Influence of gravity compensation training on synergistic movement patterns of the upper extremity after stroke, a pilot study.

BACKGROUND: The majority of stroke patients have to cope with impaired arm function. Gravity compensation of the arm instantaneously affects abnormal synergistic movement patterns. The goal of the present study is to examine whether gravity compensated training improves unsupported arm function. METHODS: Seven chronic stroke patients received 18 half-hour sessions of gravity compensated reach training, in a period of six weeks. During training a motivating computer game was played. Before and after training arm function was assessed with the Fugl-Meyer assessment and a standardized, unsupported circle drawing task. Synergistic movement patterns were identified based on concurrent changes in shoulder elevation and elbow flexion/extension angles. RESULTS: Median increase of Fugl-Meyer scores was 3 points after training. The training led to significantly increased work area of the hemiparetic arm, as indicated by the normalized circle area. Roundness of the drawn circles and the occurrence of synergistic movement patterns remained similar after the training. CONCLUSIONS: A decreased strength of involuntary coupling might contribute to the increased arm function after training. More research is needed to study working mechanisms involved in post stroke rehabilitation training. The used training setup is simple and affordable and is therefore suitable to use in clinical settings.

Changes in muscle activation after reach training with gravity compensation in chronic stroke patients.

The objective of this study is to examine the effect of gravity compensation training on reaching and underlying changes in muscle activation. In this clinical trial, eight chronic stroke patients with limited arm function received 18 sessions (30 min) of gravity-compensated reach training (during 6 weeks) in combination with a rehabilitation game. Before and after training, unsupported reach (assessing maximal distance, joint angles and muscle activity of eight shoulder and elbow muscles) and the Fugl-Meyer assessment were compared. After training, the maximal reach distance improved significantly by 3.5% of arm length, together with increased elbow extension (+9.2°) and increased elbow extensor activity (+68%). In some patients, a reduced cocontraction of biceps and anterior deltoid was also involved, although this was not significant on group level. Improvements in unsupported reach after gravity compensation training in chronic stroke patients with mild to severe hemiparesis were mainly accompanied by increased activation of prime movers at the elbow, although in some patients, improved selective joint control may also have been involved. Gravity compensation seems to be a suitable way to provide active, task-specific treatment, without the need for high-tech devices. Further research on a larger scale, including control groups and combinations of arm support with functional hand training, is essential to enhance the potential of arm support to complement poststroke arm rehabilitation.

Effect of position feedback during task-oriented upper-limb training after stroke: five-case pilot study.

Feedback is an important element in motor learning during rehabilitation therapy following stroke. The objective of this pilot study was to better understand the effect of position feedback during task-oriented reach training of the upper limb in people with chronic stroke. Five subjects participated in the training for 30 minutes three times a week for 6 weeks. During training, subjects performed reaching movements over a predefined path. When deviation from this path occurred, shoulder and elbow joints received position feedback using restraining forces. We recorded the amount of position feedback used by each subject. During pre- and posttraining assessments, we collected data from clinical scales, isometric strength, and workspace of the arm. All subjects showed improvement on one or several kinematic variables during a circular motion task after training. One subject showed improvement on all clinical scales. Subjects required position feedback between 7.4% and 14.7% of training time. Although augmented feedback use was limited, kinematic outcome measures and movement performance during training increased in all subjects, which was comparable with other studies. Emphasis on movement errors at the moment they occur may possibly stimulate motor learning when movement tasks with sufficiently high levels of difficulty are applied.

Influence of gravity compensation on kinematics and muscle activation patterns during reach and retrieval in subjects with cervical spinal cord injury: an explorative study.

Many interventions in upper-limb rehabilitation after cervical spinal cord injury (CSCI) use arm support (gravity compensation); however, its specific effects on kinematics and muscle activation characteristics in subjects with a CSCI are largely unknown. We conducted a cross-sectional explorative study to study these effects. Nine subjects with a CSCI performed two goal-directed arm movements (maximal reach, reach and retrieval) with and without gravity compensation. Angles at elbow and shoulder joints and muscle activation were measured and compared. Seven subjects reduced elbow extension (range 1.8°-4.5°) during the maximal reaching task with gravity compensation. In the reach and retrieval task with gravity compensation, all subjects decreased elbow extension (range 0.1°-11.0°). Eight subjects executed movement closer to the body. Regarding muscle activation, gravity compensation did not influence timing; however, the amplitude of activation decreased, especially in antigravity muscles, namely mean change +/- standard deviation of descending part of trapezius (18.2% +/- 37.5%), anterior part of deltoid (37.7% +/- 16.7%), posterior part of deltoid (32.0% +/- 13.9%), and long head biceps (49.6% +/- 20.0%). Clinical implications for the use of gravity compensation in rehabilitation (during activities of daily living or exercise therapy) should be further investigated with a larger population.

Long-term use of custom-made orthopedic shoes: 1.5-year follow-up study.

This study investigated long-term use of custom-made orthopedic shoes (OS) at 1.5 years follow-up. In addition, the association between short-term outcomes and long-term use was studied. Patients from a previously published study who did use their first-ever pair of OS 3 months after delivery received another questionnaire after 1.5 years. Patients with different pathologies were included in the study (n = 269, response = 86%). Mean age was 63 ± 14 years, and 38% were male. After 1.5 years, 87% of the patients still used their OS (78% frequently [4-7 days/week] and 90% occasionally [1-3 days/week]) and 13% of the patients had ceased using their OS. Patients who were using their OS frequently after 1.5 years had significantly higher scores for 8 of 10 short-term usability outcomes (p-values ranged from <0.001 to 0.046). The largest differences between users and nonusers were found for scores on the short-term outcomes of OS fit and communication with the medical specialist and shoe technician (effect size range = 0.16 to 0.46). We conclude that patients with worse short-term usability outcomes for their OS are more likely to use their OS only occasionally or not at all at long-term follow-up.

Patients' expectations and actual use of custom-made orthopaedic shoes.

OBJECTIVE: To investigate the association between patients' expectations and the actual use of custom-made orthopaedic shoes. DESIGN: A prospective cohort study with internal comparison. SETTING: Twelve orthopaedic shoe companies. PATIENTS: During six months, consecutive patients who were provided with their first ever pair of orthopaedic shoes and aged 16 years or older were recruited. A total of 339 patients with different pathologies were included (response 67%). Mean (SD) age of the patients was 63 (15) years, and 129 patients (38%) were male. MAIN MEASURES: A practical and reproducible questionnaire, measuring: frequency of use of orthopaedic shoes, patients' expectations and experiences of aspects of the usability of orthopaedic shoes, and communication about patients' expectations. RESULTS: Patients' expectations were not associated with the use of orthopaedic shoes (P-values range: 0.106 to 0.607), but the difference between expectations and experiences was (P-values range: <0.001 to 0.012). The expectations of patients who frequently used their orthopaedic shoes were in concordance with their experiences, whereas the expectations of patients who did not use their orthopaedic shoes were much higher than their experiences. There was no communication of patients' expectations with the medical specialist or orthopaedic shoe technician in 34% and 25% of the patients respectively. CONCLUSIONS: In relation to the actual use of orthopaedic shoes, it is crucial that patients' expectations are not much higher than their experiences.

Use and usability of custom-made orthopedic shoes.

The goal of this study was to investigate the use of custom-made orthopedic shoes (OS) and the association between the use of OS and the most relevant aspects of their usability. Over a 6-month period, patients meeting the inclusion criteria were recruited by 12 orthopedic shoe companies scattered throughout the Netherlands and asked to complete a questionnaire composed of a pre- and post-OS section. Patients with different pathologies were included in the study (n = 339; response 67%). Mean age of the patients was 63 +/- 15 years, and 38% were male. Three months after delivery, 81% of the patients used their OS frequently (4-7 days/week), 13% occasionally (1-3 days/week), and 6% did not use their OS. Associations were found between use and all measured aspects of usability (p-values varied from <0.001 to 0.028). Patients who used their OS more often had a more positive opinion regarding all the aspects of usability. We conclude that all aspects of the usability of OS are relevant in relation to their use and should be taken into account when prescribing and evaluating OS.

Nature, timing, frequency and type of augmented feedback; does it influence motor relearning of the hemiparetic arm after stroke? A systematic review.

PURPOSE: To investigate the effect of different aspects and types of augmented feedback on motor functions and motor activities of the hemiparetic arm after stroke. METHOD: Systematic search of the scientific literature was performed in the Pubmed and Cochrane database from 1975 to March 2009. The augmented feedback used in the intervention was classified with respect to aspects (nature, timing and frequency) and types (auditory, sensory and visual). RESULTS: The systematic literature search resulted in 299 citations. On the basis of inclusion and exclusion criteria, 23 full-text articles were included for analysis. There are some trends in favour of providing augmented knowledge of performance feedback, augmented auditory and combined sensory and visual feedback. No consistent effects on motor relearning were observed for summary or faded, terminal or concurrent, solely visual or solely sensory augmented feedback. CONCLUSIONS: On the basis of this study, it was not possible to determine which combinations of aspects and types of augmented feedback are most essential for a beneficial effect on motor activities and motor functions of the hemiparetic arm after stroke. This was due to the combination of multiple aspects and types of augmented feedback in the included studies. This systematic review indicates that augmented feedback in general has an added value for stroke rehabilitation.

An explorative, cross-sectional study into abnormal muscular coupling during reach in chronic stroke patients.

BACKGROUND: In many stroke patients arm function is limited, which can be related to an abnormal coupling between shoulder and elbow joints. The extent to which this can be translated to activities of daily life (ADL), in terms of muscle activation during ADL-like movements, is rather unknown. Therefore, the present study examined the occurrence of abnormal coupling on functional, ADL-like reaching movements of chronic stroke patients by comparison with healthy persons. METHODS: Upward multi-joint reaching movements (20 repetitions at a self-selected speed to resemble ADL) were compared in two conditions: once facilitated by arm weight compensation and once resisted to provoke a potential abnormal coupling. Changes in movement performance (joint angles) and muscle activation (amplitude of activity and co-activation) between conditions were compared between healthy persons and stroke patients using a repeated measures ANOVA. RESULTS: The present study showed slight changes in joint excursion and muscle activation of stroke patients due to shoulder elevation resistance during functional reach. Remarkably, in healthy persons similar changes were observed. Even the results of a sub-group of the more impaired stroke patients did not point to an abnormal coupling between shoulder elevation and elbow flexion during functional reach. CONCLUSIONS: The present findings suggest that in mildly and moderately affected chronic stroke patients ADL-like arm movements are not substantially affected by abnormal synergistic coupling. In this case, it is implied that other major contributors to limitations in functional use of the arm should be identified and targeted individually in rehabilitation, to improve use of the arm in activities of daily living.

Analysis of healthy sitting behavior: interface pressure distribution and subcutaneous tissue oxygenation.

Pressure ulcers are a large problem in individuals who use a wheelchair for their mobility and have limited trunk stability and motor function. Because no relation between interface pressure and pressure ulcer development has been established and no clinical threshold for pressure ulcer development can be given, looking at the sitting behavior of nondisabled individuals is important. Nondisabled individuals do not develop pressure ulcers because they continuously shift posture. We analyzed the sitting behavior of 25 nondisabled male subjects by using a combination of interface pressure measurement and subcutaneous tissue oxygenation measurement by means of the Oxygen to See. These subjects shifted posture on average 7.8 +/- 5.2 times an hour. These posture shifts were merely a combination of posture shifts in the frontal and sagittal plane. Subcutaneous oxygen saturation increased on average 2.2% with each posture adjustment, indicating a positive effect of posture shifts on tissue viability. The results of this study can be used as a reference for seating interventions aimed at preventing pressure ulcers. Changing the sitting load at least every 8 minutes is recommended for wheelchair users.

Systematic review of the effectiveness of mirror therapy in upper extremity function.

PURPOSE: This review gives an overview of the current state of research regarding the effectiveness of mirror therapy in upper extremity function. METHOD: A systematic literature search was performed to identify studies concerning mirror therapy in upper extremity. The included journal articles were reviewed according to a structured diagram and the methodological quality was assessed. RESULTS: Fifteen studies were identified and reviewed. Five different patient categories were studied: two studies focussed on mirror therapy after an amputation of the upper limb, five studies focussed on mirror therapy after stroke, five studies focussed on mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one study on mirror therapy with complex regional pain syndrome type 2 (CRPS2) and two studies focussed on mirror therapy after hand surgery other than amputation. CONCLUSIONS: Most of the evidence for mirror therapy is from studies with weak methodological quality. The present review showed a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS, whereas the effectiveness in other patient groups has yet to be determined.

Clinical use of interface pressure to predict pressure ulcer development: a systematic review.

Pressure ulcers are a large problem in subjects who use a wheelchair for their mobility. These ulcers originate beneath the bony prominences of the pelvis and progress outward as a consequence of prolonged pressure. Interface pressure is used clinically to predict and prevent pressure ulcers. However, the relation between interface pressure and the development of pressure ulcers is not clear. A systematic review was performed to address the research question of whether interface pressure can be used to predict the development of pressure ulcers or to determine the prognosis of an ulcer once developed. Seven studies were identified that measured interface pressure and used the development or healing of pressure ulcers as an outcome measure. There appears to be a weak qualitative relation between interface pressure and the development of pressure ulcers. However, no conclusive clinical threshold for the interface pressure can be given. This, combined with the influence of individual characteristics, the low internal validity of interface pressure measurement for the prediction of pressure ulcers, and an incongruent relation between pressure magnitude and duration, results in the fact that no quantification of the predictive or prognostic value of interface pressure can be given.

Assessment of visuospatial neglect in stroke patients using virtual reality: a pilot study.

One of the neuropsychological deficits that can result from a stroke is the neglect phenomenon. Neglect has traditionally been assessed with paper-and-pencil tasks, which are administered within the reaching space of a person. The purpose of this explorative study is to investigate whether it is possible to assess neglect in the extrapersonal space based on the performance of acute stroke patients, chronic stroke patients and healthy elderly in orientation and exploration tasks when immersed in a three-dimensional (3D)-virtual environment. Six able-bodied healthy elderly and 12 stroke patients (six subacute and six chronic) participated in this explorative cross-sectional study. Neglect was assessed by means of the 3D neglect test. Different parameters were measured at two challenge levels with increasing difficulty. In the easiest level significant differences between the groups were found for total time spent in the test, mean response time left field of vision, and mean response time in the left field of vision of the left virtual reality environment. Differences in search patterns showed that subacute stroke patients had a much more fuzzy search pattern in scanning the environment than healthy elderly and chronic stroke patients. With respect to the more difficult level results showed significant differences between healthy elderly and the total group of stroke patients. The results of this study suggest that a 3D neglect test by means of virtual reality has the potential to detect and measure unilateral neglect.

An electric scooter simulation program for training the driving skills of stroke patients with mobility problems: a pilot study.

This paper describes an electric scooter simulation program and a first evaluation study in which we explored if it is possible to train the driving skills of future users of electric mobility scooters by means of an electric scooter simulation program in addition to conventional electric scooter training. Within this explorative study,10 stroke survivors were randomly assigned to either the control (n=5) or the electric scooter simulation intervention group (n=5). Participants were assessed twice on the functional evaluating rating scale. During the followup measurement, subjective experiences regarding both forms of electric scooter training were elicited by a questionnaire. After a training period of 5 weeks, both groups improved on the Functional Evaluation Rating Scale. It can be concluded that the patients with stroke were satisfied with the electric scooter simulation training.

A low-cost video game applied for training of upper extremity function in children with cerebral palsy: a pilot study.

The aim of the present study was to determine the user satisfaction of the EyeToy for the training of the upper limb in children with cerebral palsy (CP). User satisfaction was measured in 12 children with CP, using a postexperience questionnaire, primarily based on a presence questionnaire. In general, children with CP were satisfied with and motivated by the EyeToy training. In addition, a first evaluation study was performed to determine the effect of this training method on the upper limb function. Ten children with CP were randomly assigned to the intervention (mean age 11 years, 9 months; SD 2,3) and the control group (mean age 12 years, 3 months; SD 3,2). After a treatment period of 6 weeks, the intervention group completed a user satisfaction questionnaire. Functional outcome was measured using the Melbourne Assessment scores. Percentage scores of the Melbourne Assessment of 7 of the 10 children were the same or changed only 1% to 2% from baseline to followup. However, in the experimental group, two children improved more, 9% and 13% respectively. In conclusion, it can be said that the EyeToy is a motivational training tool for the training of children with CP and has the potential to improve upper extremity function.

Virtual reality for mobility devices: training applications and clinical results: a review.

Virtual reality technology is an emerging technology that possibly can address the problems encountered in training (elderly) people to handle a mobility device. The objective of this review was to study different virtual reality training applications as well as their clinical implication for patients with mobility problems. Computerized literature searches were performed using the MEDLINE, Cochrane, CIRRIE and REHABDATA databases. This resulted in eight peer reviewed journal articles. The included studies could be divided into three categories, on the basis of their study objective. Five studies were related to training driving skills, two to physical exercise training and one to leisure activity. This review suggests that virtual reality is a potentially useful means to improve the use of a mobility device, in training one's driving skills, for keeping up the physical condition and also in a way of leisure time activity. Although this field of research appears to be in its early stages, the included studies pointed out a promising transfer of training in a virtual environment to the real-life use of mobility devices.

Effectiveness of custom-made orthopaedic shoes in the reduction of foot pain and pressure in patients with degenerative disorders of the foot.

BACKGROUND: Degenerative disorders of the foot often are painful during standing and walking. It is assumed that, because of bone deformity, callus, and deformity of the plantar pads, the plantar pressure distribution changes. Prescription of orthopaedic shoes for patients with degenerative disorders of the foot is based on the hypothesis that excessive pressure under the foot causes pain. The goal of this study was to evaluate the effectiveness of custom-made orthopaedic shoes, in terms of pressure and pain, in patients with degenerative disorders of the foot. Additionally, the relationship between plantar pressure parameters and foot pain was studied, with special emphasis on second and third metatarsal heads. METHODS: Seventy-seven consecutive patients with degenerative disorders of the foot were recruited from the outpatient clinics of seven rehabilitation centers and rehabilitation departments of university hospitals in the Netherlands. The study was prospective. The Questionnaire for Usability Evaluation for Orthopaedic Shoes was used to measure perceived foot pain. To measure plantar pressures, the Pedar in-shoe pressure measurement system (Novel GmbH, Munich) was used. The effectiveness of custom-made orthopaedic shoes, in terms of pressure and pain in patients with degenerative disorders of the foot, was analyzed by means of a paired sample t-test. To select the pressure parameter (Pmax, P(TI,) and P(av)) most closely associated with walking pain, within-subject correlation coefficients were calculated. RESULTS: Custom-made orthopaedic shoes significantly decreased perceived foot pain by at least 23%, and significantly reduced plantar pressure under all foot regions by at least 9%. A significant correlation (r = 0.521) was found between walking pain and the average pressure beneath the second and third metatarsal heads. CONCLUSIONS: Based on these results, it can be concluded that custom-made orthopaedic shoes are effective in reducing foot pain and foot pressure. The moderate (significant) relationship between average pressure and walking pain can be used as a tool for evaluating custom-made orthopaedic shoes prescribed for patients with degenerative disorders of the foot.

Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke.

A limited number of clinical studies have examined the effect of poststroke rehabilitation with robotic devices on hemiparetic arm function. We systematically reviewed the literature to assess the effect of robot-aided therapy on stroke patients' upper-limb motor control and functional abilities. Eight clinical trials were identified and reviewed. For four of these studies, we also pooled short-term mean changes in Fugl-Meyer scores before and after robot-aided therapy. We found that robot-aided therapy of the proximal upper limb improves short- and long-term motor control of the paretic shoulder and elbow in subacute and chronic patients; however, we found no consistent influence on functional abilities. In addition, robot-aided therapy appears to improve motor control more than conventional therapy.

Effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients: a systematic review of randomized controlled trials.

OBJECTIVE: Assessment of the available evidence regarding the effect of augmented feedback on motor function of the upper extremity in rehabilitation patients. METHODS: A systematic literature search was performed to identify randomized controlled trials that evaluated the effect of augmented feedback on motor function. Two reviewers systematically assessed the methodological quality of the trials. The reported effects were examined to evaluate the effect of therapeutic interventions using augmented feedback and to identify a possible relationship with patient characteristics, type of intervention, or methodological quality. RESULTS: Twenty-six randomized controlled trials were included, 9 of which reported a positive effect on arm function tests. Follow-up measurements were performed in 8 trials, 1 of which reported a positive effect. Different therapeutic interventions using augmented feedback, i.e. electromyographic biofeedback, kinetic feedback, kinematic feedback, or knowledge of results, show no difference in effectiveness. CONCLUSION: No firm evidence was found of effectiveness regarding the use of augmented feedback to improve motor function of the upper extremity in rehabilitation patients. Future studies should focus more on the content, form and timing of augmented feedback concerning the therapeutic intervention. It should be emphasized that motor learning effects can only be determined by re-examining the population after a follow-up period.

Use of orthopedic shoes in patients with degenerative disorders of the foot.

OBJECTIVES: To study the actual use of orthopedic shoes by patients with degenerative foot disorders and to identify factors associated with use and nonuse, based on the parameters of the International Organization for Standardization definition of usability: effectiveness, efficiency, satisfaction, and context of use. DESIGN: Multicenter, prospective cohort study. SETTING: Outpatient clinics of 7 rehabilitation centers in the Netherlands. PARTICIPANTS: One hundred consecutive patients with degenerative foot disorders. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Usability was assessed by means of the Questionnaire for Usability Evaluation of orthopedic shoes. RESULTS: Seventy of 93 patients with degenerative foot disorders wore their orthopedic shoes for more than 3 days a week after 3 months of follow-up. Factors significantly associated with the actual use of orthopedic shoes were (1) increase in stance duration (effectiveness odds ratio [OR]=2.14; 95% confidence interval [CI], 1.19-3.85), (2) decrease in skin abnormalities (effectiveness OR=1.35; 95% CI, 1.02-1.8]), (3) problems experienced with putting on and taking off orthopedic shoes (efficiency OR=.46; 95% CI, .26-.82), and (4) cosmetic appearance of orthopedic shoes (satisfaction OR=1.54; 95% CI, 1.1-2.15). The overall fit of the multiple logistic regression model ( R 2 ) was 56.3%. CONCLUSIONS: By adding efficiency and satisfaction factors and not focusing only on the effectiveness factors, the amount of explained variance increases, and it becomes possible to evaluate and design products for people with special needs more comprehensively.