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Höhler C, Trigili E, Astarita D, Hermsdörfer J, Jahn K, Krewer C. The efficacy of hybrid neuroprostheses in the rehabilitation of upper limb impairment after stroke, a narrative and systematic review with a meta-analysis. Artif Organs 2024; 48:232-253. [PMID: 37548237 DOI: 10.1111/aor.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Paresis of the upper limb (UL) is the most frequent impairment after a stroke. Hybrid neuroprostheses, i.e., the combination of robots and electrical stimulation, have emerged as an option to treat these impairments. METHODS To give an overview of existing devices, their features, and how they are linked to clinical metrics, four different databases were systematically searched for studies on hybrid neuroprostheses for UL rehabilitation after stroke. The evidence on the efficacy of hybrid therapies was synthesized. RESULTS Seventy-three studies were identified, introducing 32 hybrid systems. Among the most recent devices (n = 20), most actively reinforce movement (3 passively) and are typical exoskeletons (3 end-effectors). If classified according to the International Classification of Functioning, Disability and Health, systems for proximal support are expected to affect body structures and functions, while the activity and participation level are targeted when applying Functional Electrical Stimulation distally plus the robotic component proximally. The meta-analysis reveals a significant positive effect on UL functions (p < 0.001), evident in a 7.8-point Mdiff between groups in the Fugl-Meyer assessment. This positive effect remains at the 3-month follow-up (Mdiff = 8.4, p < 0.001). CONCLUSIONS Hybrid neuroprostheses have a positive effect on UL recovery after stroke, with effects persisting at least three months after the intervention. Non-significant studies were those with the shortest intervention periods and the oldest patients. Improvements in UL functions are not only present in the subacute phase after stroke but also in long-term chronic stages. In addition to further technical development, more RCTs are needed to make assumptions about the determinants of successful therapy.
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Affiliation(s)
- Chiara Höhler
- Research Department, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Chair of Human Movement Science, Faculty of Sport and Health Science, Technical University Munich, Munich, Germany
| | - Emilio Trigili
- The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Davide Astarita
- The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Joachim Hermsdörfer
- Chair of Human Movement Science, Faculty of Sport and Health Science, Technical University Munich, Munich, Germany
| | - Klaus Jahn
- Research Department, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians University of Munich (LMU), Munich, Germany
| | - Carmen Krewer
- Research Department, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Chair of Human Movement Science, Faculty of Sport and Health Science, Technical University Munich, Munich, Germany
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Höhler C, Wild L, de Crignis A, Jahn K, Krewer C. Contralaterally EMG-triggered functional electrical stimulation during serious gaming for upper limb stroke rehabilitation: a feasibility study. Front Neurorobot 2023; 17:1168322. [PMID: 37304665 PMCID: PMC10248145 DOI: 10.3389/fnbot.2023.1168322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Virtual Reality/serious games (SG) and functional electrical stimulation (FES) therapies are used in upper limb stroke rehabilitation. A combination of both approaches seems to be beneficial for therapy success. The feasibility of a combination of SG and contralaterally EMG-triggered FES (SG+FES) was investigated as well as the characteristics of responders to such a therapy. Materials and methods In a randomized crossover trial, patients performed two gaming conditions: SG alone and SG+FES. Feasibility of the therapy system was assessed using the Intrinsic Motivation Inventory (IMI), the Nasa Task Load Index, and the System Usability Scale (SUS). Gaming parameters, fatigue level and a technical documentation was implemented for further information. Results In total, 18 patients after stroke (62.1 ± 14.1 years) with a unilateral paresis of the upper limb (MRC ≤4) were analyzed in this study. Both conditions were perceived as feasible. Comparing the IMI scores between conditions, perceived competence was significantly increased (z = -2.88, p = 0.004) and pressure/tension during training (z = -2.13, p = 0.034) was decreased during SG+FES. Furthermore, the task load was rated significantly lower for the SG+FES condition (z = -3.14, p = 0.002), especially the physical demand (z = -3.08, p = 0.002), while the performance was rated better (z = -2.59, p = 0.010). Responses to the SUS and the perceived level of fatigue did not differ between conditions (SUS: z = -0.79, p = 0.431; fatigue: z = 1.57, p = 0.115). For patients with mild to moderate impairments (MRC 3-4) the combined therapy provided no or little gaming benefit. The additional use of contralaterally controlled FES (ccFES), however, enabled severely impaired patients (MRC 0-1) to play the SG. Discussion The combination of SG with ccFES is feasible and well-accepted among patients after stroke. It seems that the additional use of ccFES may be more beneficial for severely impaired patients as it enables the execution of the serious game. These findings provide valuable implications for the development of rehabilitation systems by combining different therapeutic interventions to increase patients' benefit and proposes system modifications for home use. Clinical trial registration https://drks.de/search/en, DRKS00025761.
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Affiliation(s)
- Chiara Höhler
- Faculty of Sport and Health Science, Chair of Human Movement Science, Technical University Munich, Munich, Germany
- Department of Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Laura Wild
- Faculty of Sport and Health Science, Chair of Human Movement Science, Technical University Munich, Munich, Germany
| | - Alexandra de Crignis
- Department of Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Klaus Jahn
- Department of Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Ludwig-Maximilians University of Munich (LMU), German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
| | - Carmen Krewer
- Faculty of Sport and Health Science, Chair of Human Movement Science, Technical University Munich, Munich, Germany
- Department of Neurology, Research Group, Schoen Clinic Bad Aibling, Bad Aibling, Germany
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Höhler C, Rasamoel ND, Rohrbach N, Hansen JP, Jahn K, Hermsdörfer J, Krewer C. The impact of visuospatial perception on distance judgment and depth perception in an Augmented Reality environment in patients after stroke: an exploratory study. J Neuroeng Rehabil 2021; 18:127. [PMID: 34419086 PMCID: PMC8379833 DOI: 10.1186/s12984-021-00920-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Augmented Reality (AR)-based interventions are applied in neurorehabilitation with increasing frequency. Depth perception is required for the intended interaction within AR environments. Until now, however, it is unclear whether patients after stroke with impaired visuospatial perception (VSP) are able to perceive depth in the AR environment. METHODS Different aspects of VSP (stereovision and spatial localization/visuoconstruction) were assessed in 20 patients after stroke (mean age: 64 ± 14 years) and 20 healthy subjects (HS, mean age: 28 ± 8 years) using clinical tests. The group of HS was recruited to assess the validity of the developed AR tasks in testing stereovision. To measure perception of holographic objects, three distance judgment tasks and one three-dimensionality task were designed. The effect of impaired stereovision on performance in each AR task was analyzed. AR task performance was modeled by aspects of VSP using separate regression analyses for HS and for patients. RESULTS In HS, stereovision had a significant effect on the performance in all AR distance judgment tasks (p = 0.021, p = 0.002, p = 0.046) and in the three-dimensionality task (p = 0.003). Individual quality of stereovision significantly predicted the accuracy in each distance judgment task and was highly related to the ability to perceive holograms as three-dimensional (p = 0.001). In stroke-survivors, impaired stereovision had a specific deterioration effect on only one distance judgment task (p = 0.042), whereas the three-dimensionality task was unaffected (p = 0.317). Regression analyses confirmed a lacking impact of patients' quality of stereovision on AR task performance, while spatial localization/visuoconstruction significantly prognosticated the accuracy in distance estimation of geometric objects in two AR tasks. CONCLUSION Impairments in VSP reduce the ability to estimate distance and to perceive three-dimensionality in an AR environment. While stereovision is key for task performance in HS, spatial localization/visuoconstruction is predominant in patients. Since impairments in VSP are present after stroke, these findings might be crucial when AR is applied for neurorehabilitative treatment. In order to maximize the therapy outcome, the design of AR games should be adapted to patients' impaired VSP. Trial registration: The trial was not registered, as it was an observational study.
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Affiliation(s)
- Chiara Höhler
- Technical University of Munich, Georg-Brauchle Ring 60/62, 80992, Munich, Germany.
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany.
| | - Nils David Rasamoel
- Technical University of Denmark, Anker Engelunds Vej 1, 2800, Kgs. Lyngby, Denmark
| | - Nina Rohrbach
- Technical University of Munich, Georg-Brauchle Ring 60/62, 80992, Munich, Germany
| | - John Paulin Hansen
- Technical University of Denmark, Anker Engelunds Vej 1, 2800, Kgs. Lyngby, Denmark
| | - Klaus Jahn
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany
- Ludwig-Maximilians University of Munich, University Hospital Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Joachim Hermsdörfer
- Technical University of Munich, Georg-Brauchle Ring 60/62, 80992, Munich, Germany
| | - Carmen Krewer
- Technical University of Munich, Georg-Brauchle Ring 60/62, 80992, Munich, Germany
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany
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Gabriel A, Lehner CT, Höhler C, Schneider T, Pfeiffer TPT, Diehl-Schmid J, Hermsdörfer J. Anticipatory and Reactive Grip Force Control in Patients with Alzheimer's Disease: A Pilot Study. J Alzheimers Dis 2021; 82:1651-1665. [PMID: 34219727 DOI: 10.3233/jad-210387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Alzheimer's disease (AD) affects several cognitive functions and causes altered motor function. Fine motor deficits during object manipulation are evident in other neurological conditions, but have not been assessed in dementia patients yet. OBJECTIVE Investigate reactive and anticipatory grip force control in response to unexpected and expected load force perturbation in AD. METHODS Reactive and anticipatory grip force was investigated using a grip-device with force sensors. In this pilot study, fifteen AD patients and fourteen healthy controls performed a catching task. They held the device with one hand while a sandbag was dropped into an attached receptacle either by the experimenter or by the participant. RESULTS In contrast to studies of other neurological conditions, the majority of AD patients exerted lower static grip force levels than controls. Interestingly, patients who were slow in the Luria's three-step test produced normal grip forces. The timing and magnitude of reactive grip force control were largely preserved in patients. In contrast, timing and extent of anticipatory grip forces were impaired in patients, although anticipatory control was generally preserved. These deficits were correlated with decreasing Mini-Mental State Examination scores. Apraxia scores, assessed by pantomime of tool-use, did not correlate with performance in the catching task. CONCLUSION We interpreted the decreased grip force in AD in the context of loss of strength and lethargy, typical for patients with AD. The lower static grip force during object manipulation may emerge as a potential biomarker for early stages of AD, but more studies with larger sample sizes are necessary.
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Affiliation(s)
- Anna Gabriel
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Carolin T Lehner
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Chiara Höhler
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany.,Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thomas Schneider
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany.,Department of Neurology, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Tessa P T Pfeiffer
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Janine Diehl-Schmid
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Joachim Hermsdörfer
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
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