Nika Goljar

Telerehabilitation using virtual reality task can improve balance in patients with stroke

Purpose: The objective of the telerehabilitation is a continuation of the rehabilitation process on patients’ home. The study also compares the balance training in clinical environment with the telerehabilitation approach when the physiotherapists and physicians can follow the progress remotely. Method: In this paper, the preliminary study of the pilot project with virtual reality (VR)-based tasks for dynamic standing frame supported balance training is presented. Six patients with stroke participated in the study. The patients performed the balance training 3 weeks, 2 weeks in the clinical settings and 1 week in the home environment, five times a week, and each time for up to 20 minutes. Objective effectiveness was demonstrated by parameters as track time, number of collisions and the clinical instruments Berg Balance Scale (BBS), Timed Up & Go (TUG), 10-m walk test and standing on the unaffected and affected extremity. The outcomes were compared to the balance training group without VR and telerehabilitation support. A 2-way ANOVA was used to explore the differences between the both stroke groups. Results: In patients who were subject to VR supported balance training, the BBS demonstrated improvement for 15%, the TUG for 29%, the 10-m walk for 26%, stance time on the affected and unaffected extremity for 200 and 67%, respectively. The follow-up demonstrated that the patients preserved the gained functional improvement. The VR task performance time and number of collisions decreased to 45 and 68%, respectively. Besides, no statistical differences were found between the telerehabilitation approach with VR supported balance training and conventional balance training in clinical settings either regarding the overall mean level or regarding the mean improvement. Conclusions: The telerehabilitation approach in VR supported balance training improved balance in stroke patients and had similar effect on patients’ postural functional improvement as conventional balance training in clinical settings. However, when balance training is continued on patient’s home instead of the hospital, it would eventually decrease the number of outpatients’ visits, reduce related costs and enable treatment of larger number of patients. Implications for Rehabilitation People suffering from stroke have severe problems with posture and balance. This study demonstrates that using target based tasks in a virtual environment can improve balance in stroke population. Telerehabilitation offers continuation of balance training in the remote centres or at home. The longer rehabilitation period improves functionality and therefore the quality of life.

Variable structure pantograph mechanism with spring suspension system for comprehensive upper-limb haptic movement training.

Numerous haptic devices have been developed for upper-limb neurorehabilitation, but their widespread use has been largely impeded because of complexity and cost. Here, we describe a variable structure pantograph mechanism combined with a spring suspension system that produces a versatile rehabilitation robot, called Universal Haptic Pantograph, for movement training of the shoulder, elbow, and wrist. The variable structure is a 5-degree-of-freedom (DOF) mechanism composed of 7 joints, 11 joint axes, and 3 configurable joint locks that reduce the number of system DOFs to between 0 and 3. The resulting device has eight operational modes: Arm, Wrist, ISO (isometric) 1, ISO 2, Reach, Lift 1, Lift 2, and Steer. The combination of available work spaces (reachable areas) shows a high suitability for movement training of most upper-limb activities of daily living. The mechanism, driven by series elastic actuators, performs similarly in all operational modes, with a single control scheme and set of gains. Thus, a single device with minimal setup changes can be used to treat a variety of upper-limb impairments that commonly afflict veterans with stroke, traumatic brain injury, or other direct trauma to the arm. With appropriately selected design parameters, the developed multimode haptic device significantly reduces the costs of robotic hardware for full-arm rehabilitation while performing similarly to that of single-mode haptic devices. We conducted case studies with three patients with stroke who underwent clinical training using the developed mechanism in Arm, Wrist, and/or Reach operational modes. We assessed outcomes using Fugl-Meyer Motor Assessment and Wolf Motor Function Test scores showing that upper-limb ability improved significantly following training sessions.

Virtual reality task for telerehabilitation dynamic balance training in stroke subjects

The paper presents a virtual reality based dynamic balance training. The telerehabilitation balance training in stroke subject took place in smarthome, simulating a home environment. Virtual environment was designed as a game in web-explorer enabling the medical professionals to remotely supervise and control the balance training. In preliminary testing a right-side hemiparetic subject participated and demonstrated high motivation, high level of learning and accomplished the therapy with promising clinical outcomes. The subject performed the therapy five times a week, each time for 17 to 20 minutes for four weeks. The results were evaluated by objective game parameter as track time, number of hits and clinical instruments Berg Balance Scale, Timed Up&Go and 10m Walk tests. The outcomes indicate similar progress to those obtained in the clinical environment.

Design and Test of a Novel Closed-Loop System That Exploits the Nociceptive Withdrawal Reflex for Swing-Phase Support of the Hemiparetic Gait

A novel closed-loop system for improving gait in hemiparetic patients by supporting the production of the swing phase using electrical stimulations evoking the nociceptive withdrawal reflex was designed. The system exploits the modular organization of the nociceptive withdrawal reflex and its stimulation site- and gait-phase modulation in order to evoke movements of the hip, knee, and ankle joints during the swing phase. A modified model reference adaptive controller (MRAC) was designed to select the best stimulation parameters from a set of 12 combinations of four electrode locations on the sole of the foot and three different stimulation onset times between heel-off and toe-off. It was hypothesized that the MRAC system would result in a better walking pattern compared with an open-loop preprogrammed fixed pattern of stimulation (FPS) controller. Thirteen chronic or subacute hemiparetic subjects participated in a study to compare the performance of the two control schemes. Both control schemes resulted in a more functional gait compared to no stimulation (P <; 0.05) with a weighted joint angle peak change of 4.0 ± 1.6 (mean ± Standard deviation) degrees and 3.1 ± 1.4 degrees for the MRAC and FPS schemes, respectively. This indicates that the MRAC scheme performed better than the FPS scheme (P <; 0.001) in terms of reaching the control target.

Dynamic balance training with sensory electrical stimulation in chronic stroke patients

A case study investigating the impact of sensory electrical stimulation during perturbed stance in one chronic stroke patient is presented. A special apparatus called the BalanceTrainer was used. It allows the application of perturbations to neurologically impaired people during standing, while protecting the subject from falling. The subject underwent two different periods of perturbation training, each lasting ten days. During the first period the subject was perturbed in eight different directions. During the second period the subject was also perturbed, but was assisted by sensory electrical stimulation of the soleus, tibialis anterior, tensor fascia latae, and vastus muscles in the impaired leg. After each period of training an assessment was carried out to measure the forces the subject applied on the ground via two force plates. The subject improved his ability to balance throughout the training, with the largest improvements during the final period when electrical stimulation was used

Psychophysiological responses to robot training in different recovery phases after stroke

Psychophysiological responses have become a valuable tool in human-robot interaction since they provide an objective estimate of the users psychological state. Unfortunately, their usefulness in rehabilitation robotics is uncertain since they are influenced by both physical activity and pathological conditions such as stroke. We performed psychophysiological measurements in subacute and chronic stroke patients as well as healthy controls during a reaching and grasping exercise task performed in a multimodal virtual environment. Furthermore, we evaluated the differences in kinematic and static parameters between the three groups of subjects. The results of the observed kinematic and static evaluation parameters showed significant differences when different assistive modes enabled the subject to focus on a particular function of the exercise, like reaching or grasping, or coordinated actions that combine reaching and grasping, reflecting the motor abilities of the individual. The analysis of psychophysiological responses suggests that both chronic and subacute stroke subjects have weaker psychophysiological responses than healthy subjects, though the responses of chronic patients have recovered somewhat. This certainly indicates that further studies are needed before psychophysiological responses can be used in clinical practice.

Continuation of balance training for stroke subjects in home environment using virtual reality

Abstract The objective of telerehabilitation is a continuation of the rehabilitation process in the subjects’ home whilst allowing the therapists and physicians the possibility to follow the progress remotely. In this article a pilot project with virtual reality based tasks for dynamic standing, frame supported, balance training is presented. Six stroke subjects participated in the preliminary study. The subjects performed the therapy five times a week, each time for up to 20 min, over a period of 3 weeks. The results were evaluated by objective game parameters as track time, number of collisions and clinical instruments Berg Balance Scale, Timed Up & Go and a 10 m walk test. The outcomes demonstrated a significant improvement of all parameters. However, the follow-up after 2 weeks demonstrated that functional improvement could be possible on a longer term if the subjects continue with targeted tasks for an extended period of time. Additionally, the balance training could be continued at the subject’s home instead of the hospital, which would decrease the number of outpatient visits and reduce related costs.

A multisession evaluation of an adaptive competitive arm rehabilitation game

BackgroundPeople with neurological injuries such as stroke should exercise frequently and intensely to regain their motor abilities, but are generally hindered by lack of motivation. One way to increase motivation in rehabilitation is through competitive exercises, but such exercises have only been tested in single brief sessions and usually did not adapt difficulty to the patient’s abilities.MethodsWe designed a competitive arm rehabilitation game for two players that dynamically adapts its difficulty to both players’ abilities. This game was evaluated by two participant groups: 15 participants with chronic arm impairment who exercised at home with an unimpaired friend or relative, and 20 participants in the acute or subacute phase of stroke who exercised in pairs (10 pairs) at a rehabilitation clinic. All participants first played the game against their human opponent for 3 sessions, then played alone (against a computer opponent) in the final, fourth session. In all sessions, participants’ subjective experiences were assessed with the Intrinsic Motivation Inventory questionnaire while exercise intensity was measured using inertial sensors built into the rehabilitation device. After the fourth session, a final brief questionnaire was used to compare competition and exercising alone.ResultsParticipants who played against an unimpaired friend or relative at home tended to prefer competition (only 1 preferred exercising alone), and exhibited higher enjoyment and exercise intensity when competing (first three sessions) than when exercising alone (last session).Participants who played against each other in the clinic, however, did not exhibit significant differences between competition and exercising alone. For both groups, there was no difference in enjoyment or exercise intensity between the first three sessions, indicating no negative effects of habituation or novelty.ConclusionsCompetitive exercises have high potential for unsupervised home rehabilitation, as they improve enjoyment and exercise intensity compared to exercising alone. Such exercises could thus improve rehabilitation outcome, but this needs to be tested in long-term clinical trials. It is not clear why participants who competed against each other at the clinic did not exhibit any advantages of competition, and further studies are needed to determine how different factors (environment, nature of opponent etc.) influence patients’ experiences with competitive exercises.Trial registrationThe study is not a clinical trial. While human subjects are involved, they do not participate in a full rehabilitation intervention, and no health outcomes are examined.

Overground gait training using a motorized assistive device in patients with severe disabilities after stroke.

Regaining of the patient’s ability to walk after stroke is an important goal of rehabilitation programmes. The ultimate goal of gait rehabilitation is to empower patients for overground walking. We have previously developed a prototype of a therapist-controlled mobile platform with compliant pelvis support mechanism that enables balance training during overground walking (device E-go). The aim of this pilot randomized controlled study was to explore the usefulness of the E-go in reducing the number of therapists needed during walking training, and to explore the effectiveness of the E-go on walking abilities in severely affected stroke patients. The study included 19 subacute poststroke patients divided into two groups. The experimental group (nine patients) trained to walk with the E-go and the control group trained within conventional physiotherapy programs for 3 weeks. Outcome measures were walking distance and speed, Fugl–Meyer Assessment, Berg Balance Scale, Functional Ambulation Category and the number of therapists needed during training. At the end of the training both groups significantly improved in walking speed, walking distance, Berg Balance Scale and Fugl–Meyer Assessment (P⩽0.001), but there were no between-group differences. The experimental group on average needed a lower number of therapists (P=0.040). These findings highlight the potential of the E-go for overground walking training in severely disabled subacute stroke patients.

Effectiveness of a fall-risk reduction programme for inpatient rehabilitation after stroke

Abstract Purpose: To evaluate effectiveness of fall-risk-assessment-based fall prevention for stroke rehabilitation inpatients. Method: A consecutive series of 232 patients admitted for the first time to a subacute stroke-rehabilitation ward during 2010–2011 was studied in detail. The Assessment Sheet for Fall Prediction in Stroke Inpatients (ASFPSI by Nakagawa et al.) was used to assess fall-risk upon admission. Association of ASFPSI score and patient characteristics with actual falls was statistically tested. Yearly incidence of falls per 1000 hospital days (HD) was retrospectively audited for the 2006–2014 period to evaluate effectiveness of fall-risk reduction measures. Results: The observed incidence of falls over the detailed-study-period was 3.0/1000 HD; 39% of the fallers fell during the first week after admission. ASFPSI score was not significantly associated with falls. Longer hospital stay, left body-side affected and non-extreme FIM score (55–101) were associated with higher odds of fall. Introduction of fall-risk reduction measures followed by compulsory fall-risk assessment lead to incidence of falls dropping from 7.1/1000 HD in 2006 to 2.8/1000 HD in 2011 and remaining at that level until 2014. Conclusions: The fall-risk-assessment-based measures appear to have led to decreasing falls risk among post-stroke rehabilitation inpatients classified as being at high risk of falls. The fall prevention programme as a whole was successful. Patients with non-extreme level of functional independence should receive enhanced fall prevention. Implications for Rehabilitation Recognising the fall risk upon the patients admission is essential for preventing falls in rehabilitation wards. Assessing the fall risk is a team tasks and combines information from various sources. Assessing fall risk in stroke patients using the assessment sheet by Nakagawa et al. immediately upon admission systematically draws attention to the risk of falls in each individual patient.