Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial

Abstract

Background Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period. Objective To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT). Methods A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day. Results There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC. Conclusions Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

Moving outside the lab: The viability of conducting sensorimotor learning studies online

“…The loss of experimental control with online data collection may be especially problematic for kinematic data: Not only will the response devices (e.g., mouse or trackpad) be variable, but the setting in which movements are produced (e.g., focused or distracted environment) would be difficult to control. While previous efforts examining motor learning "in the wild" have advanced our understanding of motor learning [20,21,22,23,24,25,26,27,28], these studies have tended to focus on testing specific hypotheses (but see [29] -a recently published study), and their online findings not readily comparable to those obtained in the lab.…”

A focus group study of therapists’ views on using a novel neuroanimation virtual reality game to deliver intensive upper-limb rehabilitation early after stroke

“…Current guidelines encourage intensive practice of functional, task-orientated repetitive training to significantly improve the performance of everyday activities with the upper-limb [ 14 ], but recent studies suggest that intensive impairment-focussed training, specifically targeting the quality of movement, as opposed to functional task completion, may prove more beneficial [ 33 ]. The SMARTS2 trial is the first to deliver true intensive impairment-focussed NAT, finding that it was equivalent to time matched additional therapy, but significantly more beneficial than usual care [ 25 ]. The results of this qualitative study highlight some of the key perceptions, barriers and facilitators around using this kind of NAT in clinical practice and so are both significant and meaningful.…”

“…A recent phase II randomised, single-blinded, pilot multicentre trial, Study to enhance Motor Acute Recovery with intensive Training after Stroke, (SMARTS 2; NCT02292251) [ 25 ] utilised intensive (one hourly twice daily sessions, five days a week for three weeks) impairment-focussed, interactive NAT during the first ten weeks after stroke. A proprietary game, MindPod Dolphin® (Fig.…”

Gamified Neurorehabilitation Strategies for Post-stroke Motor Recovery: Challenges and Advantages

“…Novel approaches to NRGN continue to emerge in the neurorehabilitation space. A recent study by Krakauer et al investigated a novel NRGN approach, neuroanimation therapy (NAT) [ 33 ]. In this multi-center, single-blinded parallel randomized controlled trial, Krakauer et al compared high-intensity upper limb rehabilitation using NAT, traditional occupation therapy, and historical controls in individuals with subacute stroke.…”