Alma Merians

Comparing integrated training of the hand and arm with isolated training of the same effectors in persons with stroke using haptically rendered virtual environments, a randomized clinical trial

BackgroundRobotically facilitated therapeutic activities, performed in virtual environments have emerged as one approach to upper extremity rehabilitation after stroke. Body function level improvements have been demonstrated for robotically facilitated training of the arm. A smaller group of studies have demonstrated modest activity level improvements by training the hand or by integrated training of the hand and arm. The purpose of this study was to compare a training program of complex hand and finger tasks without arm movement paired with a separate set of reaching activities performed without hand movement, to training the entire upper extremity simultaneously, utilizing integrated activities.MethodsForty individuals with chronic stroke recruited in the community, participated in a randomized, blinded, controlled trial of two interventions. Subjects were required to have residual hand function for inclusion. The first, hand and arm separate (HAS) training (nu2009=u200921), included activities controlled by finger movement only, and activities controlled by arm movement only, the second, hand and arm together (HAT) training (nu2009=u200920) used simulations controlled by a simultaneous use of arm and fingers.ResultsNo adverse reactions occurred. The entire sample demonstrated mean improvements in Wolf Motor Function Test scores (21%) and Jebsen Test of Hand Function scores (15%), with large effect sizes (partial r2u2009=u2009.81 and r2u2009=u2009.67, respectively). There were no differences in improvement between HAS and HAT training immediately after the study. Subjects in the HAT group retained Wolf Motor Function Test gains better than in the HAS group measured three months after the therapy but the size of this interaction effect was small (partial r2u2009=u2009.17).ConclusionsShort term changes in upper extremity motor function were comparable when training the upper extremity with integrated activities or a balanced program of isolated activities. Further study of the retention period is indicated.Trial registrationNCT01072461.

Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study

Abstract Purpose: The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated. Methods: This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl–Meyer examination scoreu2009=u200925/66, Wrist and Hand itemsu2009=u20092/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation. Results: Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing. Conclusion: This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes. Implications for rehabilitation Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke. Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis. Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning. Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.

Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis

Abstract Objective: To contrast changes in clinical and kinematic measures of upper extremity movement in response to virtually simulated and traditionally presented rehabilitation interventions in persons with upper extremity hemiparesis due to chronic stroke. Design: Non-randomized controlled trial. Setting: Ambulatory research facility. Participants: Subjects were a volunteer sample of twenty one community-dwelling adults (mean age: 51u2009±u200912 years) with residual hemiparesis due to stroke more than 6 months before enrollment (mean: 74u2009±u200948 months), recruited at support groups. Partial range, against gravity shoulder movement and at least 10° of active finger extension were required for inclusion. All subjects completed the study without adverse events. Interventions: A 2 weeks, 24-hour program of robotic/virtually simulated, arm and finger rehabilitation activities was compared to the same dose of traditionally presented arm and finger activities. Results: Subjects in both groups demonstrated statistically significant improvements in the ability to interact with real-world objects as measured by the Wolf Motor Function Test (Pu2009=u20090.01). The robotic/virtually simulated activity (VR) group but not the traditional, repetitive task practice (RTP) group demonstrated significant improvements in peak reaching velocity (Pu2009=u20090.03) and finger extension excursion (Pu2009=u20090.03). Both groups also demonstrated similar improvements in kinematic measures of reaching and grasping performance such as increased shoulder and elbow excursion along with decreased trunk excursion. Conclusions: Kinematic measurements identified differing adaptations to training that clinical measurements did not. These adaptations were targeted in the design of four of the six simulations performed by the simulated activity group. Finer grained measures may be necessary to accurately depict the relative benefits of dose matched motor interventions.

Neural Patterns of Reorganization after Intensive Robot-Assisted Virtual Reality Therapy and Repetitive Task Practice in Patients with Chronic Stroke

Several approaches to rehabilitation of the hand following a stroke have emerged over the last two decades. These treatments, including repetitive task practice (RTP), robotically assisted rehabilitation and virtual rehabilitation activities, produce improvements in hand function but have yet to reinstate function to pre-stroke levels—which likely depends on developing the therapies to impact cortical reorganization in a manner that favors or supports recovery. Understanding cortical reorganization that underlies the above interventions is therefore critical to inform how such therapies can be utilized and improved and is the focus of the current investigation. Specifically, we compare neural reorganization elicited in stroke patients participating in two interventions: a hybrid of robot-assisted virtual reality (RAVR) rehabilitation training and a program of RTP training. Ten chronic stroke subjects participated in eight 3-h sessions of RAVR therapy. Another group of nine stroke subjects participated in eight sessions of matched RTP therapy. Functional magnetic resonance imaging (fMRI) data were acquired during paretic hand movement, before and after training. We compared the difference between groups and sessions (before and after training) in terms of BOLD intensity, laterality index of activation in sensorimotor areas, and the effective connectivity between ipsilesional motor cortex (iMC), contralesional motor cortex, ipsilesional primary somatosensory cortex (iS1), ipsilesional ventral premotor area (iPMv), and ipsilesional supplementary motor area. Last, we analyzed the relationship between changes in fMRI data and functional improvement measured by the Jebsen Taylor Hand Function Test (JTHFT), in an attempt to identify how neurophysiological changes are related to motor improvement. Subjects in both groups demonstrated motor recovery after training, but fMRI data revealed RAVR-specific changes in neural reorganization patterns. First, BOLD signal in multiple regions of interest was reduced and re-lateralized to the ipsilesional side. Second, these changes correlated with improvement in JTHFT scores. Our findings suggest that RAVR training may lead to different neurophysiological changes when compared with traditional therapy. This effect may be attributed to the influence that augmented visual and haptic feedback during RAVR training exerts over higher-order somatosensory and visuomotor areas.

Exploring the impact of visual and movement based priming on a motor intervention in the acute phase post-stroke in persons with severe hemiparesis of the upper extremity

Abstract Purpose: Explore the potential benefits of using priming methods prior to an active hand task in the acute phase post-stroke in persons with severe upper extremity hemiparesis. Methods: Five individuals were trained using priming techniques including virtual reality (VR) based visual mirror feedback and contralaterally controlled passive movement strategies prior to training with an active pinch force modulation task. Clinical, kinetic, and neurophysiological measurements were taken pre and post the training period. Clinical measures were taken at six months post training. Results: The two priming simulations and active training were well tolerated early after stroke. Priming effects were suggested by increased maximal pinch force immediately after visual and movement based priming. Despite having no clinically observable movement distally, the subjects were able to volitionally coordinate isometric force and muscle activity (EMG) in a pinch tracing task. The Root Mean Square Error (RMSE) of force during the pinch trace task gradually decreased over the training period suggesting learning may have occurred. Changes in motor cortical neurophysiology were seen in the unaffected hemisphere using Transcranial Magnetic Stimulation (TMS) mapping. Significant improvements in motor recovery as measured by the Action Research Arm Test (ARAT) and the Upper Extremity Fugl Meyer Assessment (UEFMA) were demonstrated at six months post training by three of the five subjects. Conclusion: This study suggests that an early hand-based intervention using visual and movement based priming activities and a scaled motor task allows participation by persons without the motor control required for traditionally presented rehabilitation and testing. Implications for Rehabilitation Rehabilitation of individuals with severely paretic upper extremities after stroke is challenging due to limited movement capacity and few options for therapeutic training. Long-term functional recovery of the arm after stroke depends on early return of active hand control, establishing a need for acute training methods focused distally. This study demonstrates the feasibility of an early hand-based intervention using virtual reality based priming and scaled motor activities which can allow for participation by persons without the motor control required for traditionally presented rehabilitation and testing.

Rehabilitation Applications Using Virtual Reality for Persons with Residual Impairments Following Stroke

This chapter describes current clinical evidence for the effectiveness of VR applications on upper limb recovery in individuals who have had a stroke. The chapter summarizes outcomes of upper limb rehabilitation studies using the International Classification of Functioning, Disability, and Health model as a framework and describes motor learning approaches that have been used in VR simulations and interventions for upper limb recovery after stroke. The chapter includes a case study that explores how to effectively use VR/robotic technology for an individualized treatment intervention based on motor learning principles.

Clinical and neurophysiologic responses to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: A case study

The need to quickly discharge patients following stroke from acute rehabilitation facilities to the home has resulted in an intense focus on restoring safe and independent, if not normal, motor function. Rehabilitation of hand function in patients with upper limb impairment is often de-prioritized to allow for an emphasis on practicing activities necessary for a safe discharge to the home, such as walking and bed mobility. This case study describes a patient with slow recovering hand motor function (hand sub-section of Fugl-Meyer examination score = 2 on post-stroke day 37) following a stroke. The patient received an intensive eight-session intervention that focused on the recovery of finger extension, finger individuation and pinch-grasp force modulation as well as the recovery of proximal upper extremity movement. Over the eight sessions, the patient demonstrated a dramatic increase in hand function and a corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing. Gains in motor control transferred to clinically meaningful hand function measured at the activity level.

Early versus delayed VR-based hand training in persons with acute stroke

Introduction: Several large trials of task based rehabilitation examining interventions designed to meet the main tenets of experience-dependent neuroplasticity have failed to identify an approach to rehabilitation that produces improvements in hand function that consistently returns persons with stroke to their pre-stroke levels of activity and participation. Several scholars have identified the heightened levels of neuroplasticity occurring immediately after a stroke as an important opportunity to present rehabilitation interventions that will optimize the functional recovery. The study described in this paper begins to examine whether the heightened plasticity occurring early after stroke, when combined with intense technology based upper extremity training, will have a more positive impact than the spontaneous recovery process on its own, or similar interventions presented later, on the long-term recovery of hand and arm function. We hypothesized that early training would allow subjects to integrate their recovering motor abilities into higher levels of activity level performance and that this early integration would result in higher levles of activity level function normalized for impairment level at retention.

Examining VR/Robotic Hand Retraining in an Acute Rehabilitation Unit: A Pilot Study

Current service delivery models limit treatment time and length of hospital stay during the period of post-ischemic heightened neuronal plasticity when intensive training may optimally affect recovery. Prioritization for rehabilitation of independence in transfers and ambulation, negatively impacts the provision of intensive hand and upper extremity therapy. Our pilot data show that we are able to integrate intensive, targeted hand therapy that uses robotics and a library of gaming activities into the routine of an acute rehabilitation setting. Our system has been specifically designed to deliver hand training when motion and strength are limited. The system uses adaptive algorithms to drive individual finger movement, gain adaptation and workspace modification, and haptic and visual feedback from mirrored movements. The data establishes a foundation for a future clinical trial to investigate the potential benefits of robot-assisted gaming during the early phase of recovery.

Virtual reality-augmented rehabilitation in the acute phase post-stroke for individuals with flaccid upper extremities: A feasibility study

Rehabilitation of individuals with flaccid or severely affected upper extremities is challenging due to their limited motor ability and few options for therapeutic training. This initial study tested the feasibility of training individuals with severe hemiparesis using virtual reality (VR) based mirrored feedback and pinch force modulation tasks. The results demonstrated that the simulations were well tolerated early after stroke. Priming effects of the mirror tasks were suggested by increased maximal pinch force immediately after training. Furthermore, despite having no clinically observable movement distally, the subjects were able to consciously activate their muscles as shown by force traces and EMG recorded during the pinch trace task. Motor learning was also suggested by the decrease in Root Mean Square Error (RMSE) during this task. Lastly the benefits of using objective, technology based measurement tools was demonstrated by the ability of the force sensor to detect small changes in force production that could not be measured with a clinical scale of impairment.