The Effect of Trunk Stability Training Based on Visual Feedback on Trunk Stability, Balance, and Upper Limb Function in Stroke Patients: A Randomized Control Trial

Wearable Smartphone-Based Multisensory Feedback System for Torso Posture Correction: Iterative Design and Within-Subjects Study

BACKGROUND

The prevalence of stroke is high in both males and females, and it rises with age. Stroke often leads to sensor and motor issues, such as hemiparesis affecting one side of the body. Poststroke patients require torso stabilization exercises, but maintaining proper posture can be challenging due to their condition.

OBJECTIVE

Our goal was to develop the Postural SmartVest, an affordable wearable technology that leverages a smartphone's built-in accelerometer to monitor sagittal and frontal plane changes while providing visual, tactile, and auditory feedback to guide patients in achieving their best-at-the-time posture during rehabilitation.

METHODS

To design the Postural SmartVest, we conducted brainstorming sessions, therapist interviews, gathered requirements, and developed the first prototype. We used this initial prototype in a feasibility study with individuals without hemiparesis (n=40, average age 28.4). They used the prototype during 1-hour seated sessions. Their feedback led to a second prototype, which we used in a pilot study with a poststroke patient. After adjustments and a kinematic assessment using the Vicon Gait Plug-in system, the third version became the Postural SmartVest. We assessed the Postural SmartVest in a within-subject experiment with poststroke patients (n=40, average age 57.1) and therapists (n=20, average age 31.3) during rehabilitation sessions. Participants engaged in daily activities, including walking and upper limb exercises, without and with app feedback.

RESULTS

The Postural SmartVest comprises a modified off-the-shelf athletic lightweight compression tank top with a transparent pocket designed to hold a smartphone running a customizable Android app securely. This app continuously monitors sagittal and frontal plane changes using the built-in accelerometer sensor, providing multisensory feedback through audio, vibration, and color changes. Patients reported high ratings for weight, comfort, dimensions, effectiveness, ease of use, stability, durability, and ease of adjustment. Therapists noted a positive impact on rehabilitation sessions and expressed their willingness to recommend it. A 2-tailed t-test showed a significant difference (P<.001) between the number of the best-at-the-time posture positions patients could maintain in 2 stages, without feedback (mean 13.1, SD 7.12) and with feedback (mean 4.2, SD 3.97), demonstrating the effectiveness of the solution in improving posture awareness.

CONCLUSIONS

The Postural SmartVest aids therapists during poststroke rehabilitation sessions and assists patients in improving their posture during these sessions.

Contributing factors and interventions for fear of falling in stroke survivors: a systematic review

OBJECTIVES

The purpose of this study was to provide a comprehensive overview of the prevalence, measurement tools, influencing factors, and interventions for fear of falling (FOF) in stroke survivors.

METHODS

A PRISMA-guided systematic literature review was conducted. PubMed, EMBASE, Cochrane, and Web of Science were systematically searched. The search time was up to February 2023. All observational and experimental studies investigating FOF in stroke patients were included. The assessment tool of the Joanna Briggs Institute was used to assess the quality of the included studies and the risk of bias assessment. (PROSPERO: CRD42023412522).

RESULT

A total of 25 observational studies and 10 experimental studies were included. The overall quality of the included studies was "low" to "good." The most common tool used to measure the FOF was the Falls Efficacy Scale-International (FES-I). The prevalence of FOF was 42%- 93.8%. Stroke survivors with physical impairments have the highest prevalence of FOF. The main risk factors for the development of FOF in stroke survivors were female gender, use of assistive devices, balance, limb dysfunction, and functional mobility. The combination of cognitive behavioral and exercise interventions is the most effective strategy.

CONCLUSIONS

This review suggests that the prevalence of FOF in stroke survivors is high and that understanding the factors associated with FOF in stroke patients can help develop multifactorial prevention strategies to reduce FOF and improve quality of life. In addition, a uniform FOF measurement tool should be used to better assess the effectiveness of interventions for stroke survivors.

ETHICS APPROVAL

PROSPERO registration (CRD42023412522).

Effects of scapulo-humeral training on ultrasonographic and clinical evaluations in stroke: a randomized controlled trial

BACKGROUND

After stroke, the effects of focused scapulo-humeral training with simultaneous assessment of the changes in shoulder subluxation, related muscle thicknesses and upper limb performance have not been studied in the literature.

OBJECTIVES

This study aimed to investigate the effects of an 8-week scapulo-humeral training program in addition to conventional rehabilitation on upper extremity/trunk functions, shoulder pain, and sonographic measurements of the shoulder joint and periscapular muscles.

METHODS

Thirty stroke individuals were randomly separated into two groups as Group I-scapulo-humeral training (5F/10 M) and Group II - control (5F/10 M). Conventional rehabilitation program was applied to both groups, and a scapulo-humeral training exercise protocol was added for the scapulo-humeral group. All the treatments were applied for 1 hour/day, 3 days/week, 8 weeks. Clinical evaluations were made using the Fugl Meyer Assessment-Upper Extremity(FMA-UE), Action Research Arm Test(ARAT), ABILHAND, Visual Analog Scale, and Trunk Impairment Scale(TIS). Ultrasound was used to measure serratus anterior/lower trapezius muscle thicknesses, and acromion-greater tubercule/acromio-humeral distances.

RESULTS

FMA-UE, ARAT, ABILHAND and TIS scores increased in both groups, with greater increases in most parameters in the scapulo-humeral training group. Shoulder pain decreased only in the scapulo-humeral training group. Subacromial distances were decreased on the paretic side, and muscle thicknesses increased on both sides in the scapulo-humeral training group, and in the control group, only serratus anterior muscle thickness increased on the paretic side (p < 0.05 for all).

CONCLUSIONS

Additional scapulo-humeral exercises to conventional rehabilitation was seen to improve upper extremity/trunk performance and shoulder pain, and to increase scapula stabilizer muscle thicknesses in stroke individuals with mild-moderate upper extremity disability.

Mitigating Trunk Compensatory Movements in Post-Stroke Survivors through Visual Feedback during Robotic-Assisted Arm Reaching Exercises

Trunk compensatory movements frequently manifest during robotic-assisted arm reaching exercises for upper limb rehabilitation following a stroke, potentially impeding functional recovery. These aberrant movements are prevalent among stroke survivors and can hinder their progress in rehabilitation, making it crucial to address this issue. This study evaluated the efficacy of visual feedback, facilitated by an RGB-D camera, in reducing trunk compensation. In total, 17 able-bodied individuals and 18 stroke survivors performed reaching tasks under unrestricted trunk conditions and visual feedback conditions. In the visual feedback modalities, the target position was synchronized with trunk movement at ratios where the target moved at the same speed, double, and triple the trunk's motion speed, providing real-time feedback to the participants. Notably, trunk compensatory movements were significantly diminished when the target moved at the same speed and double the trunk's motion speed. Furthermore, these conditions exhibited an increase in the task completion time and perceived exertion among stroke survivors. This outcome suggests that visual feedback effectively heightened the task difficulty, thereby discouraging unnecessary trunk motion. The findings underscore the pivotal role of customized visual feedback in correcting aberrant upper limb movements among stroke survivors, potentially contributing to the advancement of robotic-assisted rehabilitation strategies. These insights advocate for the integration of visual feedback into rehabilitation exercises, highlighting its potential to foster more effective recovery pathways for post-stroke individuals by minimizing undesired compensatory motions.

Effectiveness of Visual Feedback in Reducing Trunk Compensation During Arm Reaching for Home-Based Stroke Rehabilitation

This study investigates the effectiveness of visual feedback in reducing trunk compensation during one-arm reaching exercises using an end-effector robot. Results suggest that visual feedback is more effective than verbal feedback in suppressing trunk compensation, as evidenced by lower trunk movements. Synchronized target position with respect to trunk motion exhibited a suppressive effect on trunk motion, as observed by a reduction in trunk standard deviation, trunk root mean square, and trunk difference between the starting and ending positions. These findings have important implications for developing feedback techniques to address unnatural upper limb reach movements in stroke survivors during rehabilitation programs. However, the study's limitations, such as small sample size, should be considered. Future research should explore feedback techniques in different patient populations and exercise types and evaluate their long-term effects.

Effects of Virtual Reality-Based Exercise on Balance in Patients With Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to quantify the effects of virtual reality-based exercise on balance after stroke.

DESIGN

The PubMed, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, and Web of Science databases were searched until December 31, 2021. Independent investigators abstracted data, assessed the quality of the evidence, and rated the certainty of the evidence. The intergroup differences were determined by calculating mean difference and 95% confidence interval by RevMan 5.3 software.

RESULTS

Fourteen randomized controlled trials involving 423 stroke patients were included. Patients who received virtual reality-based exercise illustrated marked improvements in the Berg Balance Scale (mean difference, 1.35; 95% confidence interval, 0.58 to 1.86; P < 0.00001; I2 = 44%), Timed Up and Go test (mean difference, -0.81; 95% confidence interval, -1.18 to -0.44; P < 0.0001; I2 = 0%), Functional Reach Test (mean difference, 3.06; 95% confidence interval, 1.31-4.80; P = 0.0006; I2 = 0%), 10-Meters Walking Test (mean difference, -1.53; 95% confidence interval, -2.92 to -0.13; P = 0.03; I2 = 33%), and Modified Barthel Index (mean difference, 5.26; 95% confidence interval, 1.70 to 8.82; P = 0.004; I2 = 0%) compared with the control group.

CONCLUSIONS

Existing low-evidence analyses showed that virtual reality-based exercise could effectively and safely improve balance in chronic stroke. Longer-term virtual reality-based exercise was more effective on functional ability of stroke.

Effect of Core Exercises on Motor Function Recovery in Stroke Survivors with Very Severe Motor Impairment

Paresis of the upper and lower limbs is a typical issue in stroke survivors. This study aims to determine whether core exercises help stroke survivors with very severe motor impairment recover their motor function. This study employed a within-subjects design. Eleven hemiparetic stroke patients with very severe motor impairment (FMA score < 35) and ages ranging from 24 to 52 years old were enrolled in this study. All participants engaged in supervised core exercise training twice a week for 12 weeks. The main outcome measures were Fugl-Meyer Assessment Lower Extremity (FMA-LE) and Fugl-Meyer Assessment Upper Extremity (FMA-UE), which were measured before training and at intervals of four weeks during training. Repeated measures ANOVA was used to analyze the effect of core exercises on motor function performance and lower extremity motor function and upper extremity motor function recovery. There were significant differences in the mean scores for motor function performance, lower extremity motor function, and upper extremity motor function throughout the four time points. A post-hoc pairwise comparison using the Bonferroni correction revealed that mean scores significantly increased and were statistically different between the initial assessment and follow-up assessments four, eight, and twelve weeks later. This study suggests that 12 weeks of core exercise training is effective for improving motor function recovery in patients with very severe motor impairment.

The Mediating Effect of Age, Gender, and Post-Stroke Duration on the Association between Trunk and Upper Limb Recovery in Subacute Stroke Population: A Cross-Sectional Study with Mediation Analysis

BACKGROUND

The trunk acts as proximal support with which limbs execute smooth and purposeful movement. Furthermore, as upper extremity functions are an integral component of daily living activities, exploring the association between trunk and upper extremity recovery will guide therapists in developing appropriate rehabilitation goals and interventions. The objectives of this study were to (1) assess the association between trunk and upper extremity recovery in the subacute stroke population and (2) assess the effect of trunk control on upper extremity impairment and function with age, gender, and duration of stroke as mediators using mediation analysis in subacute stroke individuals.

METHODS

This cross-sectional study included 54 subacute stroke participants with a mean age of 58.37 ± 6.11 years. The trunk impairment scale (TIS) assessed the trunk's stability, mobility, and coordination. The level of upper extremity impairment was evaluated using the Fugl-Meyer Assessment scale (FMA). The quality and quantity of upper limb motor functions were measured using the Wolf motor function test (WMFT).

RESULTS

The TIS exhibited moderate positive correlations with the FMA-UE, WMFT-time scale (TS), and WMFT-functional ability scale (FAS) at p < 0.001. The mediation analysis reported a profound mediation effect of post-stroke duration on the association of trunk and upper limb recovery.

CONCLUSIONS

The study results substantiated that trunk control significantly correlates with upper limb impairment and the quality and quantity of its use in the subacute stroke population. Post-stroke duration proved to mediate the association between trunk and upper limb recovery. Therefore, the assessment and intervention of trunk and upper extremity motor control considering the post-stroke duration is vital and should be incorporated in stroke rehabilitation aiming at functional independence.

Effect of the Trunk and Upper Limb Passive Stabilization on Hand Movements and Grip Strength Following Various Types of Strokes—An Observational Cohort Study

Almost half of the patients surveyed report impaired function of the upper limbx and handx after stroke. The effect of the passive trunk and shoulder stabilization on the recovery of coordinated hand movement is unclear. This study examined whether passive stabilization of the trunk and shoulder could improve the functional state of the hands after various types of strokes. It is an observational prospective cohort study conducted at the Rehabilitation Clinic in two parallel groups of patients with four different types of strokes (hemorrhagic and ischemic of the brain, similar to the cerebellum). A total of 120 patients were analyzed. Patients were examined in various positions: sitting without a backrest with the upper limb adjacent to the body, supine with the upper limb perpendicular to the body, and supine with the arm stabilized in relation to the patient’s body. Hand Tutor devices and a hand dynamometer were used for the measurements. The frequency and maximum range of motion as well as the grip strength were measured in three different positions of the trunk and upper limb. Passive stabilization of the trunk and shoulder showed more statistically significant differences in Group II. In group II, both in patients after hemorrhagic stroke (wrist Hz p = 0.019; wrist ROM p = 0.005; Hz F5 p = 0.021; Hz F4 p = 0.016; Hz F3 p = 0.019; Hz F2 p = 0.021) and ischemic stroke (p = 0.001 for wrist Hz, wrist ROM, Hz F from 5 to F2; and ROM F1; ROM F3 p = 0.009; ROM F2 p = 0.010), and hemorrhagic cerebellum, improvement of parameters was observed. Stabilization of the upper limb and passive stabilization of the trunk improved the frequency and range of movements in the radiocarpal joint and in the fingers of patients after stroke, regardless of the type of stroke.

Motor Rehabilitation of Upper Limbs Using a Gesture-Based Serious Game: Evaluation of Usability and User Experience

Objective: Gesture-based serious games can be based on playful and interactive scenarios to enhance user engagement and experience during exercises, thereby increasing efficiency in the motor rehabilitation process. This study aimed to develop the Rehabilite Game (RG) as a complementary therapy tool for upper limb rehabilitation in clinics and home environments and to evaluate aspects of usability and user experience of it. Materials and Methods: The evaluation consisted of the use of a gesture-based serious game with motor rehabilitation sessions managed in a web platform. Thirty-three participants were recruited (21 physiotherapists and 12 patients). The protocol allowed each participant to have the experience of playing sessions with different combinations of settings. The User Experience Questionnaire (UEQ) was used to evaluate aspects of usability and user experience. The study was approved by the Research Ethics Board of the Federal University of Piaui (number 3,429,494). Results: The level of satisfaction with the RG was positive, with an excellent Net Promoter Score for 85.7% of physiotherapists and 100% of patients. All six UEQ scales (attractiveness, perspicuity, efficiency, dependability, stimulation, and novelty) reflected acceptance. Conclusion: The study demonstrated that, according to the results obtained in the experiments, the RG had positive feedback from physiotherapists and patients, indicating that the game can be used in a clinical trial to be compared with other rehabilitation techniques.

Exploring Alternative Measurements of Cardiorespiratory Fitness in Patients With Mild Ischemic Stroke at Acute Phase

Background

While emerging studies have suggested an association of cardiorespiratory fitness (CRF) with stroke risk and overall health outcomes, little is known regarding the optimum methods of CRF measurement in patients with mild acute ischemic stroke.

Objective

The aim of this study was to explore the association between the 6-min walk distance (6MWD) and other measurements related to CRF in patients with mild ischemic stroke at the acute stage.

Methods

A total of 30 patients with stroke and 71 healthy subjects matched for age and grip strength (GS) were prospectively recruited. All patients were within 14 days after stroke onset and presented mild motor impairment (with a full score of Fugl-Meyer Motor Assessment). Demographic data of both groups and clinical information of the stroke group were documented, and the CRF comparison between the two groups was conducted. Each participant underwent a one-time assessment of 6MWD and a series of measurements related to CRF, including GS, 10-m walk test (10mWT), five-times sit-to-stand time (FTSST), functional reaching test (FRT), Berg Balance Scale (BBS), and waistline. Pearson's product-moment correlation coefficient test and multiple linear regression were performed to explore the indicators of CRF.

Results

Significant moderate correlations (0.3 < r <0.6) were found between 6MWD and GS of left hand (GS-left) (r = 0.573, p = 0.001), GS of right hand (GS-right) (r = 0.524, p = 0.003), FTSST (r = −0.551, p = 0.002), 10mWT (r = 0.554, p = 0.001), and FRT (r = 0.449, p = 0.021) in the patient group. While 6MWD displayed significant moderate correlations with waistline (r = 0.364, p = 0.002), 10mWT (r = 0.512, p < 0.001), FTSST (r = −0.573, p < 0.001), and FRT (r = 0.550, p < 0.001) in the healthy group. All these dependent variables were entered into a stepwise multiple linear regression analysis to evaluate their values in estimating CRF as measured by 6MWD in each group. Analyses suggested that GS-left (p = 0.002) and FTSST (p = 0.003) were the indicators of CRF in the patient group with stroke and explained 51.4% of the variance of 6MWD (R² = 0.514); FTSST (p < 0.001), 10mWT (p < 0.001), and FRT (p = 0.021) were the indicators of CRF in the healthy group and explained 58.9% of variance of 6MWD (R² = 0.589).

Conclusions

Our data confirmed that CRF is impaired in patients with mild ischemic stroke at the acute phase. Moreover, GS-left may be an optional indicator of CRF in patients with mild acute ischemic stroke, but not in healthy people.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR2000031379.