Innovative technologies applied to sensorimotor rehabilitation after stroke

The Effects of Stroke and Stroke Gait Rehabilitation on Behavioral and Neurophysiological Outcomes:: Challenges and Opportunities for Future Research

Stroke continues to be a leading cause of adult disability, contributing to immense healthcare costs. Even after discharge from rehabilitation, post-stroke individuals continue to have persistent gait impairments, which in turn adversely affect functional mobility and quality of life. Multiple factors, including biomechanics, energy cost, psychosocial variables, as well as the physiological function of corticospinal neural pathways influence stroke gait function and training-induced gait improvements. As a step toward addressing this challenge, the objective of the current perspective paper is to outline knowledge gaps pertinent to the measurement and retraining of stroke gait dysfunction. The paper also has recommendations for future research directions to address important knowledge gaps, especially related to the measurement and rehabilitation-induced modulation of biomechanical and neural processes underlying stroke gait dysfunction. We posit that there is a need for leveraging emerging technologies to develop innovative, comprehensive, methods to measure gait patterns quantitatively, to provide clinicians with objective measure of gait quality that can supplement conventional clinical outcomes of walking function. Additionally, we posit that there is a need for more research on how the stroke lesion affects multiple parts of the nervous system, and to understand the neuroplasticity correlates of gait training and gait recovery. Multi-modal clinical research studies that can combine clinical, biomechanical, neural, and computational modeling data provide promise for gaining new information about stroke gait dysfunction as well as the multitude of factors affecting recovery and treatment response in people with post-stroke hemiparesis.

Evidence of neuroplasticity with brain-computer interface in a randomized trial for post-stroke rehabilitation: a graph-theoretic study of subnetwork analysis

Background

Brain-computer interface (BCI) has been widely used for functional recovery after stroke. Understanding the brain mechanisms following BCI intervention to optimize BCI strategies is crucial for the benefit of stroke patients.

Methods

Forty-six patients with upper limb motor dysfunction after stroke were recruited and randomly divided into the control group or the BCI group. The primary outcome was measured by the assessment of Fugl-Meyer Assessment of Upper Extremity (FMA-UE). Meanwhile, we performed resting-state functional magnetic resonance imaging (rs-fMRI) in all patients, followed by independent component analysis (ICA) to identify functionally connected brain networks. Finally, we assessed the topological efficiency of both groups using graph-theoretic analysis in these brain subnetworks.

Results

The FMA-UE score of the BCI group was significantly higher than that of the control group after treatment (p = 0.035). From the network topology analysis, we first identified seven subnetworks from the rs-fMRI data. In the following analysis of subnetwork properties, small-world properties including γ (p = 0.035) and σ (p = 0.031) within the visual network (VN) decreased in the BCI group. For the analysis of the dorsal attention network (DAN), significant differences were found in assortativity (p = 0.045) between the groups. Additionally, the improvement in FMA-UE was positively correlated with the assortativity of the dorsal attention network (R = 0.498, p = 0.011).

Conclusion

Brain-computer interface can promote the recovery of upper limbs after stroke by regulating VN and DAN. The correlation trend of weak intensity proves that functional recovery in stroke patients is likely to be related to the brain's visuospatial processing ability, which can be used to optimize BCI strategies.

Clinical Trial Registration

The trial is registered in the Chinese Clinical Trial Registry, number ChiCTR2000034848. Registered 21 July 2020.

Evidence of Motor Skill Learning in Acute Stroke Patients Without Lesions to the Thalamus and Internal Capsule

Background:

It is currently unknown whether motor skill learning (MSkL) with the paretic upper limb is possible during the acute phase after stroke and whether lesion localization impacts MSkL. Here, we investigated MSkL in acute (1–7 days post) stroke patients compared with healthy individuals (HIs) and in relation to voxel-based lesion symptom mapping.

Methods:

Twenty patients with acute stroke and 35 HIs were trained over 3 consecutive days on a neurorehabilitation robot measuring speed, accuracy, and movement smoothness variables. Patients used their paretic upper limb and HI used their nondominant upper limb on an MSkL task involving a speed/accuracy trade-off. Generalization was evaluated on day 3. All patients underwent a 3-dimensional magnetic resonance imaging used for VSLM.

Results:

Most patients achieved MSkL demonstrated by day-to-day retention and generalization of the newly learned skill on day 3. When comparing raw speed/accuracy trade-off values, HI achieved larger MSkL than patients. However, relative speed/accuracy trade-off values showed no significant differences in MSkL between patients and HI on day 3. In patients, MSkL progression correlated with acute motor and cognitive impairments. The voxel-based lesion symptom mapping showed that acute vascular damage to the thalamus or the posterior limb of the internal capsule reduced MSkL.

Conclusions:

Despite worse motor performance for acute stroke patients compared with HI, most patients were able to achieve MSkL with their paretic upper limb. Damage to the thalamus and posterior limb of the internal capsule, however, reduced MSkL. These data show that MSkL could be implemented into neurorehabilitation during the acute phase of stroke, particularly for patients without lesions to the thalamus and posterior limb of the internal capsule.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01519843.

Combined transcranial Direct Current Stimulation and robot-assisted arm training in patients with stroke: a systematic review

BACKGROUND

Upper limb motor deficits in patients with severe stroke often remain unresolved over time. Combining transcranial Direct Current Stimulation with robotic therapy is an innovative neurorehabilitation approach that holds promise to improve upper limb impairment after stroke.

OBJECTIVE

To investigate the effects of robotic training in combination with transcranial Direct Current Stimulation for treating poststroke upper limb impairment.

METHODS

PubMed, MEDLINE, Cochrane Library, and EMBASE electronic databases were searched using keywords, MeSH terms, and strings: "Stroke"[MeSH] AND ("Upper Extremity"[MeSH] OR "upper limb") AND ("Transcranial Direct Current Stimulation" [MeSH] OR "tDCS") AND ("robotics" OR "robotic therapy"). Full-text articles published in English up to October 2020 were included. Each was rated for quality according to the Physiotherapy Database (PEDro) score: eight out of eleven scored more than 8 points; their results were considered reliable for this review.

RESULTS

Of the total of 171 publications retrieved, 11 met the inclusion criteria. The results of studies that examined the same outcome measures were pooled to draw conclusions on the effectiveness of transcranial Direct Current Stimulation and robot-assisted training in corticomotor excitability, upper limb kinematics, muscle strength and tone, function, disability, and quality of life after stroke.

CONCLUSIONS

To date, there is insufficient evidence to support the hypothesis that transcranial Direct Current Stimulation enhances the effects of robot-assisted arm training in poststroke patients. Further studies with more accurate, comparable and standardized methodology are needed in order to better define the effects of robotic training in combination with transcranial Direct Current Stimulation on poststroke upper limb impairment. Therefore, given the scarce resources available to rehabilitation researches, other, more promising approaches should be given attention.

Post-stroke Rehabilitation of Severe Upper Limb Paresis in Germany - Toward Long-Term Treatment With Brain-Computer Interfaces

Severe upper limb paresis can represent an immense burden for stroke survivors. Given the rising prevalence of stroke, restoration of severe upper limb motor impairment remains a major challenge for rehabilitation medicine because effective treatment strategies are lacking. Commonly applied interventions in Germany, such as mirror therapy and impairment-oriented training, are limited in efficacy, demanding for new strategies to be found. By translating brain signals into control commands of external devices, brain-computer interfaces (BCIs) and brain-machine interfaces (BMIs) represent promising, neurotechnology-based alternatives for stroke patients with highly restricted arm and hand function. In this mini-review, we outline perspectives on how BCI-based therapy can be integrated into the different stages of neurorehabilitation in Germany to meet a long-term treatment approach: We found that it is most appropriate to start therapy with BCI-based neurofeedback immediately after early rehabilitation. BCI-driven functional electrical stimulation (FES) and BMI robotic therapy are well suited for subsequent post hospital curative treatment in the subacute stage. BCI-based hand exoskeleton training can be continued within outpatient occupational therapy to further improve hand function and address motivational issues in chronic stroke patients. Once the rehabilitation potential is exhausted, BCI technology can be used to drive assistive devices to compensate for impaired function. However, there are several challenges yet to overcome before such long-term treatment strategies can be implemented within broad clinical application: 1. developing reliable BCI systems with better usability; 2. conducting more research to improve BCI training paradigms and 3. establishing reliable methods to identify suitable patients.

Beneficial Effects of Robot-Assisted Gait Training on Functional Recovery in Women after Stroke: A Cohort Study

Background and Objectives: Robot-assisted gait training (RAGT) could be a rehabilitation option for patients after experiencing a stroke. This study aims to determine the sex-related response to robot-assisted gait training in a cohort of subacute stroke patients considering mixed results previously reported. Materials and Methods: In this study, 236 participants (145 males, 91 females) were admitted to a rehabilitation facility after experiencing a stroke and performed RAGT within a multidisciplinary rehabilitation program. Functional Independence Measure (FIM) and Functional Ambulatory Category (FAC) were assessed at admission and discharge to determine sex-related outcomes. Results: At the baseline, no significant difference among sexes was observed. At the end of rehabilitation, both males and females exhibited significant improvements in FIM (71% of males and 80% of females reaching the MCID cut-off value) and FAC (∆score: men 1.9 ± 1.0; women 2.1 ± 1.1). A more remarkable improvement was observed in women of the whole population during the study, but statistical significance was not reached. When analysing the FAC variations with respect to the total number of RAGT sessions, a more significant improvement was observed in women than men (p = 0.025). Conclusion: In conclusion, among subacute stroke patients, benefits were observed following RAGT during a multidisciplinary rehabilitation program in both sexes. A greater significant recovery for women with an ischemic stroke or concerning the number of sessions attended was also highlighted. The use of gait robotics for female patients may favour a selective functional recovery after stroke.

Recovering arm function in chronic stroke patients using combined anodal HD-tDCS and virtual reality therapy (ReArm): a study protocol for a randomized controlled trial

BACKGROUND

After a stroke, 80% of the chronic patients have difficulties to use their paretic upper limb (UL) in activities of daily life (ADL) even after rehabilitation. Virtual reality therapy (VRT) and anodal transcranial direct current stimulation (tDCS) are two innovative methods that have shown independently to positively impact functional recovery of the paretic UL when combined with conventional therapy. The objective of the project will be to evaluate the impact of adding anodal high-definition (HD)-tDCS during an intensive 3-week UL VRT and conventional therapy program on paretic UL function in chronic stroke.

METHODS

The ReArm project is a quadruple-blinded, randomized, sham-controlled, bi-centre, two-arm parallel, and interventional study design. Fifty-eight chronic (> 3 months) stroke patients will be recruited from the Montpellier and Nimes University Hospitals. Patients will follow a standard 3-week in-patient rehabilitation program, which includes 13 days of VRT (Armeo Spring, 1 × 30 min session/day) and conventional therapy (3 × 30 min sessions/day). Twenty-nine patients will receive real stimulation (4x1 anodal HD-tDCS montage, 2 mA, 20 min) to the ipsilesional primary motor cortex during the VRT session and the other 29 patients will receive active sham stimulation (2 mA, 30 s). All outcome measures will be assessed at baseline, at the end of rehabilitation and again 3 months later. The primary outcome measure will be the wolf motor function test. Secondary outcomes will include measures of UL function (Box and Block Test), impairment (Fugl Meyer Upper Extremity), compensation (Proximal Arm Non-Use), ADL (Actimetry, Barthel Index). Other/exploratory outcomes will include pain, fatigue, effort and performance, kinematics, and motor cortical region activation during functional motor tasks.

DISCUSSION

This will be the first trial to determine the impact of adding HD-tDCS during UL VRT and conventional therapy in chronic stroke patients. We hypothesize that improvements in UL function will be greater and longer-lasting with real stimulation than in those receiving sham.

TRIAL REGISTRATION

The ReArm project was approved by The French Research Ethics Committee, (Comité de Protection des Personnes-CPP SUD-EST II, N°ID-RCB: 2019-A00506-51, http://www.cppsudest2.fr/ ). The ReArm project was registered on ClinicalTrials.gov ( NCT04291573 , 2nd March 2020.

Validity of Hololens Augmented Reality Head Mounted Display for Measuring Gait Parameters in Healthy Adults and Children with Cerebral Palsy

Serious games are a promising approach to improve gait rehabilitation for people with gait disorders. Combined with wearable augmented reality headset, serious games for gait rehabilitation in a clinical setting can be envisaged, allowing to evolve in a real environment and provide fun and feedback to enhance patient’s motivation. This requires a method to obtain accurate information on the spatiotemporal gait parameters of the playing patient. To this end, we propose a new algorithm called HoloStep that computes spatiotemporal gait parameters using only the head pose provided by an augmented reality headset (Hololens). It is based on the detection of peaks associated to initial contact event, and uses a combination of locking distance, locking time, peak amplitude detection with custom thresholds for children with CP. The performance of HoloStep was compared during a walking session at comfortable speed to Zeni’s reference algorithm, which is based on kinematics and a full 3D motion capture system. Our study included 62 children with cerebral palsy (CP), classified according to Gross Motor Function Classification System (GMFCS) between levels I and III, and 13 healthy participants (HP). Metrics such as sensitivity, specificity, accuracy and precision for step detection with HoloStep were above 96%. The Intra-Class Coefficient between steps length calculated with HoloStep and the reference was 0.92 (GMFCS I), 0.86 (GMFCS II/III) and 0.78 (HP). HoloStep demonstrated good performance when applied to a wide range of gait patterns, including children with CP using walking aids. Findings provide important insights for future gait intervention using augmented reality games for children with CP.

Upregulating excitability of corticospinal pathways in stroke patients using TMS neurofeedback; A pilot study

Upper limb weakness following a stroke affects 80% of survivors and is a key factor in preventing their return to independence. State-of-the art approaches to rehabilitation often require that the patient can generate some activity in the paretic limb, which is not possible for many patients in the early period following stroke. Approaches that enable more patients to engage with upper limb therapy earlier are urgently needed. Motor imagery has shown promise as a potential means to maintain activity in the brain's motor network, when the patient is incapable of generating functional movement. However, as imagery is a hidden mental process, it is impossible for individuals to gauge what impact this is having upon their neural activity. Here we used a novel brain-computer interface (BCI) approach allowing patients to gain an insight into the effect of motor imagery on their brain-muscle pathways, in real-time. Seven patients 2-26 weeks post stroke were provided with neurofeedback (NF) of their corticospinal excitability measured by the size of motor evoked potentials (MEP) in response to transcranial magnetic stimulation (TMS). The aim was to train patients to use motor imagery to increase the size of MEPs, using the BCI with a computer game displaying neurofeedback. Patients training finger muscles learned to elevate MEP amplitudes above their resting baseline values for the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles. By day 3 for ADM and day 4 for FDI, MEP amplitudes were sustained above baseline in all three NF blocks. Here we have described the first clinical implementation of TMS NF in a population of sub-acute stroke patients. The results show that in the context of severe upper limb paralysis, patients are capable of using neurofeedback to elevate corticospinal excitability in the affected muscles. This may provide a new training modality for early intervention following stroke.

Kinematic parameters obtained with the ArmeoSpring for upper-limb assessment after stroke: a reliability and learning effect study for guiding parameter use

BACKGROUND

After stroke, kinematic measures obtained with non-robotic and robotic devices are highly recommended to precisely quantify the sensorimotor impairments of the upper-extremity and select the most relevant therapeutic strategies. Although the ArmeoSpring exoskeleton has demonstrated its effectiveness in stroke motor rehabilitation, its interest as an assessment tool has not been sufficiently documented. The aim of this study was to investigate the psychometric properties of selected kinematic parameters obtained with the ArmeoSpring in post-stroke patients.

METHODS

This study involved 30 post-stroke patients (mean age = 54.5 ± 16.4 years; time post-stroke = 14.7 ± 26.7 weeks; Upper-Extremity Fugl-Meyer Score (UE-FMS) = 40.7 ± 14.5/66) who participated in 3 assessment sessions, each consisting of 10 repetitions of the 'horizontal catch' exercise. Five kinematic parameters (task and movement time, hand path ratio, peak velocity, number of peak velocity) and a global Score were computed from raw ArmeoSpring' data. Learning effect and retention were analyzed using a 2-way repeated-measures ANOVA, and reliability was investigated using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC).

RESULTS

We observed significant inter- and intra-session learning effects for most parameters except peak velocity. The measures performed in sessions 2 and 3 were significantly different from those of session 1. No additional significant difference was observed after the first 6 trials of each session and successful retention was also highlighted for all the parameters. Relative reliability was moderate to excellent for all the parameters, and MDC values expressed in percentage ranged from 42.6 to 102.8%.

CONCLUSIONS

After a familiarization session, the ArmeoSpring can be used to reliably and sensitively assess motor impairment and intervention effects on motor learning processes after a stroke. Trial registration The study was approved by the local hospital ethics committee in September 2016 and was registered under number 05-0916.

Repetitions, duration and intensity of upper limb practice following the implementation of robot assisted therapy with sub-acute stroke survivors: an observational study

BACKGROUND

Robot assisted upper limb (UL) therapy has been identified as an intervention with the potential to help improve the amount of practice performed by stroke survivors.

OBJECTIVES

This study aimed to measure the amount of UL practice (i.e., repetitions, duration, intensity) performed by subacute stroke survivors, in particular those with severe UL impairment, pre and post implementation of robot assisted upper limb therapy (RT-UL) into an inpatient rehabilitation setting.

METHODS

Two observational study phases (pre-RT-UL and post-RT-UL) were undertaken of occupational therapy and physiotherapy sessions performed by subacute stroke survivors. Upper limb tasks observed and recorded in therapy were classified as either impairment-related therapy or activity-related.

RESULTS

In the pre-RT-UL observational phase, 7 subacute stroke survivors were observed across 11 days involving 25 therapy sessions. Post-RT-UL, 12 subacute stroke survivors were observed across 12 days involving 29 therapy sessions. There were no significant differences in characteristics of patients observed in each phase (p > .05). The mean difference (95% CI) between pre and post RT-UL for repetitions (reps) (569 (1 to 1136) and intensity (7 (4-11)) reps/min of practice increased for all patients, including those with severe UL impairment (337 (37-638)) reps and 8 (2-14) reps/minute, with the duration of therapy unchanged.

CONCLUSIONS

This is the first study to have observed an increase in UL practice with the inclusion of RT-UL as part of routine clinical practice. This increase in practice is considered to be due to RT-UL providing highly supportive and expeditious semi-supervised practice. Notably, RT-UL was able to be implemented within the existing organisational structures with only basic training of therapy staff.IMPLICATIONS FOR REHABILITATIONRobotics presents as a viable intervention to increase the amount and intensity of upper limb practice performed by stroke survivors in routine clinical practiceRobotics were able to be implemented within the existing organisational structures with only basic training of therapy staff.

Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke

Upper limb motor deficits in severe stroke survivors often remain unresolved over extended time periods. Novel neurotechnologies have the potential to significantly support upper limb motor restoration in severely impaired stroke individuals. Here, we review recent controlled clinical studies and reviews focusing on the mechanisms of action and effectiveness of single and combined technology-aided interventions for upper limb motor rehabilitation after stroke, including robotics, muscular electrical stimulation, brain stimulation and brain computer/machine interfaces. We aim at identifying possible guidance for the optimal use of these new technologies to enhance upper limb motor recovery especially in severe chronic stroke patients. We found that the current literature does not provide enough evidence to support strict guidelines, because of the variability of the procedures for each intervention and of the heterogeneity of the stroke population. The present results confirm that neurotechnology-aided upper limb rehabilitation is promising for severe chronic stroke patients, but the combination of interventions often lacks understanding of single intervention mechanisms of action, which may not reflect the summation of single intervention’s effectiveness. Stroke rehabilitation is a long and complex process, and one single intervention administrated in a short time interval cannot have a large impact for motor recovery, especially in severely impaired patients. To design personalized interventions combining or proposing different interventions in sequence, it is necessary to have an excellent understanding of the mechanisms determining the effectiveness of a single treatment in this heterogeneous population of stroke patients. We encourage the identification of objective biomarkers for stroke recovery for patients’ stratification and to tailor treatments. Furthermore, the advantage of longitudinal personalized trial designs compared to classical double-blind placebo-controlled clinical trials as the basis for precise personalized stroke rehabilitation medicine is discussed. Finally, we also promote the necessary conceptual change from ‘one-suits-all’ treatments within in-patient clinical rehabilitation set-ups towards personalized home-based treatment strategies, by adopting novel technologies merging rehabilitation and motor assistance, including implantable ones.

Advanced Neurotechnologies for the Restoration of Motor Function

Stroke is one of the leading causes of long-term disability. Advanced technological solutions ("neurotechnologies") exploiting robotic systems and electrodes that stimulate the nervous system can increase the efficacy of stroke rehabilitation. Recent studies on these approaches have shown promising results. However, a paradigm shift in the development of new approaches must be made to significantly improve the clinical outcomes of neurotechnologies compared with those of traditional therapies. An "evolutionary" change can occur only by understanding in great detail the basic mechanisms of natural stroke recovery and technology-assisted neurorehabilitation. In this review, we first describe the results achieved by existing neurotechnologies and highlight their current limitations. In parallel, we summarize the data available on the mechanisms of recovery from electrophysiological, behavioral, and anatomical studies in humans and rodent models. Finally, we propose new approaches for the effective use of neurotechnologies in stroke survivors, as well as in people with other neurological disorders.

Dissociating motor learning from recovery in exoskeleton training post-stroke

Background

A large number of robotic or gravity-supporting devices have been developed for rehabilitation of upper extremity post-stroke. Because these devices continuously monitor performance data during training, they could potentially help to develop predictive models of the effects of motor training on recovery. However, during training with such devices, patients must become adept at using the new “tool” of the exoskeleton, including learning the new forces and visuomotor transformations associated with the device. We thus hypothesized that the changes in performance during extensive training with a passive, gravity-supporting, exoskeleton device (the Armeo Spring) will follow an initial fast phase, due to learning to use the device, and a slower phase that corresponds to reduction in overall arm impairment. Of interest was whether these fast and slow processes were related.

Methods

To test the two-process hypothesis, we used mixed-effect exponential models to identify putative fast and slow changes in smoothness of arm movements during 80 arm reaching tests performed during 20 days of exoskeleton training in 53 individuals with post-acute stroke.

Results

In line with our hypothesis, we found that double exponential models better fit the changes in smoothness of arm movements than single exponential models. In contrast, single exponential models better fit the data for a group of young healthy control subjects. In addition, in the stroke group, we showed that smoothness correlated with a measure of impairment (the upper extremity Fugl Meyer score - UEFM) at the end, but not at the beginning, of training. Furthermore, the improvement in movement smoothness due to the slow component, but not to the fast component, strongly correlated with the improvement in the UEFM between the beginning and end of training. There was no correlation between the change of peaks due to the fast process and the changes due to the slow process. Finally, the improvement in smoothness due to the slow, but not the fast, component correlated with the number of days since stroke at the onset of training – i.e. participants who started exoskeleton training sooner after stroke improved their smoothness more.

Conclusions

Our results therefore demonstrate that at least two processes are involved in in performance improvements measured during mechanized training post-stroke. The fast process is consistent with learning to use the exoskeleton, while the slow process independently reflects the reduction in upper extremity impairment.

A Multiple-Plasticity Spiking Neural Network Embedded in a Closed-Loop Control System to Model Cerebellar Pathologies

The cerebellum plays a crucial role in sensorimotor control and cerebellar disorders compromise adaptation and learning of motor responses. However, the link between alterations at network level and cerebellar dysfunction is still unclear. In principle, this understanding would benefit of the development of an artificial system embedding the salient neuronal and plastic properties of the cerebellum and operating in closed-loop. To this aim, we have exploited a realistic spiking computational model of the cerebellum to analyze the network correlates of cerebellar impairment. The model was modified to reproduce three different damages of the cerebellar cortex: (i) a loss of the main output neurons (Purkinje Cells), (ii) a lesion to the main cerebellar afferents (Mossy Fibers), and (iii) a damage to a major mechanism of synaptic plasticity (Long Term Depression). The modified network models were challenged with an Eye-Blink Classical Conditioning test, a standard learning paradigm used to evaluate cerebellar impairment, in which the outcome was compared to reference results obtained in human or animal experiments. In all cases, the model reproduced the partial and delayed conditioning typical of the pathologies, indicating that an intact cerebellar cortex functionality is required to accelerate learning by transferring acquired information to the cerebellar nuclei. Interestingly, depending on the type of lesion, the redistribution of synaptic plasticity and response timing varied greatly generating specific adaptation patterns. Thus, not only the present work extends the generalization capabilities of the cerebellar spiking model to pathological cases, but also predicts how changes at the neuronal level are distributed across the network, making it usable to infer cerebellar circuit alterations occurring in cerebellar pathologies.

The sensory side of post-stroke motor rehabilitation

Contemporary strategies to promote motor recovery following stroke focus on repetitive voluntary movements. Although successful movement relies on efficient sensorimotor integration, functional outcomes often bias motor therapy toward motor-related impairments such as weakness, spasticity and synergies; sensory therapy and reintegration is implied, but seldom targeted. However, the planning and execution of voluntary movement requires that the brain extracts sensory information regarding body position and predicts future positions, by integrating a variety of sensory inputs with ongoing and planned motor activity. Neurological patients who have lost one or more of their senses may show profoundly affected motor functions, even if muscle strength remains unaffected. Following stroke, motor recovery can be dictated by the degree of sensory disruption. Consequently, a thorough account of sensory function might be both prognostic and prescriptive in neurorehabilitation. This review outlines the key sensory components of human voluntary movement, describes how sensory disruption can influence prognosis and expected outcomes in stroke patients, reports on current sensory-based approaches in post-stroke motor rehabilitation, and makes recommendations for optimizing rehabilitation programs based on sensory stimulation.

Entrenamiento motor en el continuo de la realidad a la virtualidad

Introducción. La trasformación de la capacidad de movimiento de las personas es un reto que el fisioterapeuta asume como estrategia de aprendizaje motor.Objetivo. Plantear los referentes teóricos y prácticos más relevantes en el uso de ambientes terapéuticos en el continuo de la realidad a la virtualidad en el entrenamiento motor de pacientes con accidente cerebrovascular y enfermedad de Parkinson. Materiales y métodos. Revisión de la literatura que analiza y aporta de manera conceptual, en el área de la rehabilitación y la fisioterapia, información sobre entrenamiento y aprendizaje motor.Resultados. Se evidencia potencial en el uso de la realidad virtual para la rehabilitación de alteraciones del movimiento debidas a disfunciones neurológicas. Las herramientas tecnológicas propias de la realidad virtual permiten un mayor conocimiento de los resultados con respecto a las características del movimiento, lo cual ayuda a mejorar el aprendizaje motor, en comparación con el entrenamiento tradicional.Conclusiones. Se requiere objetivar el proceso de rehabilitación para medir con precisión los cambios que producen estrategias de aprendizaje en las capacidades de movimiento de las personas con deficiencias del sistema neuromuscular para generar evidencia del impacto que tienen los programas de entrenamiento motor en el continuo de la realidad a la virtualidad.

Intrapersonal and interpersonal evaluation of upper extremity kinematics

BACKGROUND

The quality of upper extremity (UE) function can be evaluated by measuring the kinematic parameters of patient movements.

OBJECTIVE

This investigation focused on finding the angles and angular velocity amplitudes of UE motions in healthy participants to compare with the experimental results of patients with a UE disability who are trying to recover previous movement conditions.

METHODS

The UE motions of 23 healthy adult volunteers were tested using a three-dimensional motion capture system and measuring hand segment motions. A simplified 7 degrees of freedom (DOF) human arm kinematic model created within MATLAB and used to process the experimental data.

RESULTS

The interpersonal CV (coefficients of variability) of left-side motions showed that the lowest CV of linear velocity amplitudes was at elbow flexion (4.2%), but the highest was at wrist extension (48.3%). The lowest and highest CV of angular velocity amplitudes were 19.6% and 55.7%, during shoulder adduction and wrist extension, respectively.

CONCLUSIONS

High interpersonal CV may restrict the direct comparison of kinematic parameters of UE in different healthy and disabled persons.

Comprehensive, technology-based, team approach for a patient with locked-in syndrome: A case report of improved function & quality of life

One of the most severe types of stroke is locked-in syndrome (LIS) due to the loss of almost all voluntary motor functions and a high mortality rate. The majority of the literature regarding LIS is based on case reports that utilized multidisciplinary interventions focused on improving functional communication and respiratory care with minimal focus on motor retraining. These reports were neither dynamic nor multi-sensory, and the only technology utilized was in the form of augmentative communication. There are additional types of technology frequently used in the general stroke population that can address similar motor deficits that occur in the LIS population. This case report explains an interdisciplinary approach using motor and communication interventions that are multisensory, progressive, multi-modal, and technology- based. The length of stay was 153 days in acute rehabilitation, after which the patient returned home making significant gains in overall function. In this patient, the FIM changes in motor (+42), cognitive (+29) and total change score of (+71) surpassed what was determined to be a minimal clinically important difference. These results suggest that this treatment program and approach may be a key reason why this patient was able to achieve significant functional gains and report improved quality of life.

Effects of virtual reality for stroke individuals based on the International Classification of Functioning and Health: a systematic review

OBJECTIVE

This review determines the effects of virtual reality interventions for stroke subjects based on the International Classification of Functioning, Disability,and Health (ICF) framework. Virtual reality is a promising tool for therapy for stroke rehabilitation, but the effects of virtual reality interventions on post-stroke patients based on the specific ICF domains (Body Structures, Body Functions, Activity, and Participation) have not been investigated.

METHOD

A systematic review was conducted, including trials with adults with a clinical diagnosis of a chronic, subacute, or acute stroke. Eligible trials had to include studies with an intervention protocol and follow-up, with a focus on upper limbs and/or lower limbs and/or balance. The Physiotherapy Evidence Database (PEDro) was used to assess the methodological quality of randomized controlled trials. Each trial was separated according to methodological quality into a high-quality trial (PEDro ≥ 6) and a low-quality trial (PEDro ≤ 6). Only high-quality trials were analyzed specifically based on the outcome of these trials.

RESULTS

In total, 54 trials involving 1811 participants were included. Of the papers included and considered high quality, 14 trials evaluated areas of the Body Structures component, 20 trials of the Body Functions domain, 17 trials of the Activity component, and 8 trials of the Participation domain. In relation to ICF Part 2, four trials evaluated areas of the Personal Factors component and one trial evaluated domains of the Environmental Factors component.

DISCUSSION

The effects of virtual reality on stroke rehabilitation based on the ICF framework are positive in Body Function and Body Structure. However, the results in the domains Activity and Participation are inconclusive. More high-quality clinical trials are needed to confirm the effectiveness of virtual reality in the domains of Activity and Participation.

Does a Combination of Virtual Reality, Neuromodulation and Neuroimaging Provide a Comprehensive Platform for Neurorehabilitation? - A Narrative Review of the Literature

In the last decade, virtual reality (VR) training has been used extensively in video games and military training to provide a sense of realism and environmental interaction to its users. More recently, VR training has been explored as a possible adjunct therapy for people with motor and mental health dysfunctions. The concept underlying VR therapy as a treatment for motor and cognitive dysfunction is to improve neuroplasticity of the brain by engaging users in multisensory training. In this review, we discuss the theoretical framework underlying the use of VR as a therapeutic intervention for neurorehabilitation and provide evidence for its use in treating motor and mental disorders such as cerebral palsy, Parkinson’s disease, stroke, schizophrenia, anxiety disorders, and other related clinical areas. While this review provides some insights into the efficacy of VR in clinical rehabilitation and its complimentary use with neuroimaging (e.g., fNIRS and EEG) and neuromodulation (e.g., tDCS and rTMS), more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations.

Voluntary Modulation of Hemodynamic Responses in Swallowing Related Motor Areas: A Near-Infrared Spectroscopy-Based Neurofeedback Study

In the present study, we show for the first time that motor imagery of swallowing, which is defined as the mental imagination of a specific motor act without overt movements by muscular activity, can be successfully used as mental strategy in a neurofeedback training paradigm. Furthermore, we demonstrate its effects on cortical correlates of swallowing function. Therefore, N = 20 healthy young adults were trained to voluntarily increase their hemodynamic response in swallowing related brain areas as assessed with near-infrared spectroscopy (NIRS). During seven training sessions, participants received either feedback of concentration changes in oxygenated hemoglobin (oxy-Hb group, N = 10) or deoxygenated hemoglobin (deoxy-Hb group, N = 10) over the inferior frontal gyrus (IFG) during motor imagery of swallowing. Before and after the training, we assessed cortical activation patterns during motor execution and imagery of swallowing. The deoxy-Hb group was able to voluntarily increase deoxy-Hb over the IFG during imagery of swallowing. Furthermore, swallowing related cortical activation patterns were more pronounced during motor execution and imagery after the training compared to the pre-test, indicating cortical reorganization due to neurofeedback training. The oxy-Hb group could neither control oxy-Hb during neurofeedback training nor showed any cortical changes. Hence, successful modulation of deoxy-Hb over swallowing related brain areas led to cortical reorganization and might be useful for future treatments of swallowing dysfunction.

Hemodynamic Signal Changes Accompanying Execution and Imagery of Swallowing in Patients with Dysphagia: A Multiple Single-Case Near-Infrared Spectroscopy Study

In the present multiple case study, we examined hemodynamic changes in the brain in response to motor execution (ME) and motor imagery (MI) of swallowing in dysphagia patients compared to healthy matched controls using near-infrared spectroscopy (NIRS). Two stroke patients with cerebral lesions in the right hemisphere, two stroke patients with lesions in the brainstem, and two neurologically healthy control subjects actively swallowed saliva (ME) and mentally imagined to swallow saliva (MI) in a randomized order while changes in concentration of oxygenated hemoglobin (oxy-Hb) and deoxygenated hemoglobin (deoxy-Hb) were assessed. In line with recent findings in healthy young adults, MI and ME of swallowing led to the strongest NIRS signal change in the inferior frontal gyrus in stroke patients as well as in healthy elderly. We found differences in the topographical distribution and time course of the hemodynamic response in dependence on lesion location. Dysphagia patients with lesions in the brainstem showed bilateral hemodynamic signal changes in the inferior frontal gyrus during active swallowing comparable to healthy controls. In contrast, dysphagia patients with cerebral lesions in the right hemisphere showed more unilateral activation patterns during swallowing. Furthermore, patients with cerebral lesions showed a prolonged time course of the hemodynamic response during MI and ME of swallowing compared to healthy controls and patients with brainstem lesions. Brain activation patterns associated with ME and MI of swallowing were largely comparable, especially for changes in deoxy-Hb. Hence, the present results provide new evidence regarding timing and topographical distribution of the hemodynamic response during ME and MI of swallowing in dysphagia patients and may have practical impact on future dysphagia treatment.