to trigger the execution of the task.

In this paper, a BMI allows, through two different methods, the control of a hybrid upper limb exoskeleton. Both methods are based in the analysis of EEG signals. EEG techniques are a non-invasive method which provides a higher patient acceptance, eliminates the health risks of operations and reduces impediments related to ethical issues. The exoskeleton is used to assist the upper limb rehabilitation process by performing extension and flexion elbow movements of the arm applying FES. The methods used in the BMI are based on motor imagery and movement intention detection through the Event-Related Desynchronization (ERD) and Event-Related Synchronization (ERS) detection. The accuracy of both methods are analyzed to demonstrate their usability and to determine which of them is better to be used in the rehabilitation therapy.

More at link

ReoGo by Motorika - Robotic Rehabilitation- Treatment for Stroke

I know this is a commercial site but this is so easy to duplicate at home except for the video part. Its simple because this unweights the arm. My way of doing this was suggested by my OT with my cane. My example here, the last large paragraph:
http://oc1dean.blogspot.com/2010/10/cane-exercise-for-stroke-rehab.html
Or another commercial product here:

Armeo(®)Spring

The new one here:
 http://www.youtube.com/user/MotorikaMedical

Efficacy of Armeo(®)Spring during the chronic phase of stroke. Study in mild to moderate hemiparesis cases

I suggest that the gravity reduction is the main reason for the benefit and you can do the same thing with my cane exercises. But don't listen to me, I'm not medically trained and those exercises are obviously too dangerous to be used without your doctors ok. Good luck on getting that approval.
http://www.ncbi.nlm.nih.gov/pubmed/22727271

Abstract

OBJECTIVE:

To evaluate the efficacy of a gravity-supported, computer-enhanced device (Armeo(®)Spring) for upper limb rehabilitation in chronic stroke patients.

MATERIAL AND METHODS:

We included 23 chronic hemiparetic patients (chronicity: 328 ± 90.8 days; distribution: 17 men and 6 women) aged 54.6 ± 9.5 years, who had sustained ischaemic (n=12) or haemorrhagic (n=11) stroke. All patients completed 36 one-hour sessions using the Armeo(®)Spring system. Arm movement was assessed at the beginning and end of the treatment programme, and once more 4 months later. Main outcome measurements covered structure, activity, and function, as per the International Classification of Functioning, Disability and Health: Modified Ashworth Scale, Motricity Index (MI), Fugl-Meyer Assessment Scale (FM), Motor Assessment Scale (MAS), Manual Function Test (MFT), and Wolf Motor Function Test (WMFT).

RESULTS:

Repeated measures ANOVA showed significant improvement (time effect) for all function scales (P<.01 for FM and MI) and activity scales (P<.01 for MAS, MFT and WMFT-ability, and P<.05 WMFT-time) without significant changes in muscle tone. The post-hoc analysis (Bonferroni) showed different evolutionary patterns for function and activity measurements, and clear benefits related to Armeo(®)Spring training, especially on activity scales.

CONCLUSIONS:

Armeo(®)Spring is an effective tool for rehabilitating the affected arm in patients with hemiparesis secondary to ictus, even in the chronic stage.