Combining rTMS and Task-Oriented Training in the Rehabilitation of the Arm after Stroke: A Pilot Randomized Controlled Trial.
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ABSTRACT:
SUBMITTER: Higgins J
PROVIDER: S-EPMC3865731 | biostudies-literature | 2013
REPOSITORIES: biostudies-literature
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Combining rTMS and Task-Oriented Training in the Rehabilitation of the Arm after Stroke: A Pilot Randomized Controlled Trial.
Higgins Johanne J Koski Lisa L Xie Haiqun H
Stroke research and treatment 20131203
Introduction. Repetitive transcranial magnetic stimulation (rTMS) is a promising technique for promoting rehabilitation of arm function after stroke. The feasibility and impact of rTMS as an adjunct to traditional task-oriented training to improve arm function have not yet been demonstrated. Objective. Evaluate the feasibility of a randomized controlled trial aimed at determining the efficacy of rTMS as an adjunct to task-oriented therapy in facilitating restoration of arm function after stroke. ...[more]
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Project description:Purpose: To investigate the effect of adding cognitive strategy training to task-specific training (TST), called Cognitive Oriented Strategy Training Augmented Rehabilitation (COSTAR), compared with TST on activity and participation for chronic stroke survivors in an outpatient occupational therapy settingMaterials and methods: We conducted an exploratory, single-blind, randomized controlled trial. Participants were randomized to TST or COSTAR protocol. Our primary outcomes measured activity and participation after stroke: the Stroke Impact Scale (SIS), Canadian Occupational Performance Measure (COPM), and Performance Quality Rating Scale (PQRS).Results: Forty-four participants were randomized. The COSTAR group had an attrition rate of 50% and an average of 9.8 of 12 sessions were completed; the TST group had an attrition rate of 25% and an average of 10.7 sessions were completed. Generally both groups improved on the majority of primary and secondary outcomes. There is little evidence to support a beneficial effect of COSTAR over TST for improvement of primary measures of activity performance or secondary measures.Conclusion: Negligible findings may be attributed to an inadvertent treatment group equivalency. Further, the research design did not allow for adequate measurement of the effect of each intervention on participants' ability to generalize learned skills.Implications for rehabilitationStroke rehabilitation is largely based upon the principles of task-specific training, which is associated with improvements in upper extremity motor performance; however, TST requires a heavy dosage and lacks generalization to untrained activities.Cognitive strategy use has been associated with improved generalization of treatment to untrained activities and novel contexts however, it is often not used in TST protocols.The results of this preliminary study found no clear advantage between task-specific training and strategy-adapted task-specific training on trained and untrained activities when both interventions targeted activity performance.Task-specific training, if focused at the activity performance level rather than the impairment reduction level, may have a stronger effect on improving in individual's ability to participate in everyday life activities even without the use of cognitive-strategies.Incorporating cognitive strategy-use into TST would likely produce the greatest effect on generalization and transfer of the treatment effects to other activities and contexts rather than solely on activity performance of trained activities.
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Project description:Action selection (AS), or selection of an action from a set of alternatives, is an important movement preparation process that engages a frontal-parietal network. The addition of AS demands to arm training after stroke could be used to engage this motor planning process and the neural network that supports it. The purpose of this case series is to describe the feasibility and outcomes associated with task-oriented arm training aimed at engaging the AS behavioral process and the related neural network in three individuals with chronic stroke. Three participants with mild to moderate motor deficits completed 13 to 15 sessions of task-oriented arm training that included AS cues for each movement repetition; cues dictated movement direction, height, or distance. Before and after training, individuals completed an AS brain-behavior probe during functional MRI. AS behavioral performance improved after training (increased accuracy, decreased reaction time) in all participants while brain activation in the AS network (dorsal premotor, parietal, dorsolateral prefrontal cortices) decreased in two participants. Gains in motor function were also found in all three participants, especially on patient-reported measures of perceived difficulty and confidence to complete upper extremity functional tasks. It was feasible to target the AS behavioral process and the related neural network through the addition of AS demands to functional, task-oriented arm training in three individuals with mild to moderate motor dysfunction poststroke.
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Project description:BackgroundImproving arm-hand skill performance is a major therapeutic target in stroke rehabilitation. Arm-hand rehabilitation may be enriched in content and variation by using technology-assisted training. Especially for people with a severely affected arm, technology-assisted training offers more challenging training possibilities.ObjectiveThe aim of this study was to explore the feasibility of ReHab-TOAT, a "Remote Handling Based Task-Oriented Arm Training" approach featuring enriched haptic feedback aimed at improving daily activities and participation.MethodsFive subacute or chronic stroke patients suffering moderate to severe arm-hand impairments and five rehabilitation therapists participated. All participants received 2 ReHab-TOAT sessions. Outcome measure was a bespoke feasibility questionnaire on user experiences and satisfaction regarding 'motivation', 'individualization of training', 'potential training effects', and 'implementation in rehabilitation' of patients and therapists.ResultsBoth patients and therapists experienced ReHab-TOAT as being feasible. They found ReHab-TOAT very motivating and challenging. All patients perceived an added value of ReHab-TOAT and would continue the training. Small improvements regarding exercise variability were suggested.ConclusionReHab-TOAT seems to be a feasible and very promising training approach for arm-hand rehabilitation of stroke patients with a moderately or severely affected arm. Further research is necessary to investigate potential training effects of ReHab-TOAT.
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Project description:PurposeMotor recovery of persons after stroke may be enhanced by a novel approach where residual muscle activity is facilitated by patient-controlled electrical muscle activation. Myoelectric activity from hemiparetic muscles is then used for continuous control of functional electrical stimulation (MeCFES) of same or synergic muscles to promote restoration of movements during task-oriented therapy (TOT). Use of MeCFES during TOT may help to obtain a larger functional and neurological recovery than otherwise possible.Study designMulticenter randomized controlled trial.MethodsEighty two acute and chronic stroke victims were recruited through the collaborating facilities and after signing an informed consent were randomized to receive either the experimental (MeCFES assisted TOT (M-TOT) or conventional rehabilitation care including TOT (C-TOT). Both groups received 45 minutes of rehabilitation over 25 sessions. Outcomes were Action Research Arm Test (ARAT), Upper Extremity Fugl-Meyer Assessment (FMA-UE) scores and Disability of the Arm Shoulder and Hand questionnaire.ResultsSixty eight subjects completed the protocol (Mean age 66.2, range 36.5-88.7, onset months 12.7, range 0.8-19.1) of which 45 were seen at follow up 5 weeks later. There were significant improvements in both groups on ARAT (median improvement: MeCFES TOT group 3.0; C-TOT group 2.0) and FMA-UE (median improvement: M-TOT 4.5; C-TOT 3.5). Considering subacute subjects (time since stroke < 6 months), there was a trend for a larger proportion of improved patients in the M-TOT group following rehabilitation (57.9%) than in the C-TOT group (33.2%) (difference in proportion improved 24.7%; 95% CI -4.0; 48.6), though the study did not meet the planned sample size.ConclusionThis is the first large multicentre RCT to compare MeCFES assisted TOT with conventional care TOT for the upper extremity. No adverse events or negative outcomes were encountered, thus we conclude that MeCFES can be a safe adjunct to rehabilitation that could promote recovery of upper limb function in persons after stroke, particularly when applied in the subacute phase.
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Project description:Objective: It was the aim to assess feasibility, safety, and potential efficacy of a new intensive, focused arm-hand BOOST program and to investigate whether there is a difference between early vs. late delivery of the program in the sub-acute phase post stroke. Methods: In this pilot RCT, patients with stroke were randomized to the immediate group (IG): 4 weeks (4 w) BOOST +4 w CONTROL or the delayed group (DG): 4 w CONTROL +4 w BOOST, on top of their usual inpatient care program. The focused arm-hand BOOST program (1 h/day, 5x/week, 4 weeks) consisted of group exercises with focus on scapula-setting, core-stability, manipulation and complex ADL tasks. Additionally, 1 h per week the Armeo®Power (Hocoma AG, Switzerland) was used. The CONTROL intervention comprised a dose-matched program (24 one-hour sessions in 4 w) of lower limb strengthening exercises and general reconditioning. At baseline, after 4 and 8 weeks of training, the Fugl-Meyer assessment upper extremity (FMA-UE), action research arm test (ARAT), and stroke upper limb capacity scale (SULCS) were administered. Results: Eighteen participants (IG: n = 10, DG: n = 8) were included, with a median (IQR) time post stroke of 8.6 weeks (5-12). No adverse events were experienced. After 4 weeks of training, significant between-group differences were found for FMA-UE (p = 0.003) and SULCS (p = 0.033) and a trend for ARAT (p = 0.075) with median (IQR) change scores for the IG of 9 (7-16), 2 (1-3), and 12.5 (1-18), respectively, and for the DG of 0.5 (-3 to 3), 1 (0-1), and 1.5 (-1 to 9), respectively. In the IG, 80% of patients improved beyond the minimal clinical important difference of FMA-UE after 4 weeks, compared to none of the DG patients. Between 4 and 8 weeks of training, patients in the DG tend to show larger improvements when compared to the IG, however, between-group comparisons did not reach significance. Conclusions: Results of this pilot RCT showed that an intensive, specific arm-hand BOOST program, on top of usual care, is feasible and safe in the sub-acute phase post stroke and suggests positive, clinical meaningful effects on upper limb function, especially when delivered in the early sub-acute phase post stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04584177.
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Project description:IntroductionThe Rehabilitation Training (ReTrain) intervention aims to improve functional mobility, adherence to poststroke exercise guidelines and quality of life for people after stroke. A definitive randomised controlled trial (RCT) is required to assess the clinical and cost-effectiveness of ReTrain, which is based on Action for Rehabilitation from Neurological Injury (ARNI). The purpose of this pilot study is to assess the feasibility of such a definitive trial and inform its design.Methods and analysisA 2-group, assessor-blinded, randomised controlled external pilot trial with parallel mixed-methods process evaluation and economic evaluation. 48 participants discharged from clinical rehabilitation despite residual physical disability will be individually randomised 1:1 to ReTrain (25 sessions) or control (exercise advice booklet). Outcome assessment at baseline, 6 and 9 months include Rivermead Mobility Index; Timed Up and Go Test; modified Patient-Specific Functional Scale; 7-day accelerometry; Stroke Self-efficacy Questionnaire, exercise diary, Fatigue Assessment Scale, exercise beliefs and self-efficacy questionnaires, SF-12, EQ-5D-5L, Stroke Quality of Life, Carer Burden Index and Service Receipt Inventory. Feasibility, acceptability and process outcomes include recruitment and retention rates; with measurement burden and trial experiences being explored in qualitative interviews (20 participants, 3 intervention providers). Analyses include descriptive statistics, with 95% CI where appropriate; qualitative themes; intervention fidelity from videos and session checklists; rehearsal of health economic analysis.Ethics and disseminationNational Health Service (NHS) National Research Ethics Service approval granted in April 2015; recruitment started in June. Preliminary studies suggested low risk of serious adverse events; however (minor) falls, transitory muscle soreness and high levels of postexercise fatigue are expected. Outputs include pilot data to inform whether to proceed to a definitive RCT and support a funding application; finalised Trainer and Intervention Delivery manuals for multicentre replication of ReTrain; presentations at conferences, public involvement events; internationally recognised peer-reviewed journal publications, open access sources and media releases.Trial registration numberNCT02429180; Pre-results.
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| S-EPMC8728417 | biostudies-literature
Project description:BackgroundIn contrast to the large and increasing number of patients with stroke, clinical rehabilitation resources cannot meet their rehabilitation needs. Especially for those discharged, ways to carry out effective rehabilitation training without the supervision of physicians and receive guidance from physicians remain urgent problems to be solved in clinical rehabilitation and have become a research hot spot at home and abroad. At present, there are many studies on home rehabilitation training based on wearable devices, Kinect, among others, but these have disadvantages (eg, complex systems, high price, and unsatisfactory rehabilitation effects).ObjectiveThis study aims to design a remote intelligent rehabilitation training system based on wearable devices and human-computer interaction training tasks, and to evaluate the effectiveness and safety of the remote rehabilitation training system for nonphysician-supervised motor rehabilitation training of patients with stroke through a clinical trial study.MethodsA total of 120 inpatients with stroke having limb motor dysfunction were enrolled via a randomized, parallel-controlled method in the rehabilitation institutions, and a 3-week clinical trial was conducted in the rehabilitation hall with 60 patients in the experimental group and 60 in the control group. The patients in the experimental group used the remote rehabilitation training system for rehabilitation training and routine clinical physical therapy (PT) training and received routine drug treatment every day. The patients in the control group received routine clinical occupational therapy (OT) training and routine clinical PT training and routine drug treatment every day. At the beginning of the training (baseline) and after 3 weeks, the Fugl-Meyer Motor Function Rating scale was scored by rehabilitation physicians, and the results were compared and analyzed.ResultsStatistics were performed using SAS software (version 9.4). The total mean Fugl-Meyer score improved by 11.98 (SD 8.46; 95% CI 9.69-14.27) in the control group and 17.56 (SD 11.65; 95% CI 14.37-20.74) in the experimental group, and the difference between the 2 groups was statistically significant (P=.005). Among them, the mean Fugl-Meyer upper extremity score improved by 7.45 (SD 7.24; 95% CI 5.50-9.41) in the control group and 11.28 (SD 8.59; 95% CI 8.93-13.62) in the experimental group, and the difference between the 2 groups was statistically significant (P=.01). The mean Fugl-Meyer lower extremity score improved by 4.53 (SD 4.42; 95% CI 3.33-5.72) in the control group and 6.28 (SD 5.28; 95% CI 4.84-7.72) in the experimental group, and there was no significant difference between the 2 groups (P=.06). The test results showed that the experimental group was better than the control group, and that the patients' motor ability was improved.ConclusionsThe remote rehabilitation training system designed based on wearable devices and human-computer interaction training tasks can replace routine clinical OT training. In the future, through medical device registration certification, the system will be used without the participation of physicians or therapists, such as in rehabilitation training halls, and in remote environments, such as communities and homes.Trial registrationChinese Clinical Trial Registry ChiCTR2200061310; https://tinyurl.com/34ka2725.
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Project description:ObjectiveTo compare the effects of 2 types of robotic-assisted gait training (RAGT) devices that have been used in stroke rehabilitation.DesignRetrospective cohort.SettingRehabilitation hospital.Participants24 community dwelling people with stroke (N=24).InterventionsRAGT with either an exoskeleton (Lokomat) (mean age=53.8 years; 30% men; mean duration of stroke =17.8 months) or an end-effector (G-EO) (mean age=50.5 years; 77.8% men; mean duration of stroke =13.11) delivered 3 times per week (36 sessions total).Main outcome measuresThe following tests/scales were employed before and after RAGT: Functional Ambulation Categories (FACs), timed Up and Go (TUG), 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), Trunk Impairment Scale, Dynamic Gait Index (DGI), Berg Balance Scale (BBS), and ability to climb stairs (time to climb 6 steps of 15 cm each; ability to climb stairs).ResultsThere were 5 dropouts, all from the G-EO group. At the end, 10 participants in the Lokomat and 9 in the G-EO group completed the intervention. From pre- to post-RAGT, G-EO patients improved on all functional tests/scales, whereas Lokomat patients improved only on the TUG, DGI, and BBS. Most patients showed improvements above the relative smallest real difference in the TUG, 10MWT, and 6MWT.ConclusionsBoth end-effectors and exoskeletons may improve clinically relevant aspects of walking function. However, this study had a small sample, was retrospective, non-randomized, and had a significant number of drop-outs, therefore its findings should be interpreted carefully. Future studies are needed for investigating potential differences in clinical results, side effects, contraindications, and cost effectiveness between these 2 different types of RAGT.
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Project description:This systematic review aims to reveal the effectiveness of proprioceptive exercise combined with dual-task training in stroke patients. The research was conducted using PubMed, Cochrane Library, Web of Science, and Scopus databases to evaluate studies of rehabilitation interventions with proprioceptive and dual-task exercises in patients with stroke. The keywords for the search were: "stroke" AND "proprioception" OR "proprioceptive" AND "rehabilitation" OR "training" OR "exercises" AND "dual-task" OR "task-performance" with the following inclusion criteria: comparative studies of rehabilitation interventions with proprioceptive and dual-task exercises in stroke patients. Of the 104,014 studies identified, 23 were included according to the inclusion criteria. Proprioceptive and dual-task exercises stimulate and promote postural balance, gait, and quality of life and reduce the risk of falls in stroke patients compared with traditional rehabilitation programs. In conclusion, this systematic review suggests that proprioceptive exercise combined with dual-task training is needed to improve balance and recover gait. Moreover, it provides a comprehensive overview of the literature on the various proprioceptive treatments with contextual dual-task exercises for imbalance after stroke, providing a guide for choosing a complete rehabilitation protocol that combines these two techniques.
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