Mirror Therapy for the Lower-Extremities Post-Stroke

Despite extensive rehabilitation post-stroke gait remains slow, variable and asymmetric. There is a need for simple interventions to improve lower-extremity motor control and walking ability. Mirror therapy is a promising intervention though little attention has focused on its use on the lower-extremities post-stroke. This thesis investigates the feasibility and potential effects of a bilateral lower-extremity mirror therapy intervention (LE-MT) post-stroke. A case series involving three participants, who performed twelve 30 minute sessions of LE-MT over four weeks, is presented. Session duration and number of repetitions completed improved over the course of the intervention indicating LE-MT post-stroke is feasible. Some cases demonstrated improved motor recovery of the leg and clinically meaningful improvements to gait velocity and step variability post-intervention indicating some potential benefits of LE-MT. Future directions will identify who may respond best to LE-MT, investigate the dose-response relationship and the underlying mechanisms of the observed improvements associated with LE-MT

Immersive Virtual Reality Training Improved Upper Extremity Function in Patients with Spinal Cord Injuries: A Case Series

Virtual reality (VR) is an emerging treatment tool to engage people in environments that appear and feel similar to real-world objects and events.1 There are various levels of evidence that VR can potentially promote functional activity and neuroplasticity in patients with neurological disorders like spinal cord injury (SCI).2,3 In this case series, we explored the feasibility of using commercially available immersive VR technology as an augmented treatment in the SCI population and compare participant’s suitability for this intervention. Three male SCI participants were recruited in a subacute inpatient rehabilitation facility and participated in VR intervention twice a week in addition to their conventional therapies. Manual strength and functional testing were recorded biweekly until participants discharged. Training includes reaching activities, wrist rotation, gripping, and thumb movement to simulate real-life activities. A questionnaire regarding their experience with VR training was administered at the end. All participants had improvement in strength and functional tests. 9-hole peg test demonstrated clinically meaningful change in two of three participants. Manual muscle test changes were 2, 4.5 and 13.5 points individually. Participants with lower manual muscle test scores at baseline showed more potential to change compared to those who had high scores, which would possibly due to plateau effect. Pinch and grip strength demonstrated small changes which were not clinically important. Participants also rated VR technology of high reality level and great enjoyment in the questionnaire. This case series suggests that immersive VR with head mount display may be viable to provide safe and effective treatment for patients with SCI. VR training appears to be a possible adjunct to physical and occupational therapy as a method of muscle strengthening, improving upper extremity function and improving motivation during subacute rehabilitation

Visual cue training to improve walking and turning after stroke:a study protocol for a multi-centre, single blind randomised pilot trial

Visual information comprises one of the most salient sources of information used to control walking and the dependence on vision to maintain dynamic stability increases following a stroke. We hypothesize, therefore, that rehabilitation efforts incorporating visual cues may be effective in triggering recovery and adaptability of gait following stroke. This feasibility trial aims to estimate probable recruitment rate, effect size, treatment adherence and response to gait training with visual cues in contrast to conventional overground walking practice following stroke.Methods/design: A 3-arm, parallel group, multi-centre, single blind, randomised control feasibility trial will compare overground visual cue training (O-VCT), treadmill visual cue training (T-VCT), and usual care (UC). Participants (n = 60) will be randomly assigned to one of three treatments by a central randomisation centre using computer generated tables to allocate treatment groups. The research assessor will remain blind to allocation. Treatment, delivered by physiotherapists, will be twice weekly for 8 weeks at participating outpatient hospital sites for the O-VCT or UC and in a University setting for T-VCT participants.Individuals with gait impairment due to stroke, with restricted community ambulation (gait spee

Technology-assisted stroke rehabilitation in Mexico: a pilot randomized trial comparing traditional therapy to circuit training in a Robot/technology-assisted therapy gym

Background Stroke rehabilitation in low- and middle-income countries, such as Mexico, is often hampered by lack of clinical resources and funding. To provide a cost-effective solution for comprehensive post-stroke rehabilitation that can alleviate the need for one-on-one physical or occupational therapy, in lower and upper extremities, we proposed and implemented a technology-assisted rehabilitation gymnasium in Chihuahua, Mexico. The Gymnasium for Robotic Rehabilitation (Robot Gym) consisted of low- and high-tech systems for upper and lower limb rehabilitation. Our hypothesis is that the Robot Gym can provide a cost- and labor-efficient alternative for post-stroke rehabilitation, while being more or as effective as traditional physical and occupational therapy approaches. Methods A typical group of stroke patients was randomly allocated to an intervention (n = 10) or a control group (n = 10). The intervention group received rehabilitation using the devices in the Robot Gym, whereas the control group (n = 10) received time-matched standard care. All of the study subjects were subjected to 24 two-hour therapy sessions over a period of 6 to 8 weeks. Several clinical assessments tests for upper and lower extremities were used to evaluate motor function pre- and post-intervention. A cost analysis was done to compare the cost effectiveness for both therapies. Results No significant differences were observed when comparing the results of the pre-intervention Mini-mental, Brunnstrom Test, and Geriatric Depression Scale Test, showing that both groups were functionally similar prior to the intervention. Although, both training groups were functionally equivalent, they had a significant age difference. The results of all of the upper extremity tests showed an improvement in function in both groups with no statistically significant differences between the groups. The Fugl-Meyer and the 10 Meters Walk lower extremity tests showed greater improvement in the intervention group compared to the control group. On the Time Up and Go Test, no statistically significant differences were observed pre- and post-intervention when comparing the control and the intervention groups. For the 6 Minute Walk Test, both groups presented a statistically significant difference pre- and post-intervention, showing progress in their performance. The robot gym therapy was more cost-effective than the traditional one-to-one therapy used during this study in that it enabled therapist to train up to 1.5 to 6 times more patients for the approximately same cost in the long term. Conclusions The results of this study showed that the patients that received therapy using the Robot Gym had enhanced functionality in the upper extremity tests similar to patients in the control group. In the lower extremity tests, the intervention patients showed more improvement than those subjected to traditional therapy. These results support that the Robot Gym can be as effective as traditional therapy for stroke patients, presenting a more cost- and labor-efficient option for countries with scarce clinical resources and funding. Trial registration ISRCTN98578807

Peak Trailing Limb Angle and Propulsion Symmetry in Individuals with Below Knee Amputation

Background: Individuals with lower extremity amputation often present with kinematic and kinetic gait asymmetries and often have difficulty achieving symmetrical walking using their prescribed prosthesis. To understand the impact of limb loss on gait measures, studies often compare individuals with lower limb amputation to healthy control participants or compare the amputated limb to the uninvolved limb while completing a specified task like steady state walking. Commonly implemented treatments for individuals with lower limb amputation are based upon the assumption that equal use of both legs (symmetry) while completing bipedal tasks (e.g., walking) would be beneficial, matching the behavior seen in healthy control individuals. Underlying kinematic or kinetic symmetry, as well as a potential relationship of the two biomechanical gait variables in individuals with below knee amputation have not been thoroughly evaluated during steady state treadmill walking. Methods: We explored potential underlying (a)symmetries in peak trailing limb angle (kinematic) and peak anterior ground reaction force (kinetic) in individuals with below knee amputation walking at self-selected walking speed on a treadmill without upper extremity support. We then implemented real-time visual feedback to alter symmetry and examine the potential relationship between peak trailing limb angle and peak anterior ground reaction force. Later, we recruited and tested healthy control individuals with and without a solid ankle foot orthosis (SAFO) walking at their self-selected walking speed on a treadmill and exposed them to a similar visual feedback program to alter their baseline (a)symmetry. Population: We enrolled eleven of the planned twenty-four individuals with unilateral below knee amputation and fourteen healthy control participants without any lower extremity pathology or gait abnormality. Results: We found that individuals with below knee amputation do have peak trailing limb and anterior ground reaction force asymmetries and unencumbered healthy control individuals demonstrate symmetry of the same outcome measures while walking on a treadmill at self-selected walking speed. The use of real time visual feedback yielded statistically significant differences in peak trailing limb angle in healthy control participants without a solid ankle foot orthosis (p=0.04), peak and impulse anterior ground reaction forces when wearing a solid ankle foot orthosis (p=0.04). Statistically significant correlation between peak trailing limb angle and peak anterior ground reaction force were found in individuals with below knee amputation at baseline (p=0.0004), with real time visual feedback for peak trailing limb angle (p\u3c0.0001), and peak anterior ground reaction force (p=0.0002). Conclusions: Real time visual feedback is one intervention used to alter walking symmetry. Our results do not demonstrate an overwhelming response to real time visual feedback by individuals with below knee amputation or their healthy control counterparts and should be interpreted with caution. This work does provide meaningful information for further studies and interventions to alter symmetry during steady state walking and begins to explore the potential relationship between peak trailing limb angel and peak anterior ground reaction force production during self-selected treadmill walking in individuals with below knee amputation as well as otherwise healthy control individuals

Combining brain-computer interfaces and assistive technologies: state-of-the-art and challenges

In recent years, new research has brought the field of EEG-based Brain-Computer Interfacing (BCI) out of its infancy and into a phase of relative maturity through many demonstrated prototypes such as brain-controlled wheelchairs, keyboards, and computer games. With this proof-of-concept phase in the past, the time is now ripe to focus on the development of practical BCI technologies that can be brought out of the lab and into real-world applications. In particular, we focus on the prospect of improving the lives of countless disabled individuals through a combination of BCI technology with existing assistive technologies (AT). In pursuit of more practical BCIs for use outside of the lab, in this paper, we identify four application areas where disabled individuals could greatly benefit from advancements in BCI technology, namely,“Communication and Control”, “Motor Substitution”, “Entertainment”, and “Motor Recovery”. We review the current state of the art and possible future developments, while discussing the main research issues in these four areas. In particular, we expect the most progress in the development of technologies such as hybrid BCI architectures, user-machine adaptation algorithms, the exploitation of users’ mental states for BCI reliability and confidence measures, the incorporation of principles in human-computer interaction (HCI) to improve BCI usability, and the development of novel BCI technology including better EEG devices

Utilization Of Postural Control Training To Improve Gait Symmetry And Walking Ability In A Patient Following A Lacunar Stroke: A Case Report

Background and Purpose: Stroke affects approximately 800,000 people annually and alterations in gait is one of the most noted impairments following stroke. The purpose of this case report is to outline physical therapy (PT) rehabilitation that utilized postural control training, task-oriented training, and visual feedback to address walking ability and functional capacity in a patient following a stroke. Case Description: The patient was a 67-year-old male apple orchard owner three months post a lacunar ischemic stroke affecting the posterior limb of the internal capsule, the basal ganglia, and part of the cerebellum. His initial examination revealed impaired strength, sensation, range of motion, balance, endurance, and mobility. This case report describes his initial ten outpatient PT visits primarily focused on improving the patient\u27s functional mobility, ambulation in particular, through postural control training and task-oriented training. Outcomes: After ten outpatient visits, the patient demonstrated improvements in gait and postural symmetry on observation. Improvements were shown in both gait speed (from 0.24 m/s to 0.30 m/s) and gait endurance (from feet to 130 feet) and although the improvements did not meet established minimally important clinical difference values, he did demonstrate trends toward improvement. Discussion: Postural control training and task oriented training are common PT interventions utilized in patients following stroke. Utilizing postural control training and task-oriented training, the patient showed initial improvements in postural symmetry and gait mechanics, which translated to improved access to his environment. Despite initial improvements, the patient’s various comorbidities likely contributed to his plateau in progress. Future research on lacunar stroke should address how comorbidities affect the acquisition of PT goals and improvements in gait speed

Technology-supported training of arm-hand skills in stroke

Impaired arm-hand performance is a serious consequence of stroke that is associated with reduced self-efficacy and poor quality of life. Task-oriented arm training is a therapy approach that is known to improve skilled arm-hand performance, even in chronic stages after stroke. At the start of this project, little knowledge had been consolidated regarding taskoriented arm training characteristics, especially in the field of technology-supported rehabilitation. The feasibility and effects of technology-supported client-centred task-oriented training on skilled arm-hand performance had not been investigated but to a very limited degree. Reviewing literature on rehabilitation and motor learning in stroke led to the identification of therapy oriented criteria for rehabilitation technology aiming to influence skilled arm-hand performance (chapter 2). Most rehabilitation systems reported in literature to date are robotic systems that are aimed at providing an engaging exercise environment and feedback on motor performance. Both, feedback and engaging exercises are important for motivating patients to perform a high number of exercise repetitions and prolonged training, which are important factors for motor learning. The review also found that current rehabilitation technology is focussed mainly on providing treatment at a function level, thereby improving joint range of motion, muscle strength and parameters such as movement speed and smoothness of movement during analytical movements. However, related research has found no effects of robot-supported training at the activity level. The review concluded that a challenge exists for upper extremity rehabilitation technology in stroke patients to also provide more patienttailored task-oriented arm-hand training in natural environments to support the learning of skilled arm-hand performance. Besides mapping the strengths of different technological solutions, the use of outcome measures and training protocols needs to become more standardized across similar interventions, in order to help determine which training solutions are most suitable for specific patient categories. Chapter 4 contributes towards such a standardization of outcome measurement. A concept is introduced which may guide the clinician/researcher to choose outcome measures for evaluating specific and generalized training effects. As an initial operationalization of this concept, 28 test batteries that have been used in 16 task-oriented training interventions were rated as to whether measurement components were measured by the test. Future research is suggested that elaborates the concept with information on the relative weighing of components in each test, with more test batteries (which may lead to additional components) and by adding more test properties into the concept (e.g. psychometric properties of the tests, possible floor- or ceiling effects). Task-oriented training is one of the training approaches that has been shown to be beneficial for skilled arm-hand performance after stroke. Important mechanisms for motor learning that are identified are patient motivation for such training, and the learning of efficient goaloriented movement strategies and task-specific problem solving. In this thesis we operationalize task-oriented training in terms of 15 components (chapter 3). A systematic review that included 16 randomized controlled trials using task-oriented training in stroke patients, evaluated the effects of these training components on skilled arm-hand performance. The number of training components used in an intervention aimed at improving arm-hand performance after stroke was not associated with the post-treatment effect size. Distributed practice and feedback were associated with the largest post-intervention effect sizes. Random practice and use of clear functional training goals were associated with the largest follow-up effect sizes. It may be that training components that optimize the storage of learned motor performance in the long-term memory are associated with larger treatment effects. Unfortunately, feedback, random practice and distributed practice were reported in very few of the included randomized controlled trials (in only 6,3 and 1 out of the 17 studies respectively). Client-centred training, i.e. training on exercises that support goals that are selected by the patients themselves, improves patient motivation for training. Motivation in turn has proven to positively influence motor learning in stroke patients, as attention during training is heightened and storage of information in the long-term memory improves. Chapter 5 reports on an interview of 40 stroke patients, investigating into training preferences. A list of 46 skills, ranked according to descending training preference scores, was provided that can be used for implementation of exercises in rehabilitation technology, in order for technologysupported training to be client-centred. Chapter 6 introduces T-TOAT, a technology supported task-oriented arm training method that was developed together with colleagues at Adelante (Hoensbroek, NL). T-TOAT enables the implementation of exercises that support task-oriented training in rehabilitation technology. The training method is applicable for different technological systems, e.g. robot and sensor systems, or in combination with functional electrical stimulation, etc. To enable the use of TTOAT for training with the Haptic Master Robot (MOOG-FCS, NL), special software named Haptic TOAT was developed in Adelante together with colleagues at the Centre of Technology in Care of Zuyd University (chapter 6). The software enables the recording of the patient’s movement trajectories, given task constraints and patient possibilities, using the Haptic Master as a recording device. A purpose-made gimbal was attached to the endeffector, leaving the hand free for the use and manipulating objects. The recorded movement can be replayed in a passive mode or in an active mode (active, active-assisted or activeresisted). Haptic feedback is provided when the patient deviates from the recorded movement trajectory, as the patient receives the sensation of bouncing into a wall, as well as feeling a spring that pulls him/her back to the recorded path. The diameter of the tunnel around the recorded trajectory (distance to the wall), and the spring force can be adjusted for each patient. An ongoing clinical trial in which chronic stroke patients train with Haptic-TOAT examines whether Haptic Master provides additional value compared to supporting the same exercises by video-instruction only. Together with Philips Research Europe (Eindhoven,Aachen), the T-TOAT method has been implemented in a sensor based prototype, called Philips Stroke Rehabilitation Exerciser. This system included movement tracking sensors and an exercise board interacting with real life objects. A very strong feature of the system is that feedback is provided to patients (real-time and after exercise performance), based on a comparison of the patient’s exercise performance to individual targets set by the therapist. Chapter 7 reports on a clinical trial investigating arm-hand treatment outcome and patient motivation for technology-supported task-oriented training in chronic stroke patients. It was found that 8 weeks of T-TOAT training improved arm-hand performance in chronic stroke patients significantly on Fugl-Meyer, Action Research Arm Test, and Motor Activity Log. An improvement was found in health-related quality of life. Training effects lasted at least 6 months post-training. Participants reported feeling intrinsically motivated and competent to use the system. The results of this study showed that T-TOAT is feasible. Despite the small number of stroke patients tested (n=9), significant and clinically relevant improvements in skilled arm-hand performance were found. In conclusion, this thesis has made several contributions. It motivated the need for clientcentred task-oriented training, which it has operationalized in terms of 15 components. Four of these 15 components were identified as most beneficial for the patient. A prioritized inventory of arm-hand training preferences of stroke patients was compiled by means of an interview study of 40 subacute and chronic stroke patients. T-TOAT, a method for technology-supported, client-centred, task-oriented training, was conceived and implemented in two target technologies (Haptic Master and Philips Stroke Rehabilitation Exerciser). Its feasibility was demonstrated in a clinical trial showing substantial and durable benefits for the stroke patients. Finally, the thesis contributes towards the standardization of outcome measures which is necessary for charting progress and guiding future developments of technology-supported stroke rehabilitation. Methodological considerations were discussed and several suggestions for future research were presented. The variety of treatment approaches and the various ways of support and challenge that are offered by existing rehabilitation technologies hold a large potential for offering a variety of extra training opportunities to stroke patients that may improve their arm-hand performance. Such solutions will be of increasing importance, to alleviate therapists and reduce economic pressure on the health care system, as the stroke incidence is increasing rapidly over the coming decades

Two Weeks of Ischemic Conditioning Improves Walking Speed and Reduces Neuromuscular Fatigability in Chronic Stroke Survivors

This pilot study examined whether ischemic conditioning (IC), a noninvasive, cost-effective, and easy-to-administer intervention, could improve gait speed and paretic leg muscle function in stroke survivors. We hypothesized that 2 wk of IC training would increase self-selected walking speed, increase paretic muscle strength, and reduce neuromuscular fatigability in chronic stroke survivors. Twenty-two chronic stroke survivors received either IC or IC Sham on their paretic leg every other day for 2 wk (7 total sessions). IC involved 5-min bouts of ischemia, repeated five times, using a cuff inflated to 225 mmHg on the paretic thigh. For IC Sham, the cuff inflation pressure was 10 mmHg. Self-selected walking speed was assessed using the 10-m walk test, and paretic leg knee extensor strength and fatigability were assessed using a Biodex dynamometer. Self-selected walking speed increased in the IC group (0.86 ± 0.21 m/s pretest vs. 1.04 ± 0.22 m/s posttest, means ± SD; P\u3c 0.001) but not in the IC Sham group (0.92 ± 0.47 m/s pretest vs. 0.96 ± 0.46 m/s posttest; P= 0.25). Paretic leg maximum voluntary contractions were unchanged in both groups (103 ± 57 N·m pre-IC vs. 109 ± 65 N·m post-IC; 103 ± 59 N·m pre-IC Sham vs. 108 ± 67 N·m post-IC Sham; P = 0.81); however, participants in the IC group maintained a submaximal isometric contraction longer than participants in the IC Sham group (278 ± 163 s pre-IC vs. 496 ± 313 s post-IC, P = 0.004; 397 ± 203 s pre-IC Sham vs. 355 ± 195 s post-IC Sham; P = 0.46). The results from this pilot study thus indicate that IC training has the potential to improve walking speed and paretic muscle fatigue resistance poststroke