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

Abstract

The anatomical and physiological heterogeneity of strokes and persons with stroke, along with the complexity of normal upper extremity movement make the possibility that any single treatment approach will become the definitive solution for all persons with upper extremity hemiparesis due to stroke unlikely. This situation and the non-inferiority level outcomes identified by many studies of virtual rehabilitation are considered by some to indicate that it is time to consider other treatment modalities. Our group, among others, has endeavored to build on the initial positive outcomes in studies of virtual rehabilitation by identifying patient populations, treatment settings and training schedules that will best leverage virtual rehabilitation's strengths. We feel that data generated by our lab and others suggest that (1) persons with stroke may adapt to virtual rehabilitation of hand function differently based on their level of impairment and stage of recovery and (2) that less expensive, more accessible home based equipment seems to be an effective alternative to clinic based treatment that justifies continued optimism and study.

Keywords: arm; hand; rehabilitation; stroke; virtual reality.

Figure 1

Top left panel: Total UEFMA score for 10 subjects that participated in a 2 week robot assisted virtual rehabilitation (RAVR) training protocol. Measurements taken pre – training and post-training as well as 1, 4, and 6 months post-stroke. These subjects all initiated training <30 days post-stroke and scored <20 on the UEFMA pre-training. Four of the subjects demonstrated an increase from pre to post-test, that exceeds the minimum clinically important difference (MCID) for persons with acute/early subacute stroke of 10 (71). Note the two distinct patterns of response to training and non-response to training at 1 month post-stroke. Top right panel: Total UEFMA score for 10 subjects that participated in the same RAVR training protocol. Measurements taken pre – training and post-training as well as 1, 4, and 6 months post-stroke. These subjects all initiated training <30 days post-stroke and scored more than 20 on the UEFMA pre-training. Seven of the subjects demonstrated an increase from pre to post-test, that exceeds the MCID. Bottom Panel: Total UEFMA score for 14 subjects that participated in a 12 week home virtual rehabilitation system (HoVRS) training protocol, 10 subjects that participated in a 2 week robot assisted virtual rehabilitation (RAVR) training protocol and 11 subjects that participated in a 2 week repetitive task practice (RTP) protocol. All subjects demonstrated residual impairments from stroke at least 6 months post-stroke and were tested immediately before and after training. Nine of the 14 HoVRS subjects demonstrated improvements that exceeded the MCID of 4.25 (72). Six of 17 RAVR subjects and five of 15 RTP subjects exceeded the MCID. Note the more homogenous improvements demonstrated by the subjects performing HoVRS training. RAVR and RTP subjects were described in detail in Ref. (22).

Figure 2

Total UEFMA score for 13 subjects that participated in a 10 session early virtual rehabilitation (EVR) training protocol added to their standard inpatient rehabilitation care, early home or outpatient rehabilitation and 7 subjects that performed usual care (UC) which consisted of standard inpatient rehabilitation care, early home or outpatient rehabilitation only. Both groups demonstrated changes that exceed the minimum detectable change of 5.25 from pre to post-test and from post-test to 6 month retention. Eight of the nine EVR subjects and eight of the 11 UC “subjects” improvements from pre to post-test exceeded the minimum clinically important difference of 10. Measurements taken pre – training and post-training (2–3 weeks after pre test for UC) as well as 1 month post-training and 6 months post-stroke. Note the differences in UEFMA score at 1 month post-training.