Hand Focused Upper Extremity Rehabilitation in the Subacute Phase Post-stroke Using Interactive Virtual Environments

Abstract

Introduction: Innovative motor therapies have attempted to reduce upper extremity impairment after stroke but have not made substantial improvement as over 50% of people post-stroke continue to have sensorimotor deficits affecting their self-care and participation in daily activities. Intervention studies have focused on the role of increased dosing, however recent studies have indicated that timing of rehabilitation interventions may be as important as dosing and importantly, that dosing and timing interact in mediating effectiveness. This study is designed to empirically test dosing and timing.Methods and Analysis: In this single-blinded, interventional study, subjects will be stratified on two dimensions, impairment level (Fugl-Meyer Upper Extremity Assessment (FM) and presence or absence of Motor Evoked Potentials (MEPs) as follows; (1) Severe, FM score 10–19, MEP+, (2) Severe, FM score 10–19, MEP–, (3) Moderate, FM score 20–49, MEP+, (4) Moderate, FM score 20–49, MEP–. Subjects not eligible for TMS will be assigned to either group 2 (if severe) or group 3 (if moderate). Stratified block randomization will then be used to achieve a balanced assignment. Early Robotic/VR Therapy (EVR) experimental group will receive in-patient usual care therapy plus an extra 10 h of intensive upper extremity therapy focusing on the hand using robotically facilitated rehabilitation interventions presented in virtual environments and initiated 5–30 days post-stroke. Delayed Robotic/VR Therapy (DVR) experimental group will receive the same intervention but initiated 30–60 days post-stroke. Dose-matched usual care group (DMUC) will receive an extra 10 h of usual care initiated 5–30 days post-stroke. Usual Care Group (UC) will receive the usual amount of physical/occupational therapy.Outcomes: There are clinical, neurophysiological, and kinematic/kinetic measures, plus measures of daily arm use and quality of life. Primary outcome is the Action Research Arm Test (ARAT) measured at 4 months post-stroke.Discussion: Outcome measures will be assessed to determine whether there is an early time period in which rehabilitation will be most effective, and whether there is a difference in the recapture of premorbid patterns of movement vs. the development of an efficient, but compensatory movement strategy.Ethical Considerations: The IRBs of New Jersey Institute of Technology, Rutgers University, Northeastern University, and Kessler Foundation reviewed and approved all study protocols. Study was registered in https://ClinicalTrials.gov (NCT03569059) prior to recruitment. Dissemination will include submission to peer-reviewed journals and professional presentations.

Enhancing Upper Limb Rehabilitation of Stroke Patients With Virtual Reality: A Mini Review

“…Since it has been suggested that a higher dose of training volume is preferable, with more than 15 h of total intervention time (Laver et al, 2017), future studies are needed to determine if the dose of VR-therapy does have a significant effect on motor rehabilitation outcomes and if so, which dosage has to be applied when implementing VR in therapy. Future studies will also help specify the effects of timing of VR interventions on functional outcomes and thus, may help determine the optimal timing during which VR interventions can lead to significant improvements in stroke rehabilitation (Merians et al, 2020).…”

Virtual Rehabilitation of the Paretic Hand and Arm in Persons With Stroke: Translation From Laboratory to Rehabilitation Centers and the Patient's Home

“…This said, the two studies from this metanalysis that focused on the acute and first few weeks of the recovery stage both found non-significant trends favoring VR based interventions ( 23 , 39 ). Our group has initiated a large scale clinicial trial addressing this topic as well as comparisons with a dose–matched program of traditional rehabilitation and a delayed onset program of virtual rehabilitation ( 40 ).…”

“…Two groups using slightly different methods found no training related changes in map area ( 45 , 46 ). These differing outcomes identified across our clinical, kinematic and neurophysiological studies examining the rehabilitation of persons with chronic stroke and those of our pilot studies of earlier virtual rehabilitation, have led us to initiate a larger study, adding a fourth group of subjects that perform an additional 10 h of traditional rehabilitation in an attempt to control for the timing of hand focused intervention, the dose of rehabilitation intervention, and the additive value of VR virtual reality-based rehabilitation ( 40 ).…”

“…In a current clinical trial we are collecting cortical maps of both hemispheres at five points in the recovery process in persons with all levels of impairment (severe, moderate, and mild), that perform a standard rehab program as well as a standard rehab program plus added intensive hand training. We hope that this line of inquiry might help clarify the differing effects of rehabilitation across a wide variety of impairment levels, as this new study will include subjects with more extensive motor impairments than a majority of the major published upper extremity rehabilitation trials ( 40 ).…”