Reinforced feedback in virtual environment for rehabilitation of upper extremity dysfunction after stroke: preliminary data from a randomized controlled trial.

OBJECTIVES: To study whether the reinforced feedback in virtual environment (RFVE) is more effective than traditional rehabilitation (TR) for the treatment of upper limb motor function after stroke, regardless of stroke etiology (i.e., ischemic, hemorrhagic). DESIGN: Randomized controlled trial. Participants. Forty-four patients affected by stroke. Intervention. The patients were randomized into two groups: RFVE (N = 23) and TR (N = 21), and stratified according to stroke etiology. The RFVE treatment consisted of multidirectional exercises providing augmented feedback provided by virtual reality, while in the TR treatment the same exercises were provided without augmented feedbacks. Outcome Measures. Fugl-Meyer upper extremity scale (F-M UE), Functional Independence Measure scale (FIM), and kinematics parameters (speed, time, and peak). RESULTS: The F-M UE (P = 0.030), FIM (P = 0.021), time (P = 0.008), and peak (P = 0.018), were significantly higher in the RFVE group after treatment, but not speed (P = 0.140). The patients affected by hemorrhagic stroke significantly improved FIM (P = 0.031), time (P = 0.011), and peak (P = 0.020) after treatment, whereas the patients affected by ischemic stroke improved significantly only speed (P = 0.005) when treated by RFVE. CONCLUSION: These results indicated that some poststroke patients may benefit from RFVE program for the recovery of upper limb motor function. This trial is registered with NCT01955291

Vision After Early-Onset Lesions of the Occipital Cortex: I. Neuropsychological and Psychophysical Studies

We analyzed the visual functions of two patients (MS, FJ) with bilateral lesion of the primary visual cortex, which occurred at gestational age 33 wk in MS and at postnatal month 7 in FJ. In both patients basic visual functions— visual acuity, contrast sensitivity, color, form, motion perception—are similarly preserved or modestly impaired. Functions requiring higher visual processing, particularly figure-ground segregation based on textural cues, are severely impaired. In MS, studied longitudinally, the deficits attenuated between the ages of 4.5 and 8 y, suggesting that the developing visual system can display a considerable degree of adaptive plasticity several years after the occurrence of a lesion. In FJ (age 18:9 to 20:6 y), who is more impaired, the recovery, if any, was less

Current knowledge on selected rehabilitative methods used in post-stroke recovery

Understanding brain plasticity after stroke is important in developing rehabilitation strategies. Active movement therapies show considerable promise but their individual application is still not fully implemented. Among the analysed, available therapeutic modalities, some became widely used in therapeutic practice. Thus, we selected three relatively new methods, i.e. mirror therapy, motor imagery and constraint-induced movement therapy (CIMT). Mirror therapy was initially used in the treatment of phantom pain in patients with amputated limbs and later, in stroke patients. Motor imagery is widely used in sport to improve performance, which raises the possibility of applying it both as a rehabilitative method and in accessing the motor network independently of recovery. Whereas CIMT is based on the paradigm that impairment of arm function is exacerbated by learned non-use and that this, in turn, leads to loss of cortical representation in the upper limb

Functional changes in the lower extremity after non-immersive virtual reality and physiotherapy following stroke

Objective: To analyse the effect of virtual reality (VR) therapy combined with conventional physiotherapy on balance, gait and motor functional disturbances, and to determine whether there is an influence on motor recovery in the subacute (< 6 months) or chronic (> 6 months) phases after stroke. Methods: A total of 59 stroke inpatients (mean age 60.3 years (standard deviation (SD) 14.8); 14.0 months (SD 25.7) post-stroke) were stratified into 2 groups: subacute (n = 31) and chronic (n = 28). Clinical scales (Fugl-Meyer lower extremity (FM LE); Functional Independence Measure (FIM); Berg Balance Scale (BBS); Functional Ambulation Category (FAC); modified Ashworth scale (MAS); 10-metre walk test (10MWT); and kinematic parameters during specific motor tasks in sitting and standing position (speed; time; jerk; spatial error; length) were applied before and after treatment. The VR treatment lasted for 15 sessions, 5 days/week, 1 h/day. Results: The subacute group underwent significant change in all variables, except MAS and length. The chronic group underwent significant improvement in clinical scales, except MAS and kinematics. Motor impairment improved in the severe = 19 FM LE points, moderate 20-28 FM LE points, mild = 29 FM LE points. Neither time since stroke onset nor affected hemisphere differed significantly between groups. The correlations were investigated between the clinical scales and the kinematic parameters of the whole sample. Moreover, FM LE, BBS, MAS, and speed showed high correlations (R2> 0.70) with independent variables. Conclusion: VR therapy combined with conventional physiotherapy can contribute to functional improvement in the subacute and chronic phases after stroke

Vision After Early-Onset Lesions of the Occipital Cortex: II. Physiological Studies

In one of two patients (MS and FJ) with bilateral, early-onset lesion of the primary visual cortex, Kiper et al. (2002) observed a considerable degree of functional recovery. To clarify the physiological mechanisms involved in the recovery, we used fMRI and quantitative EEG to study both patients. The fMRI investigations indicated that in both patients, isolated islands of the primary visual cortex are functioning, in the right hemisphere in MS and in the left in FJ. The functional recovery observed in MS roughly correlated with the functional maturation of interhemispheric connections and might reflect the role of corticocortical connectivity in visual perception. The functionality of interhemispheric connections was assessed by analyzing the changes in occipital inter-hemispheric coherence of EEG signals (ICoh) evoked by moving gratings. In the patient MS, this ICoh response was present at 7:11 y and was more mature at 9:2 y. In the more visually mpaired patient, FJ, a consistent increase in ICoh to visual stimuli could not be obtained, possibly because of the later occurrence of the lesion

Virtual Feedback for Arm Motor Function Rehabilitation after Stroke: A Randomized Controlled Trial

A single-blind randomized controlled trial was conducted to compare whether the con-tinuous visualization of a virtual teacher, during virtual reality rehabilitation, is more effective than the same treatment provided without a virtual teacher visualization, for the recovery of arm motor function after stroke. Teacher and no-teacher groups received the same amount of virtual reality therapy (i.e., 1 h/d, 5 dd/w, 4 ww) and an additional hour of conventional therapy. In the teacher group, specific feedback (“virtual-teacher”) showing the correct kinematic to be emulated by the patient was always displayed online during exercises. In the no-teacher group patients performed the same exer-cises, without the virtual-teacher assistance. The primary outcome measure was Fugl-Meyer Upper Extremity after treatment. 124 patients were enrolled and randomized, 62 per group. No differences were observed between the groups, but the same number of patients (χ2 = 0.29, p = 0.59) responded to experimental and control interventions in each group. The results confirm that the manipulation of a single instant feedback does not provide clinical advantages over multimodal feedback for arm rehabilitation after stroke, but combining 40 h conventional therapy and virtual reality provides large effect of intervention (i.e., Cohen’s d 1.14 and 0.92 for the two groups, respectively)

Does the score on the mrc strength scale reflect instrumented measures of maximal torque and muscle activity in post‐stroke survivors?

It remains unknown whether variation of scores on the Medical Research Council (MRC) scale for muscle strength is associated with operator‐independent techniques: dynamometry and surface electromyography (sEMG). This study aimed to evaluate whether the scores of the MRC strength scale are associated with instrumented measures of torque and muscle activity in post-stroke survivors with severe hemiparesis both before and after an intervention. Patients affected by a first ischemic or hemorrhagic stroke within 6 months before enrollment and with complete paresis were included in the study. The pre‐ and post‐treatment assessments included the MRC strength scale, sEMG, and dynamometry assessment of the triceps brachii (TB) and biceps brachii (BB) as measures of maximal elbow extension and flexion torque, respectively. Proprioceptive‐based training was used as a treatment model, which consisted of multidirectional exercises with verbal feedback. Each treatment session lasted 1 h/day, 5 days a week for a total 15 sessions. Nineteen individuals with stroke participated in the study. A significant correlation between outcome measures for the BB (MRC and sEMG p = 0.0177, ϱ = 0.601; MRC and torque p = 0.0001, ϱ = 0.867) and TB (MRC and sEMG p = 0.0026, ϱ = 0.717; MRC and torque p = 0.0001, ϱ = 0.873) were observed post intervention. Regression models revealed a relationship between the MRC score and sEMG and torque measures for both the TB and BB. The results confirmed that variation on the MRC strength scale is associated with variation in sEMG and torque measures, especially post intervention. The regression model showed a causal relationship between MRC scale scores, sEMG, and torque assessments

Use of virtual reality-based training in different fields of rehabilitation: A systematic review and meta-analysis

Objectives: To analyse the effectiveness of virtual reality-based interventions within several fields of rehabilitation, and to investigate whether the outcomes of virtual realitybased interventions, in terms of upper or lower limb function, gait and balance, differ with respect to the virtual reality system used. Methods: A search of PubMed database resulted in an initial total of 481 records. Of these, 27 articles were included in the study. A final total of 20 articles, with neurological, orthoapedic, geriatric or paediatric patients, published between 2012 and 2019, were included in the study. Two independent reviewers selected potentially relevant articles based on the inclusion criteria for fulltext reading. They extracted data, and evaluated the methodological quality of each study. Results: Seventeen studies were included in the metaanalysis. Eight studies analysed upper limb function, with no significant evidence that specialized VR is superior to conventional treatment. Regarding Fugl-Meyer scale results, the effect of specialized virtual reality therapy was found to be significantly better than conventional treatment. No significant differences between specialized VR and conventional treatment were observed in effects on hand dexterity and gait. There was a significant difference in effects on balance in favour of specialized virtual reality as compared to conventional treatment. Gaming virtual reality was significantly better than conventional treatment for upper limb function, but not for hand dexterity, gait and balance. Conclusion: Use of specialized virtual reality and gaming virtual reality can be advantageous for treatment of the upper extremity, but not for hand dexterity and gait in all pathologies considered. Specialized virtual reality can improve balance in neurological patients

Virtual reality rehabilitation in patients with chronic obstructive pulmonary disease: A randomized controlled trial

Purpose: This study compared the effects of inpatient-based rehabilitation program of patients with chronic obstructive pulmonary disease (COPD) using non-immersive virtual reality (VR) training with a traditional pulmonary rehabilitation program. The aims of this study were to determine 1) whether rehabilitation featuring both VR as well as exercise training provides benefits over exercise training (ET) alone and 2) whether rehabilitation featuring VR training instead of exercise training provides equivalent benefits. Patients and Methods: The study recruited 106 patients with COPD to a 2-week high-intensity, five times a week intervention. Randomized into three groups, 34 patients participated in a traditional pulmonary rehabilitation program including endurance exercise training (ET), 38 patients participated in traditional pulmonary rehabilitation, including both endurance exercise training and virtual reality training (ET+VR) and 34 patients participated in pulmonary rehabilitation program including virtual reality training but no endurance exercise training (VR). The traditional pulmonary rehabilitation program consisted of fitness exercises, resistance respiratory muscle and relaxation training. Xbox 360® and Kinect® Adventures software were used for the VR training of lower and upper body strength, endurance, trunk control and dynamic balance. Comparison of the changes in the Senior Fitness Test was the primary outcome. Analysis was performed using linear mixed-effects models. Results: The comparison between ET and ET+VR groups showed that ET+VR group was superior to ET group in Arm Curl (p<0.003), Chair stand (p<0.008), Back scratch (p<0.002), Chair sit and reach (p<0.001), Up and go (p<0.000), 6-min walk test (p<0.011). Whereas, the comparison between ET and VR groups showed that VR group was superior to ET group in Arm Curl (p<0.000), Chair stand (p<0.001), 6-min walk test (p<0.031). Conclusion: Results suggest that pulmonary rehabilitation program supplemented with VR training is beneficial intervention to improve physical fitness in patients with COPD

Virtual reality and physiotherapy in post-stroke functional re-education of the lower extremity: A controlled clinical trial on a new approach

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP