Rehabilitation robotics for the upper extremity: review with new directions for orthopaedic disorders

The focus of research using technological innovations such as robotic devices has been on interventions to improve upper extremity function in neurologic populations, particularly patients with stroke. There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders. The most promising approaches are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity. Based on this evidence, we describe application and feasibility of virtual reality-enhanced robotics integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with upper extremity disorders, specifically emphasizing the wrist and hand. The purpose of this paper is to describe virtual reality-enhanced rehabilitation robotic devices, review evidence of application in patients with upper extremity deficits related to neurologic disorders, and suggest how this technology and task-oriented rehabilitation approach can also benefit patients with orthopaedic disorders of the wrist and hand. We will also discuss areas for further research and development using a task-oriented approach and a commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

• Implications for Rehabilitation

• There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders.

• The most promising approaches using rehabilitation robotics are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity.

• Based on the evidence in neurologic populations, virtual reality-enhanced robotics may be integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with UE disorders, specifically emphasizing the wrist and hand.

• Clinical application of a task-oriented approach may be accomplished using commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

     

Improving manual skills in persons with disabilities (PWD) through a multimodal assistance system

Abstract

In this research work, we present a Multimodal Guidance System (MGS) whose aim is to provide dynamic assistance to persons with disabilities (PWD) while performing manual activities such as drawing, coloring in and foam-cutting tasks. The MGS provides robotic assistance in the execution of 2D tasks through haptic and sound interactions. Haptic technology provides the virtual path of 2D shapes through the point-based approach, while sound technology provides audio feedback inputs related to the hand’s velocity while sketching and filling or cutting operations. By combining this Multimodal System with the haptic assistance, we have created a new approach with possible applications to such diverse fields as physical rehabilitation, scientific investigation of sensorimotor learning and assessment of hand movements in PWD. The MGS has been tested by people with specific disorders affecting coordination, such as Down syndrome and developmental disabilities, under the supervision of their teachers and care assistants inside their learning environment. A Graphic User Interface has been designed for teachers and care assistants in order to provide training during the test sessions. Our results provide conclusive evidence that the effect of using the MGS increases the accuracy in the tasks operations.

• Implications for Rehabilitation

• The Multimodal Guidance System (MGS) is an interface that offers haptic and sound feedback while performing manual tasks.

• Several studies demonstrated that the haptic guidance systems can help people in recovering cognitive function at different levels of complexity and impairment.

• The applications supported by our device could also have an important role in supporting physical therapist and cognitive psychologist in helping patients to recover motor and visuo-spatial abilities.

     

Explicit motor sequence learning with the paretic arm after stroke

Purpose: Motor sequence learning is important for stroke recovery, but experimental tasks require dexterous movements, which are impossible for people with upper limb impairment. This makes it difficult to draw conclusions about the impact of stroke on learning motor sequences. We aimed to test a paradigm requiring gross arm movements to determine whether stroke survivors with upper limb impairment were capable of learning a movement sequence as effectively as age-matched controls.

Materials and methods: In this case-control study, 12 stroke survivors (10–138 months post-stroke, mean age 64 years) attempted the task once using their affected arm. Ten healthy controls (mean 66 years) used their non-dominant arm. A sequence of 10 movements was repeated 25 times. The variables were: time from target illumination until the cursor left the central square (onset time; OT), accuracy (path length), and movement speed.

Results: OT reduced with training (p?p?>?0.1). We quantified learning as the OT difference between the end of training and a random sequence; this was smaller for stroke survivors than controls (p?=?0.015).

Conclusions: Stroke survivors can learn a movement sequence with their paretic arm, but demonstrate impairments in sequence specific learning.

• Implications for Rehabilitation

• Motor sequence learning is important for recovery of movement after stroke.

• Stroke survivors were found to be capable of learning a movement sequence with their paretic arm, supporting the concept of repetitive task training for recovery of movement.

• Stroke survivors showed impaired sequence specific learning in comparison with age-matched controls, indicating that they may need more repetitions of a sequence in order to re-learn movements.

• Further research is required into the effect of lesion location, time since stroke, hand dominance and gender on learning of motor sequences after stroke.

     

Effects of electromyography-driven robot-aided hand training with neuromuscular electrical stimulation on hand control performance after chronic stroke

Purpose: An electromyography-driven robot system integrated with neuromuscular electrical stimulation (NMES) was developed to investigate its effectiveness on post-stroke rehabilitation. Methods: The performance of this system in assisting finger flexion/extension with different assistance combinations was evaluated in five stroke subjects. Then, a pilot study with 20-sessions training was conducted to evaluate the training’s effectiveness. Results: The results showed that combined assistance from the NMES–robot could improve finger movement accuracy, encourage muscle activation of the finger muscles and suppress excessive muscular activities in the elbow joint. When assistances from both NMES and the robot were 50% of their maximum assistances, finger-tracking performance had the best results, with the lowest root mean square error, greater range of motion, higher voluntary muscle activations of the finger joints and lower muscle co-contraction in the finger and elbow joints. Upper limb function improved after the 20-session training, indicated by the increased clinical scores of Fugl-Meyer Assessment, Action Research Arm Test and Wolf Motor Function Test. Muscle co-contraction was reduced in the finger and elbow joints reflected by the Modified Ashworth Scale. Conclusions: The findings demonstrated that an electromyography-driven NMES–robot used for chronic stroke improved hand function and tracking performance. Further research is warranted to validate the method on a larger scale.

• Implications for Rehabilitation

• The hand robotics and neuromuscular electrical stimulation (NMES) techniques are still separate systems in current post-stroke hand rehabilitation. This is the first study to investigate the combined effects of the NMES and robot on hand rehabilitation.

• The finger tracking performance was improved with the combined assistance from the EMG-driven NMES–robot hand system. The assistance from the robot could improve the finger movement accuracy and the assistance from the NMES could reduce the muscle co-contraction on finger and elbow joints.

• The upper limb functions were improved on chronic stroke patients after the pilot study of 20-session hand training with the combined assistance from the EMG-driven NMES–robot. The muscle spasticity on finger and elbow joints was reduced after the training.

     

Understanding nursing practice in stroke units: a Q-methodological study

Abstract

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.

• Implications for Rehabilitation

• Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.

• Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.

• Nurses can routinely incorporate rehabilitation principles in their care.

• Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

     

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

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.

     

Developing a personalised self-management system for post stroke rehabilitation; utilising a user-centred design methodology

Abstract

Purpose: To develop and evaluate an information and communication technology (ICT) solution for a post-stroke Personalised Self-Managed Rehabilitation System (PSMrS). The PSMrS translates current models of stroke rehabilitation and theories underpinning self-management and self-efficacy into an ICT-based system for home-based post-stroke rehabilitation. Methods: The interdisciplinary research team applied a hybrid of health and social sciences research methods and user-centred design methods. This included a series of home visits, focus groups, in-depth interviews, cultural probes and technology biographies. Results: The iterative development of both the content of the PSMrS and the interactive interfaces between the system and the user incorporates current models of post-stroke rehabilitation and addresses the factors that promote self-managed behaviour and self-efficacy such as mastery, verbal persuasion and physiological feedback. Conclusion: The methodological approach has ensured that the interactive technology has been driven by the needs of the stroke survivors and their carers in the context of their journey to both recovery and adaptation. Underpinned by theories of motor relearning, neuroplasticity, self-management and behaviour change, the PSMrS developed in this study has resulted in a personalised system for self-managed rehabilitation, which has the potential to change motor behaviour and promote the achievement of life goals for stroke survivors.

• Implications for Rehabilitation

• Radical innovation and the adoption of a self-management paradigm need to be considered as a way of delivering home-based post-stroke rehabilitation.

• A hybrid of health and social sciences research and user-centred design methods are required to ensure that technology for post-stroke rehabilitation has been driven by the needs of the stroke survivors and their carers.

• Personalised technology systems for self-managed post-stroke rehabilitation have the potential to change motor behaviour and promote the achievement of life goals for stroke survivors.

     

A review of technological and clinical aspects of robot-aided rehabilitation of upper-extremity after stroke

Cerebrovascular accident (CVA) or stroke is one of the leading causes of disability and loss of motor function. Millions of people around the world are effected by it each year. Stroke results in disabled arm function. Restoration of arm function is essential to regaining activities of daily living (ADL). Along with traditional rehabilitation methods, robot-aided therapy has emerged in recent years. Robot-aided rehabilitation is more intensive, of longer duration and more repetitive. Using robots, repetitive dull exercises can turn into a more challenging and motivating tasks such as games. Besides, robots can provide a quantitative measure of the rehabilitation progress. This article overviews the terms used in robot-aided upper-limb rehabilitation. It continues by investigating the requirements for rehabilitation robots. Then the most outstanding works in robot-aided upper-limb rehabilitation and their control schemes have been investigated. The clinical outcomes of the built robots are also given that demonstrates the usability of these robots in real-life applications and their acceptance. This article summarizes a review done along with a research on the design, simulation and control of a robot for use in upper-limb rehabilitation after stroke.

• Implications for Rehabilitation

• Reviewing common terms in rehabilitation of upper limb using robots

• Reviewing rehabilitation robots built up to date

• Reviewing clinical outcomes of the mentioned rehabilitation robots

     

The effect of a task-specific locomotor training strategy on gait stability in patients with cerebellar disease: a feasibility study

Purpose: There is a lack of evidence-based recommendations for the physiotherapeutic intervention specifically for locomotor training in patients with cerebellar ataxia. The purpose of this study is to determine the feasibility and effect of a more specific rehabilitation strategy that aims to improve gait quality in patients with cerebellar ataxia.

Methods: Nineteen patients with degenerative cerebellar ataxia were recruited to participate in the study. The patients participated in a 12-week locomotor training program, two times per week for 1.5?h per session (a total of 24 training sessions). The treatment approach emphasized the relearning of proper gait movement strategies through intensive practice that enhances the patient's perception and control of the essential components of normal gait movement.

Results: A quantitative analysis of step-by-step gait performance indicated that postural sway during locomotion was reduced, and the gait movement pattern became more consistent after the 12-week locomotor training program. These improvements in gait stability persisted over the 3-month period following intervention.

Conclusion: This study provides preliminary evidence that learning-based rehabilitation strategies targeting disease-specific locomotion symptoms may be helpful for reducing ataxic gait and improving motor control during walking in patients with cerebellar dysfunction.

• Implications for rehabilitation

• Physiotherapeutic interventions that aim to promote gait stability in cerebellar patients need to create a specific learning context that improve disease-related gait deficits.

• It is desirable to use explicit instructions to facilitate the conscious awareness and control of body center and posture.

• As patients reacquire the fundamental gait ability, providing training experience with various locomotor tasks that facilitate the transfer of learning may be helpful to increase generalizability of locomotor intervention.

     

A single robotic session that guides or increases movement error in survivors post-chronic stroke: which intervention is best to boost the learning of a timing task?

Purpose: Timing deficits can have a negative impact on the lives of survivors post-chronic stroke. Studies evaluating ways to improve timing post stroke are scarce. The goal of the study was to evaluate the impact of a single session of haptic guidance (HG) and error amplification (EA) robotic training interventions on the improvement of post-stroke timing accuracy.

Materials and methods: Thirty-four survivors post-chronic stroke were randomly assigned to HG or EA. Participants played a computerized pinball-like game with their affected hand positioned in a robot that either helped them perform better (HG) or worse (EA) during the task. A baseline and retention phase preceded and followed HG and EA, respectively, in order to assess their efficiency at improving absolute timing errors. The impact of the side of the stroke lesion on the participants’ performance during the timing task was also explored for each training group.

Results: An improvement in timing performance was only noted following HG (8.9?±?4.9?ms versus 7.8?±?5.3?ms, p?=?0.032). Moreover, for the EA group only, participants with a left-sided stroke lesion showed a worsening in performance as compared to those with a right-sided stroke lesion (p?=?0.001).

Conclusion: Helping survivors post-chronic stroke perform a timing-based task is beneficial to learning. Future studies should explore longer and more frequent HG training sessions in order to further promote post stroke motor recovery.

• Implications for Rehabilitation

• Timing is crucial for the accomplishment of daily tasks.

• The number of studies dedicated to improving timing is scarce in the literature, even though timing deficits are common post stroke.

• This innovative study evaluated the impact of a single session of haptic guidance-HG and error amplification-EA robotic training interventions on improvements in timing accuracy among survivors post chronic stroke.

• HG robotic training improves timing accuracy more than EA among survivors post chronic stroke.

     

An augmented reality system for upper-limb post-stroke motor rehabilitation: a feasibility study

Purpose: To determine the clinical feasibility of a system based on augmented reality for upper-limb (UL) motor rehabilitation of stroke participants. Method: A physiotherapist instructed the participants to accomplish tasks in augmented reality environment, where they could see themselves and their surroundings, as in a mirror. Two case studies were conducted. Participants were evaluated pre- and post-intervention. The first study evaluated the UL motor function using Fugl-Meyer scale. Data were compared using non-parametric sign tests and effect size. The second study used the gain of motion range of shoulder flexion and abduction assessed by computerized biophotogrammetry. Results: At a significance level of 5%, Fugl-Meyer scores suggested a trend for greater UL motor improvement in the augmented reality group than in the other. Moreover, effect size value 0.86 suggested high practical significance for UL motor rehabilitation using the augmented reality system. Conclusion: System provided promising results for UL motor rehabilitation, since enhancements have been observed in the shoulder range of motion and speed.

• Implications for Rehabilitation

• Gain of range of motion of flexion and abduction of the shoulder of post-stroke patients can be achieved through an augmented reality system containing exercises to promote the mental practice.

• NeuroR system provides a mental practice method combined with visual feedback for motor rehabilitation of chronic stroke patients, giving the illusion of injured upper-limb (UL) movements while the affected UL is resting. Its application is feasible and safe.

• This system can be used to improve UL rehabilitation, an additional treatment past the traditional period of the stroke patient hospitalization and rehabilitation

     

Rehabilitation of activities of daily living in virtual environments with intuitive user interface and force feedback

Purpose: To investigate the feasibility of using a virtual rehabilitation system with intuitive user interface and force feedback to improve the skills in activities of daily living (ADL).

Method: A virtual training system equipped with haptic devices was developed for the rehabilitation of three ADL tasks – door unlocking, water pouring and meat cutting. Twenty subjects with upper limb disabilities, supervised by two occupational therapists, received a four-session training using the system. The task completion time and the amount of water poured into a virtual glass were recorded. The performance of the three tasks in reality was assessed before and after the virtual training. Feedback of the participants was collected with questionnaires after the study.

Results: The completion time of the virtual tasks decreased during the training (p?<?0.01) while the percentage of water successfully poured increased (p?=?0.051). The score of the Borg scale of perceived exertion was 1.05 (SD?=?1.85; 95% CI?= 0.18–1.92) and that of the task specific feedback questionnaire was 31 (SD?= 4.85; 95% CI?= 28.66–33.34). The feedback of the therapists suggested a positive rehabilitation effect. The participants had positive perception towards the system.

Conclusions: The system can potentially be used as a tool to complement conventional rehabilitation approaches of ADL.

• Implications for rehabilitation

• Rehabilitation of activities of daily living can be facilitated using computer-assisted approaches.

• The existing approaches focus on cognitive training rather than the manual skills.

• A virtual training system with intuitive user interface and force feedback was designed to improve the learning of the manual skills.

• The study shows that system could be used as a training tool to complement conventional rehabilitation approaches.

     

Evaluation of hand orthoses in Duchenne muscular dystrophy

Abstract

Purpose: The purpose of this study was to evaluate whether treatment of boys with Duchenne muscular dystrophy using hand orthoses could benefit joint mobility, grip strength, or fine motor function.

Method: Eight boys with Duchenne muscular dystrophy were provided with individually customised rest orthoses. The results were analysed using single-subject design. The study included a baseline and an intervention phase. A follow-up examination was also performed.

Results: Boys with less than 50° passive wrist extension mobility were included. Wrist extension of the dominant hand increased in four and was maintained in four. Wrist extension in the non-dominant hand increased in five, was maintained in two and decreased in one. Thumb abduction in the dominant hand increased in six and two remained stable. In the non-dominant hand five increased and three remained stable. Grip strength and fine motor function showed also positive results.

Conclusions: This study indicates that the use of hand orthoses in Duchenne muscular dystrophy can delay development of contractures and improve passive wrist extension and thumb abduction. Hand orthoses can therefore be recommended for boys who start to develop contractures in the long finger flexors. Due to small sample size further studies are needed to confirm this result.

• Implications for rehabilitation

• Evaluation of hand orthoses in Duchenne muscular dystrophy.

• Preserved hand function is of uttermost importance for performance of activities in the late stages of Duchenne muscular dystrophy.

• Contractures of long finger flexors affect hand function and limit performance of daily activities.

• Hand orthoses can delay development of contractures and preserve hand function and give prerequisites for independence.

• The occupational therapists should measure wrist joint mobility regularly to be able to find the right time for intervention with hand orthoses in this progressive disorder.

     

Robot-assisted assessment of vibration perception and localization on the hand

Sensory perception is crucial for motor learning and the control of fine manipulations. However, therapy after stroke still strongly focuses on the training of motor skills. Sensory assessments are often left out or provide only very subjective data from poorly controlled stimuli. This paper presents a vibration detection/localization test with the Robotic Sensory Trainer, a device that focuses entirely on the assessment and training of sensory function of the hand, with the aim of gaining insights into the prevalence and severity of sensory deficits after stroke, and to provide semiobjective data on absolute and difference perception thresholds in patients. An initial feasibility study investigated localization performance and reaction time during the discrimination of vibration stimuli presented in four locations on the dominant and nondominant hands of 13 healthy volunteers. High correct detection rates were observed (mean ± SD of 99.6% ± 0.6%), touch screen PC Robotic Sensory Trainer which were found to be significantly different between stimulus locations on the dominant hand. Average correct detection rates were not statistically different between dominant and nondominant hand. These data will serve as baseline for future measurements on elderly and stroke subjects, and suggest that data from the nonimpaired hand could be used to identify and assess sensory deficits in the affected hand of stroke patients.

Implications for Rehabilitation

• Sensory deficits may limit functional recovery after stroke, are poorly documented and often neglected in current therapeutic programs.

• Clinical sensory assessments are not well standardized, lack sensitivity and suffer from high variability.

• We present a novel device for the semiobjective assessment of hand sensory function, capable of providing vibration, proprioception and pressure stimuli.

• Vibration perception and localization on the hand were tested on 13 healthy subjects to serve as baseline data for future measurements with stroke patients.

     

Upper extremity function and activity in facioscapulohumeral dystrophy and limb-girdle muscular dystrophies: a systematic review

Abstract

Purpose: The aims of this review were (1) to provide insight into the natural course of upper-extremity (UE) impairments and UE activity limitations associated with facioscapulohumeral dystrophy (FSHD) and limb-girdle muscular dystrophies (LGMD), and (2) to provide an overview of outcome measures used to evaluate UE function and activity in patients with FSHD and LGMD. Methods: Scientific literature databases (PubMed, MEDLINE, EMBASE, CINAHL and Cochrane) were searched for relevant publications. Inclusion criteria: (1) studies that included persons with a diagnosis of FSHD or LGMD; and (2) studies that reported the natural course of the UE functions and/or activity with outcome measures at these levels. Results: 247 publications were screened, of which 16 fulfilled the selection criteria. Most studies used manual muscle testing (MMT) to evaluate UE function and the Brooke Scale to evaluate UE mobility activities. The clinical picture of UE impairments and limitations of UE activities in FSHD and LGMD patients was highly variable. In general, FSHD and LGMD patients experience difficulty elevating their upper extremities and the execution of tasks takes considerably longer time. Conclusions: The clinical course of UE impairments and activity limitations associated with FSHD and LGMD is difficult to predict due to its high variability. Although measures like MMT and the Brooke Scale are often used, there is a lack of more specific outcome measures to assess UE function and UE capacity and performance in daily life. Measures such as 3D motion analysis and electromyography (EMG) recordings are recommended to provide additional insight in UE function. Questionnaires like the Abilhand are recommended to assess UE capacity and accelerometry to assess UE performance in daily life.

• Implications for Rehabilitation

• There is a need for specific outcome measures on the level of UE activity.

• Both the level of capacity and performance should be assessed.

• Possible outcome measures include 3D motion analysis to assess UE function, questionnaires like the Abilhand to assess UE capacity and accelerometry to assess performance of UE activities in daily life.

     

Non-invasive brain stimulation for the lower limb after stroke: what do we know so far and what should we be doing next?

Background: Non-invasive brain stimulation (NIBS) is promising as an adjuvant to rehabilitation of motor function after stroke. Despite numerous studies and reviews for the upper limb, NIBS targeting the lower limb and gait recovery after stroke is a newly emerging field of research. Purpose: To summarize findings from studies using NIBS to target the lower limb in stroke survivors. Methods: This narrative review describes studies of repetitive transcranial magnetic stimulation, paired associative stimulation and transcranial direct current stimulation with survivors of stroke. Results: NIBS appears capable of inducing changes in cortical excitability and lower limb function, but stimulation parameters and study designs vary considerably making it difficult to determine effectiveness. Conclusions: Future research should systematically assess differences in response with different stimulation parameters, test measures for determining who would be most likely to benefit and assess effectiveness with large samples before NIBS can be considered for use in clinical practice.

• Implications for Rehabilitation

• Stroke is a leading cause of disability, often resulting in dependency in activities of daily living and reduced quality of life.

• Non-invasive brain stimulation has received considerable interest as a potential adjuvant to rehabilitation after stroke and this review summarizes studies targeting the lower limb and gait recovery.

• Non-invasive brain stimulation can be used to modulate excitability of lower limb muscle representations and can lead to improvements in motor performance in stroke survivors.

• Non-invasive brain stimulation for gait recovery needs further investigation before translation to clinical practice is possible.

     

Survivors of chronic stroke – participant evaluations of commercial gaming for rehabilitation

Purpose: There has been an increase in research on the effect that virtual reality (VR) can have on physical rehabilitation following stroke. However, research exploring participant perceptions of VR for post-stroke rehabilitation has been limited.

Method: Semi-structured interviews were conducted with 10 chronic stroke participants (10 males, mean age?=?72.1, mean time since injury?=?38.6 mos.) who had recently completed an upper extremity VR stroke rehabilitation programme.

Results: Four main themes emerged: ‘the VR experience,’ ‘functional outcomes,’ ‘instruction,’ and the ‘future of VR in stroke rehabilitation,’ along with nine sub-themes. Participants illustrated the positive impact that VR training had on their functional abilities as well as their confidence towards completing activities of daily living (ADL). Participants also expressed the need for increased rehabilitation opportunities within the community.

Conclusion: Overall, participants were optimistic about their experience with VR training and all reported that they had perceived functional gain. VR is an enjoyable rehabilitation tool that can increase a stroke survivor’s confidence towards completing ADL.

• Implications for Rehabilitation

• Although there is an increase in rehabilitation programmes geared towards those with chronic stroke, we must also consider the participants’ perception of those programmes.

• Incorporating participant feedback may increase enjoyment and adherence to the rehabilitation programmes.

• The VR experience, as well as provision of feedback and instruction, are important aspects to consider when developing a VR programme for stroke survivors.

• VR for rehabilitation may be a feasible tool for increasing the survivors’ confidence in completing ADL post-stroke.

     

An exploratory analysis of the self-reported goals of individuals with chronic upper-extremity paresis following stroke

Purpose: To classify the self-identified goals of individuals post-stroke with chronic upper extremity (UE) paresis, and determine if age, UE functional capacity and pre-stroke hand dominance influence overall goal selection. Method: Sixty-five subjects participated. Using the Canadian Occupational Performance Measure (COPM) to establish treatment goals, the top five goals were categorized using the Occupational Therapy Practice Framework into five categories: activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, work and general UE movement. A Chi-square analysis determined if age, UE functional capacity (measured by the Action Research Arm Test) and UE hand dominance influenced individual goal selection. Results: The majority of goals were in the ADL (37%) and IADL (40%) categories. A small percentage (12%) was related to general UE movement. Individuals with moderate UE functional capacity identified more ADL goals than those with higher UE functional capacity. There was not a difference between age and UE dominance across all five goal areas. Conclusions: Individuals with chronic UE paresis had specific goals that were not influenced by age or hand dominance, but partially influenced by severity. General UE movement goals were identified less than goals related to specific activities.

• Implications for Rehabilitation

• Considering the specificity of individual goals following stroke, it is recommended that clinicians regularly utilize a goal setting tool to help establish client goals.

• It is recommended that clinicians further inquire about general goals in order to link upper extremity deficits to functional activity limitations.

• Age, upper extremity functional capacity and hand dominance have little influence on the rehabilitation goals for individuals with chronic paresis after stroke.

     

Strength deficits of the paretic lower extremity muscles were the impairment variables that best explained restrictions in participation after stroke

Purpose: To evaluate which measures of physical impairments of both upper extremity (UE) and lower extremity (LE) would predict restrictions in participation with 105 community-dwelling stroke subjects.

Methods: For this cross-sectional, exploratory study, participation was assessed by the daily activity and social role domains of the Assessment of Life Habits (LIFE-H). The potential predictors included measures of physical impairments (UE and LE motor recovery, sensation, motor coordination, and strength deficits).

Results: Step-wise multiple linear regression analyses revealed that, for the daily activity domain, LE strength deficits and UE motor recovery explained 28% of the variance in the LIFE-H scores and LE strength deficits alone explained 22% (F?=?29.5; p< .0001). For the social role domain, LE strength deficits and sensation explained 22% of the variance in the LIFE-H scores and LE strength deficits alone explained 16% (F?=?20.6; p< .0001).

Conclusions: Strength deficits of the LE muscles were the physical impairment variables that best predicted participation in both daily activity and social role domains of the LIFE-H. Although significant, UE motor recovery and LE sensation added little to the explained variance. Future research is needed to determine whether progressive resistance strength training program enhances participation after stroke.

• Implications for Rehabilitation

• Residual strength deficits of the LE muscles were the physical impairments that showed to be the main predictors of restrictions in participation, as determined by the daily activity and social role domains of the LIFE-H 3.1.

• It is possible that stroke individuals would benefit from physical interventions aiming at improving the strength of the LE muscles, when the goal is to enhance participation.

     

Self-training to improve UE function at the chronic stage post-stroke: a pilot randomized controlled trial

Background and purpose: On-going practice and use of the weaker upper extremity (UE) are important for maintaining and improving function in individuals with chronic stroke. The effectiveness of two self-training programs for UE function and daily-use was compared.

Methods: In this pilot, single-blinded clinical trial, individuals with chronic stroke were randomized to video-games or traditional self-training (1-hour/day, 6-times/week, 5 weeks). Assessments were performed pre-intervention (an average of two assessments), post-intervention, and at 4-week follow-up. The primary outcome was the functional ability of the upper extremity [The Action Research Arm Test (ARAT)]. Secondary measures were the daily use of the upper extremity [Motor Activity Log (MAL)] and manual dexterity (Box and Block Test). Repeated measures ANOVA was used to test the effectiveness and estimate effect sizes.

Results: Twenty-four of the 142 participants screened by phone were randomized to video-games [N?=?13, mean (SD) age – 59.1 (10.5)] or traditional [N?=?11, mean (SD) age – 64.9 (6.9)] self-training. Significant between-group differences were not detected. ARAT significantly improved by 13.9% and 9.6% following the video-games and traditional self-training programs (respectively), with a large effect size. MAL (quantity) also improved significantly between pre- intervention to follow-up with medium-large effect size.

Conclusions: UE functional improvement can be achieved by self-training at the chronic stage and, therefore, should be encouraged by clinicians.

• Implications for rehabilitation

• Video-games or traditional self-training programs can be used to practice repetitive UE movements without the supervision of a clinician

• Self-training of the UE is beneficial at the chronic stage post-stroke and, therefore, should be encouraged

• The type of self-training (video-games or traditional) should be suited to the client's abilities and preferences.

• The compliance of self-training using video-games during the follow-up period was higher than the traditional self-training. This is important since self-training programs for chronic stroke need to be long-term and sustainable.