The recovery of walking capacity is one of the main aims in stroke rehabilitation. Being able to predict if and when a patient is going to walk after stroke is of major interest in terms of ...management of the patients and their family’s expectations and in terms of discharge destination and timing previsions. This article reviews the recent literature regarding the predictive factors for gait recovery and the best recommendations in terms of gait rehabilitation in stroke patients. Trunk control and lower limb motor control (e.g. hip extensor muscle force) seem to be the best predictors of gait recovery as shown by the TWIST algorithm, which is a simple tool that can be applied in clinical practice at 1 week post-stroke. In terms of walking performance, the 6-min walking test is the best predictor of community ambulation. Various techniques are available for gait rehabilitation, including treadmill training with or without body weight support, robotic-assisted therapy, virtual reality, circuit class training and self-rehabilitation programmes. These techniques should be applied at specific timing during post-stroke rehabilitation, according to patient’s functional status.
Abstract
Background
Approximately two thirds of stroke survivors maintain upper limb (UL) impairments and few among them attain complete UL recovery 6 months after stroke. Technological progress and ...gamification of interventions aim for better outcomes and constitute opportunities in self- and tele-rehabilitation.
Objectives
Our objective was to assess the efficacy of serious games, implemented on diverse technological systems, targeting UL recovery after stroke. In addition, we investigated whether adherence to neurorehabilitation principles influenced efficacy of games specifically designed for rehabilitation, regardless of the device used.
Method
This systematic review was conducted according to PRISMA guidelines (PROSPERO registration number: 156589). Two independent reviewers searched PubMed, EMBASE, SCOPUS and Cochrane Central Register of Controlled Trials for eligible randomized controlled trials (PEDro score ≥ 5). Meta-analysis, using a random effects model, was performed to compare effects of interventions using serious games, to conventional treatment, for UL rehabilitation in adult stroke patients. In addition, we conducted subgroup analysis, according to adherence of included studies to a consolidated set of 11 neurorehabilitation principles.
Results
Meta-analysis of 42 trials, including 1760 participants, showed better improvements in favor of interventions using serious games when compared to conventional therapies, regarding UL function (SMD = 0.47; 95% CI = 0.24 to 0.70;
P
< 0.0001), activity (SMD = 0.25; 95% CI = 0.05 to 0.46;
P
= 0.02) and participation (SMD = 0.66; 95% CI = 0.29 to 1.03;
P
= 0.0005). Additionally, long term effect retention was observed for UL function (SMD = 0.42; 95% CI = 0.05 to 0.79;
P
= 0.03). Interventions using serious games that complied with at least 8 neurorehabilitation principles showed better overall effects. Although heterogeneity levels remained moderate, results were little affected by changes in methods or outliers indicating robustness.
Conclusion
This meta-analysis showed that rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components. Irrespective of the technological device used, higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of serious games. Future development of stroke-specific rehabilitation interventions should further take into consideration the consolidated set of neurorehabilitation principles.
The 6-minute walk test (6MWT) is widely used to assess walking capacity among persons with stroke. Whether a shorter and more convenient test, the 2-minute walk test (2MWT) could replace it, was ...tested. Two retrospective analyses were conducted. The first one was performed on a sample of 20 persons with stroke who performed both the 2MWT and the 6MWT, and the second one, on a group of 82 persons with stroke who performed the 6MWT while measuring the distance covered each minute. Linear regression models were applied to test the validity of 2MWT with regard to 6MWT. In the first group, distances covered during the 2MWT were highly predictive of the distances covered during the 6MWT (estimated adjusted R ² = 0.98; P < 0.001). In the second group, distances covered by participants during the first 2 min of the 6MWT were highly and linearly related to the distances they covered during the whole 6MWT (estimated adjusted R ² = 0.98; P < 0.001). Furthermore, the distance covered during the first 2 min of the whole 6MWT allowed us to predict 98% of the variance of the 6MWT. Given its good metric properties and its practical advantages, clinicians and researchers could reasonably use the 2MWT when assessing the walking capacity of persons with stroke, instead of the 6MWT.
Background. Several pilot studies have evoked interest in robot-assisted therapy (RAT) in children with cerebral palsy (CP). Objective. To assess the effectiveness of RAT in children with CP through ...a single-blind randomized controlled trial. Patients and Methods. Sixteen children with CP were randomized into 2 groups. Eight children performed 5 conventional therapy sessions per week over 8 weeks (control group). Eight children completed 3 conventional therapy sessions and 2 robot-assisted sessions per week over 8 weeks (robotic group). For both groups, each therapy session lasted 45 minutes. Throughout each RAT session, the patient attempted to reach several targets consecutively with the REAPlan. The REAPlan is a distal effector robot that allows for displacements of the upper limb in the horizontal plane. A blinded assessment was performed before and after the intervention with respect to the International Classification of Functioning framework: body structure and function (upper limb kinematics, Box and Block test, Quality of Upper Extremity Skills Test, strength, and spasticity), activities (Abilhand-Kids, Pediatric Evaluation of Disability Inventory), and participation (Life Habits). Results. During each RAT session, patients performed 744 movements on average with the REAPlan. Among the variables assessed, the smoothness of movement (P < .01) and manual dexterity assessed by the Box and Block test (P = .04) improved significantly more in the robotic group than in the control group. Conclusions. This single-blind randomized controlled trial provides the first evidence that RAT is effective in children with CP. Future studies should investigate the long-term effects of this therapy.
This cross-sectional study aimed to evaluate the effect of visual feedback, age and movement repetition on the upper limb (UL) accuracy and kinematics during a reaching task in immersive virtual ...reality (VR). Fifty-one healthy participants were asked to perform 25 trials of a reaching task in immersive VR with and without visual feedback of their hand. They were instructed to place, as accurately and as fast as possible, a controller held in their non-dominant hand in the centre of a virtual red cube of 3 cm side length. For each trial, the end-point error (distance between the tip of the controller and the centre of the cube), a coefficient of linearity (CL), the movement time (MT), and the spectral arc length of the velocity signal (SPARC), which is a movement smoothness index, were calculated. Multivariate analyses of variance were conducted to assess the influence of visual feedback, age and trial repetition on the average end-point error, SPARC, CL and MT, and their time course throughout the 25 trials. Providing visual feedback of the hand reduced average end-point error ( P < 0.001) and MT ( P = 0.044), improved SPARC ( P < 0.001) but did not affect CL ( P = 0.07). Younger participants obtained a lower mean end-point error ( P = 0.037), a higher SPARC ( P = 0.021) and CL ( P = 0.013). MT was not affected by age ( P = 0.671). Trial repetition increased SPARC ( P < 0.001) and CL ( P < 0.001), and reduced MT ( P = 0.001) but did not affect end-point error ( P = 0.608). In conclusion, the results of this study demonstrated that providing visual feedback of the hand and being younger improves UL accuracy and movement smoothness in immersive VR. UL kinematics but not accuracy can be improved with more trial repetitions. These findings could guide the future development of protocols in clinical rehabilitation and research.
Human walking has a peculiar straight-legged style. Consequently, the body's centre of mass (CM) moves up and down with each
step, which is noticeable in their up and down head bobbing while walking. ...This vertical CM movement enables humans to save
energy via a pendulum-like mechanism but is probably a relatively recent locomotor innovation insofar as earliest bipeds may
have walked flexed and flat. We investigated the mechanics, energetics, muscle efficiency and optimization of human walking
by decreasing and increasing the vertical CM displacement (flat and bouncy walking) in comparison to normal walking at six
speeds (1â6 km h â1 ). In both flat and bouncy walking, the pendular mechanism was reduced and the energy cost was increased. However, this increase
was unexpectedly much sharper in flat walking where muscles provided normal mechanical work but with a decrease in muscle
efficiency. In bouncy walking, muscles provided extra mechanical work in an efficient way. Our results showed that not only
do humans bob up and down in normal walking to save energy via a pendulum-like mechanism but also to make their muscles work
efficiently. Actually, walking flat makes the muscles work in unfavourable conditions that waste energy. Furthermore, we are
still close to a flat CM displacement relative to our current ability to change this displacement, which suggests that reducing
vertical CM displacement is indeed important but only to certain limits. Evolution may ultimately have chosen the best compromise
between flat locomotion that requires little work to move and bouncy locomotion that improves muscle efficiency to minimize
energy consumption.
Variability raises considerable interest as a promising and sensitive marker of dysfunction in physiology, in particular in neurosciences. Both internally (e.g., pathology) and/or externally (e.g., ...environment) generated perturbations and the neuro-mechanical responses to them contribute to the fluctuating dynamics of locomotion. Defective internal gait control in Parkinson's disease (PD), resulting in typical timing gait disorders, is characterized by the breakdown of the temporal organization of stride duration variability. Influence of external cue on gait pattern could be detrimental or advantageous depending on situations (healthy or pathological gait pattern, respectively). As well as being an interesting rehabilitative approach in PD, treadmills are usually implemented in laboratory settings to perform instrumented gait analysis including gait variability assessment. However, possibly acting as an external pacemaker, treadmill could modulate the temporal organization of gait variability of PD patients which could invalidate any gait variability assessment. This study aimed to investigate the immediate influence of treadmill walking (TW) on the temporal organization of stride duration variability in PD and healthy population. Here, we analyzed the gait pattern of 20 PD patients and 15 healthy age-matched subjects walking on overground and on a motorized-treadmill (randomized order) at a self-selected speed. The temporal organization and regularity of time series of walking were assessed on 512 consecutive strides and assessed by the application of non-linear mathematical methods (i.e., the detrended fluctuation analysis and power spectral density; and sample entropy, for the temporal organization and regularity of gait variability, respectively). A more temporally organized and regular gait pattern seems to emerge from TW in PD while no influence was observed on healthy gait pattern. Treadmill could afford the necessary framework to regulate gait rhythmicity in PD. Overall, the results support the hypothesis of a greater dependence to regulatory inputs as an explanatory factor of treadmill influence observed in PD. Also, since treadmill misrepresents the gait as more healthy than it is, the present findings underline that gait analysis using treadmill devices should be cautiously considered in PD and especially for gait variability assessment in gait lab.
Although many stroke patients present with spasticity, this impairment remains a riddle for physicians. Why, when, and how does a patient develop spasticity, whereas another patient with a similar ...cerebral lesion does not? Moreover, the evolution of spasticity among these chronic patients and its relation to functional activity are not straightforward. Thus, the assessment and treatment of spasticity remain a challenge in neurorehabilitation.
To plan treatment and measure post-stroke recovery, frequent and time-bounded functional assessments are recommended. With increasing needs for neurorehabilitation advances, new technology based ...methods, such as virtual reality (VR) have emerged. Here, we developed an immersive VR version of the Action Research Arm Test (ARAT-VR) to complement neurorehabilitation.
This study aimed to assess the validity, usability and test-retest reliability of the ARAT-VR among individuals with stroke, healthcare professionals and healthy control subjects (HCS).
Among the 19 items of the ARAT, 13 items were selected and developed in immersive VR. 11 healthcare professionals, 30 individuals with stroke, and 25 HCS were recruited. Content validity was assessed by asking healthcare professionals to rate the difficulty of performing each item of the ARAT-VR in comparison to the classical Action Research Arm Test (ARAT-19). Concurrent validity was first measured using correlation (Spearman tests) between the ARAT-VR and ARAT-19 scores for the individuals with stroke, and second through correlation and comparison between the scores of the ARAT-VR and the reduced version of the ARAT (ARAT-13) for both individuals with stroke and HCS (Wilcoxon signed rank tests and Bland-Altman plots). Usability was measured using the System Usability Scale. A part of individuals with stroke and HCS were re-tested following a convenient delay to measure test-retest reliability (Intra-class correlation and Wilcoxon tests).
Regarding the content validity, median difficulty of the 13 ARAT-VR items (00 to - 1 to 00-1) evaluated by healthcare professionals was rated as equivalent to the classical ARAT for all tasks except those involving the marbles. For these, the difficulty was rated as superior to the real tasks (10-1 when pinching with the thumb-index and thumb-middle fingers, and 10-2 when pinching with thumb-ring finger). Regarding the concurrent validity, for paretic hand scores, there were strong correlations between the ARAT-VR and ARAT-13 (r = 0.84), and between the ARAT-VR and ARAT-19 (r = 0.83). Usability (SUS = 82.575-90) and test-retest reliability (ICC = 0.99; p < 0.001) were excellent.
The ARAT-VR is a valid, usable and reliable tool that can be used to assess upper limb activity among individuals with stroke, providing potential to increase assessment frequency, remote evaluation, and improve neurorehabilitation. Trial registration https://clinicaltrials.gov/ct2/show/NCT04694833 ; Unique identifier: NCT04694833, Date of registration: 11/24/2020.
After a stroke, experts recommend regular monitoring and kinematic assessments of patients to objectively measure motor recovery. With the rise of new technologies and increasing needs for ...neurorehabilitation, an interest in virtual reality has emerged. In this context, we have developed an immersive virtual reality version of the Box and Block Test (BBT-VR). The aim of this study was to assess the concurrent validity of the BBT-VR among patients with stroke and healthy participants.
Twenty-three healthy participants and 22 patients with stroke were asked to perform the classical Box and Block Test (BBT) and BBT-VR three times with both hands. Concurrent validity was assessed through correlations between these two tests and reliability of the BBT-VR through correlation on test-retest. Usability of the BBT-VR was also evaluated with the System Usability Scale. Hand kinematic data extracted from controller's 3D position allowed to compute mean velocity (V
), peak velocity (V
) and smoothness (SPARC).
Results showed strong correlations between the number of blocks displaced with the BBT and the BBT-VR among patients with stroke for affected (r = 0.89; p < 0.001) and less-affected hands (r = 0.76; p < 0.001) and healthy participants for dominant (r = 0.58; p < 0.01) and non-dominant hands (r = 0.68; p < 0.001). Reliability for test-retest was excellent (ICC > 0.8; p < 0.001) and usability almost excellent (System Usability Scale = 79 ± 12.34%). On average participants moved between 30 and 40% less blocks during the BBT-VR than during the BBT. Healthy participants demonstrated significantly higher kinematic measures (V
= 0.22 ± 0.086 ms
; V
= 0.96 ± 0.341 ms
; SPARC = - 3.31 ± 0.862) than patients with stroke (V
= 0.12 ± 0.052 ms
; V
= 0.60 ± 0.202 ms
; SPARC = - 5.04- 7.050 to - 3.682).
The BBT-VR is a usable, valid and reliable test to assess manual dexterity, providing kinematic parameters, in a population of patients with stroke and healthy participants. Trial registration http://www.clinicaltrials.gov ; Unique identifier: NCT04694833, Date of registration: 11/24/2020.
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