Mirror Visual Feedback Prior to Robot-Assisted Training Facilitates Rehabilitation After Stroke: A Randomized Controlled Study

Effect of virtual reality-based upper limb training on activity of daily living and quality of life among stroke survivors: a systematic review and meta-analysis

BACKGROUND

Stroke is a leading cause of disability worldwide, significantly impairing upper limb (UL) function and reducing patients' ability to perform activities of daily living (ADL) and quality of life (QoL). Virtual reality (VR) has emerged as a promising tool for UL rehabilitation, offering immersive and engaging environments for motor recovery. However, the effectiveness of VR, its integration with conventional therapy, and their efficacy across different stroke recovery stages remain unclear. Therefore, this systematic review and meta-analysis aimed to evaluate the effectiveness of VR-based UL interventions in improving ADL and QoL among stroke survivors.

METHOD

This study adhered to PRISMA guidelines and was registered on PROSPERO (CRD42023426256). A systematic search of PubMed, Scopus, and Web of Science identified randomized controlled trials (RCTs) published in English. Inclusion criteria focused on studies using immersive VR (IVR) and non-immersive VR (NIVR) interventions to assess ADL and QoL in stroke survivors. Data extraction and quality assessment were performed independently by two reviewers using the PEDro scale to assess quality. Meta-analyses were conducted to determine the efficacy. Subgroup analyses were performed to compare IVR and NIVR, VR combined with conventional therapy versus standalone VR, and potential differences between stroke recovery stages.

RESULT

Thirty RCTs, representing 1,661 participants, were included. Overall, VR interventions significantly improved ADL (SMD = 0.27, 95% CI [0.11; 0.43], p < 0.001) and QoL (SMD = 0.94 [0.09; 1.79], p = 0.035) compared to conventional therapy. IVR demonstrated superior outcomes for ADL compared to NIVR (SMD = 0.54 [0.13; 0.95] Vs. 0.17 [0.02; 0.36], p = 0.03). Subacute stroke survivors exhibited the most significant gains in ADL (SMD = 0.52 [0.16; 0.88], p = 0.004), compared to chronic (SMD = 0.05 [-0.36; 0.46]) or acute patients (SMD = 0.08 [-0.11; 0.27]).

CONCLUSION

VR interventions, particularly IVR and VR combined with conventional therapy, significantly enhance ADL and QoL in stroke survivors with moderate certainty of evidence. These findings underscore the value of VR in rehabilitation, especially during the subacute phase, but highlight the need for further research into long-term effects and implementation in low-resource settings.

Functional Reorganization of White Matter Supporting the Transhemispheric Mechanism of Mirror Therapy After Stroke: A Multimodal MRI Study

Mirror therapy (MT) is an effective approach in stroke recovery, but its impact on subcortical neural reorganization remains unclear. Thus, we aimed to investigate the neuroplastic effects on white matter due to MT. In this study, thirty-three participants with stroke were recruited and randomly assigned into the MT group (n = 16) or the control group (n = 17) for a 4-week intervention. Before and after the intervention, motor recovery was evaluated using the Fugl-Meyer Assessment upper limb subscale (FMA-UL), and the white matter structure and function were investigated using DTI and resting-state fMRI, focusing on the corticospinal tract and the corpus callosum. Significant correlations between the improvements of the FMA-UL and the baseline fractional anisotropy of ipsilesional corticospinal tract ( ) and corpus callosum ( ) were observed only in the MT group. Additionally, no significant structural alterations were found between the two groups after the intervention. The fractional amplitude of low-frequency fluctuation of ipsilesional corticospinal tract ( ) and corpus callosum ( ) were significantly enhanced only in the MT group, which were correlated with the improvements of the FMA-UL ( ). Furthermore, partial correlation analysis and subsequent mediation model analysis suggested that the changes of fractional amplitude of low-frequency fluctuation in corpus callosum partially mediated the effect of the baseline fractional anisotropy of ipsilesional corticospinal tract on the FMA-UL improvements in the MT group. This study provided neuroimaging evidence on white matter reorganization after MT, specifically the corpus callosum, suggesting a potential interhemispheric transcallosal neuroplastic mechanism of MT.

Virtual Reality Enhanced Exercise Training in Upper Limb Function of Patients With Stroke: Meta-Analytic Study

BACKGROUND

Recovery of upper limb function after stroke secondary to ischemia or hemorrhage is crucial for patients' independence in daily living and quality of life. Virtual reality (VR) is a promising computer-based technology designed to enhance the effects of rehabilitation; however, the results of VR-based interventions remain equivocal.

OBJECTIVE

This study aims to review the plausible factors that may have influenced VR's therapeutic effects on improving upper limb function in patients with stroke, with the goal of synthesizing an optimal VR intervention protocol.

METHODS

The databases PubMed, EMBASE, Web of Science, and Cochrane Library were queried for English-language papers published from May 2022 onward. Two reviewers independently extracted data from the included papers, and discrepancies in their findings were resolved through consensus during joint meetings. The risk of bias was assessed using the Physiotherapy Evidence Database Scale and the Methodological Index for Non-Randomized Studies. Outcome variables included the Action Research Arm Test, Box-Block Test, Functional Independence Measure, Upper Extremity Fugl-Meyer Assessment, and Wolf Motor Function Test. The plausible factors examined were age, total dosage (hours), trial length (weeks), session duration (hours/session), frequency (sessions/week), and VR content design. The Bonferroni adjustment was applied to P values to prevent data from being incorrectly deemed statistically significant.

RESULTS

The final sample included 15 articles with a total of 1243 participants (age range 48.6-75.59 years). Participants in the VR therapy (VRT) group (n=455) demonstrated significantly greater improvements in upper limb function and independence in activities of daily living compared with those in the conventional therapy group (n=301). Significant factors contributing to improved outcomes in upper limb function were younger age (mean difference [MD] 5.34, 95% CI 2.18-8.5, P<.001; I2=0%), interventions lasting more than 15 hours (MD 9.67, 95% CI 4.19-15.15, P<.001; I2=0%), trial lengths exceeding 4 weeks (MD 4.02, 95% CI 1.39-6.65, P=.003; I2=15%), and more than 4 sessions per week (MD 3.48, 95% CI 0.87-6.09, P=.009; I2=0%). However, the design of the VR content, including factors such as the number of features (eg, offering exercise and functional tasks; individualized goals; activity quantification; consideration of comorbidities and baseline activity level; addressing patient needs; aligning with patient background such as education level; patient-directed goals and interests; goal setting; progressive difficulty levels; and promoting self-efficacy), did not demonstrate significant effects (MD 3.89, 95% CI -6.40 to 1.09; effect Z=1.36, P=.16).

CONCLUSIONS

Greater VR effects on improving upper limb function in patients with stroke were associated with higher training doses (exceeding 15 hours) delivered over 4-6 weeks, with shorter sessions (approximately 1 hour) scheduled 4 or more times per week. Additionally, younger patients appeared to benefit more from the VR protocol compared with older patients.

Effectiveness of robot-assisted task-oriented training intervention for upper limb and daily living skills in stroke patients: A meta-analysis

PURPOSE

Stroke is one of the leading causes of acquired disability in adults in high-income countries. This study aims to determine the intervention effects of robot-assisted task-oriented training on enhancing the upper limb function and daily living skills of stroke patients.

METHODS

A systematic search was conducted across PubMed, China National Knowledge Infrastructure, Web of Science, Cochrane Library, Embase, and Scopus databases through March 1, 2024. This process yielded 1,649 articles, from which 15 studies with 574 samples met the inclusion criteria for analysis. The quality of the included studies was evaluated using the Cochrane Risk of Bias tool. We performed meta-analyses, subgroup analyses, regression analyses, and sensitivity analyses using Review Manager 5.4 and Stata 17.0. Furthermore, publication bias was assessed using Begg's and Egger's tests. This study is registered with PROSPERO (No. CRD42024513483).

RESULTS

A random effects model was utilized. The results indicated that robot-assisted task-oriented training significantly improved Fugl-Meyer Assessment-Upper Extremity scores compared to the control group [SMD = 1.01, 95% CI (0.57, 1.45)]. Similarly, robot-assisted task-oriented training demonstrated a significant effect on the Modified Barthel Index scores [SMD = 0.61, 95% CI (0.41, 0.82)]. Subgroup and regression analyses revealed that the use of combined interventions, the geographical region of the first author, and the age of the subjects did not appear to be sources of high heterogeneity. Publication bias tests using the FMA-UE as an outcome measure yielded Begg's test (p = 0.76) and Egger's test (p = 0.93), suggesting no significant publication bias. Sensitivity analyses confirmed the robustness of the study findings.

CONCLUSIONS

Robot-assisted task-oriented training significantly enhances the rehabilitation of upper limb function and the recovery of daily living skills in stroke patients.

Motor imagery priming improves activity and impairment outcomes in people after stroke but the effects of other types of priming are unclear: a systematic review

QUESTION

In stroke rehabilitation, what is the effect of adding non-stimulation-based priming prior to task-specific practice on activity and motor impairment outcomes compared with task-specific practice alone?

DESIGN

Systematic review with meta-analysis.

PARTICIPANTS

Adult stroke survivors.

INTERVENTION

The experimental groups completed a non-stimulation priming intervention prior to task-specific practice. The priming interventions were: motor imagery; action observation; combined motor imagery and action observation; mirror therapy; movement-based priming; and aerobic exercise-based priming. The control groups completed task-specific practice alone.

OUTCOME MEASURES

Upper and lower limb activity and motor impairment.

RESULTS

Twenty-four trials involving 803 participants were included in this systematic review. Twenty trials were included in the meta-analyses of activity outcomes and 11 trials in the meta-analyses of impairment outcomes. Four trials examined the effect of motor imagery priming prior to task-specific practice on activity outcomes (SMD 0.48, 95% CI 0.13 to 0.82). Three trials examined the effect of motor imagery priming prior to task-specific practice on motor impairment outcomes (SMD 0.51, 95% CI 0.12 to 0.89). Nine trials examined the effect of action observation priming prior to task-specific practice on activity outcomes (SMD 0.18, 95% CI -0.06 to 0.41). Two trials examined the effect of movement-based priming prior to task-specific practice on activity outcomes (SMD -0.11, 95% CI -0.64 to 0.42). Three trials examined the effect of aerobic exercise priming prior to task-specific practice on activity outcomes (SMD 0.30, 95% CI -0.19 to 0.80). The quality of the evidence was low to moderate.

CONCLUSION

In stroke rehabilitation, motor imagery priming implemented prior to task-specific training has a very small to large effect on activity and motor impairment outcomes. Action observation priming implemented prior to task-specific training has a negligible to small effect on activity outcomes. Movement-based and aerobic exercise-based priming do not have any clear effect on outcomes.

REGISTRATION

CRD42020093519.

Virtual reality exergames for enhancing engagement in stroke rehabilitation: A narrative review

This narrative review focuses on upper-limb stroke rehabilitation and virtual reality (VR) exergaming interventions that seek to facilitate the rehabilitation process. We examine exergaming interventions from the perspective of diegesis ("narration"), an aspect often overlooked despite its significance in neuronal rehabilitation. The importance of diegesis and narrative engagement in rehabilitation exergames started becoming clear only recently, with findings in the field of neurology underscoring the impact of purpose-driven task engagement on neuroplasticity. We begin this review by examining various frameworks for stroke rehabilitation exergames and identifying the gaps in the existing literature. We continue with summarizing the literature on exergames in upper-limb stroke rehabilitation, emphasizing the contribution of diegesis on exercise motivation and engagement. Finally, we conclude this review by offering insights into the current state of research, along with future perspectives on the topic.

The efficacy of virtual reality for upper limb rehabilitation in stroke patients: a systematic review and meta-analysis

BACKGROUND

Stroke frequently gives rise to incapacitating motor impairments in the upper limb. Virtual reality (VR) rehabilitation has exhibited potential for augmenting upper extremity recovery; nonetheless, the optimal techniques for such interventions remain a topic of uncertainty. The present systematic review and meta-analysis were undertaken to comprehensively compare VR-based rehabilitation with conventional occupational therapy across a spectrum of immersion levels and outcome domains.

METHODS

A systematic search was conducted in PubMed, IEEE, Scopus, Web of Science, and PsycNET databases to identify randomized controlled trials about upper limb rehabilitation in stroke patients utilizing VR interventions. The search encompassed studies published in the English language up to March 2023. The identified studies were stratified into different categories based on the degree of immersion employed: non-immersive, semi-immersive, and fully-immersive settings. Subsequent meta-analyses were executed to assess the impact of VR interventions on various outcome measures.

RESULTS

Of the 11,834 studies screened, 55 studies with 2142 patients met the predefined inclusion criteria. VR conferred benefits over conventional therapy for upper limb motor function, functional independence, Quality of life, Spasticity, and dexterity. Fully immersive VR showed the greatest gains in gross motor function, while non-immersive approaches enhanced fine dexterity. Interventions exceeding six weeks elicited superior results, and initiating VR within six months post-stroke optimized outcomes.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that adjunctive VR-based rehabilitation enhances upper limb motor recovery across multiple functional domains compared to conventional occupational therapy alone after stroke. Optimal paradigms likely integrate VR's immersive capacity with conventional techniques.

TRIAL REGISTRATION

This systematic review and meta-analysis retrospectively registered in the OSF registry under the identifier [ https://doi.org/10.17605/OSF.IO/YK2RJ ].

Effects of task-based mirror therapy on upper limb motor function in hemiplegia: study protocol for a randomized controlled clinical trial

BACKGROUND AND PURPOSE

Research to date has lacked definitive evidence to determine whether mirror therapy promotes the recovery of upper extremity function after stroke. Considering that previous studies did not stratify patients based on structural retention, this may be one of the reasons for the negative results obtained in many trials. The goal evaluates the efficacy of TBMT (utilizing an innovatively designed mirror) versus standard occupational therapy for stroke patient's upper limb functionality.

METHODS AND ANALYSIS

This single-center randomized controlled trial will involve 50 patients with stroke. All patients will be randomly assigned to either the task-based mirror therapy or the control group. The interventions will be performed 5 days per week for 4 weeks. The primary outcomes will be the mean change in scores on both the FMA-UE and modified Barthel Index (MBI) from baseline to 4 weeks intervention and at 12 weeks follow-up between the two groups and within groups. The other outcomes will include the Action Research Arm Test (ARAT), the Nine Hole Peg Test (9HPT), the Functional Independence Measure, and MRI.

DISCUSSION

This trial will not only to establish that task-based mirror therapy (TBMT) could improve the recovery of hand function after stroke but also to explore the underlying mechanisms. We expect that this finding will clarify the brain activation and brain network mechanisms underlying the improvement of hand function with task-oriented mirror therapy and lead to new ideas for stroke hand function rehabilitation.

TRIAL REGISTRATION

URL: https://www.chictr.org.cn ; Unique identifier: ChiCTR2300068855. Registered on March 1, 2023.

The effect of sequential combination of mirror therapy and robot-assisted therapy on motor function, daily function, and self-efficacy after stroke

Robot-assisted therapy and mirror therapy are both effective in promoting upper limb function after stroke and combining these two interventions might yield greater therapeutic effects. We aimed to examine whether using mirror therapy as a priming strategy would augment therapeutic effects of robot-assisted therapy. Thirty-seven chronic stroke survivors (24 male/13 female; age = 49.8 ± 13.7 years) were randomized to receive mirror therapy or sham mirror therapy prior to robot-assisted therapy. All participants received 18 intervention sessions (60 min/session, 3 sessions/week). Outcome measures were evaluated at baseline and after the 18-session intervention. Motor function was assessed using Fugl-Meyer Assessment and Wolf Motor Function Test. Daily function was assessed using Nottingham Extended Activities of Daily Living Scale. Self-efficacy was assessed using Stroke Self-Efficacy Questionnaires and Daily Living Self-Efficacy Scale. Data was analyzed using mixed model analysis of variance. Both groups demonstrated statistically significant improvements in measures of motor function and daily function, but no significant between-group differences were found. Participants who received mirror therapy prior to robot-assisted therapy showed greater improvements in measures of self-efficacy, compared with those who received sham mirror therapy. Our findings suggest that sequentially combined mirror therapy with robot-assisted therapy could be advantageous for enhancing self-efficacy post-stroke.Trial registration: ClinicalTrials.gov Identifier: NCT03917511. Registered on 17/04/2019, https://clinicaltrials.gov/ct2/show/ NCT03917511.

Exploration on neurobiological mechanisms of the central–peripheral–central closed-loop rehabilitation

Central and peripheral interventions for brain injury rehabilitation have been widely employed. However, as patients’ requirements and expectations for stroke rehabilitation have gradually increased, the limitations of simple central intervention or peripheral intervention in the rehabilitation application of stroke patients’ function have gradually emerged. Studies have suggested that central intervention promotes the activation of functional brain regions and improves neural plasticity, whereas peripheral intervention enhances the positive feedback and input of sensory and motor control modes to the central nervous system, thereby promoting the remodeling of brain function. Based on the model of a central–peripheral–central (CPC) closed loop, the integration of center and peripheral interventions was effectively completed to form “closed-loop” information feedback, which could be applied to specific brain areas or function-related brain regions of patients. Notably, the closed loop can also be extended to central and peripheral immune systems as well as central and peripheral organs such as the brain–gut axis and lung–brain axis. In this review article, the model of CPC closed-loop rehabilitation and the potential neuroimmunological mechanisms of a closed-loop approach will be discussed. Further, we highlight critical questions about the neuroimmunological aspects of the closed-loop technique that merit future research attention.

Synergistic Immediate Cortical Activation on Mirror Visual Feedback Combined With a Soft Robotic Bilateral Hand Rehabilitation System: A Functional Near Infrared Spectroscopy Study

Background

Mirror visual feedback (MVF) has been widely used in neurological rehabilitation. Due to the potential gain effect of the MVF combination therapy, the related mechanisms still need be further analyzed.

Methods

Our self-controlled study recruited 20 healthy subjects (age 22.150 ± 2.661 years) were asked to perform four different visual feedback tasks with simultaneous functional near infrared spectroscopy (fNIRS) monitoring. The right hand of the subjects was set as the active hand (performing active movement), and the left hand was set as the observation hand (static or performing passive movement under soft robotic bilateral hand rehabilitation system). The four VF tasks were designed as RVF Task (real visual feedback task), MVF task (mirror visual feedback task), BRM task (bilateral robotic movement task), and MVF + BRM task (Mirror visual feedback combined with bilateral robotic movement task).

Results

The beta value of the right pre-motor cortex (PMC) of MVF task was significantly higher than the RVF task (RVF task: -0.015 ± 0.029, MVF task: 0.011 ± 0.033, P = 0.033). The beta value right primary sensorimotor cortex (SM1) in MVF + BRM task was significantly higher than MVF task (MVF task: 0.006 ± 0.040, MVF + BRM task: 0.037 ± 0.036, P = 0.016).

Conclusion

Our study used the synchronous fNIRS to compare the immediate hemodynamics cortical activation of four visual feedback tasks in healthy subjects. The results showed the synergistic gain effect on cortical activation from MVF combined with a soft robotic bilateral hand rehabilitation system for the first time, which could be used to guide the clinical application and the future studies.