Effective Therapy for Upper Extremity Stroke Patients. Anna Morgan Mills Hanah Gregory

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1 Effective Therapy for Upper Extremity Stroke Patients Anna Morgan Mills Hanah Gregory

2 Overview Introduction Background Current Research FES Virtual Reality Hypothesis Proposed Clinical Study

3 Stroke Facts Stroke is the main cause of disabilities in the world A person has a stroke every 40 seconds in the world 5th leading cause of death in America More than 800,000 strokes happen in the US per year An American dies every 4 minutes from a stroke

4 Causes of Strokes Ischemic Caused by blockages or narrowing of arteries that provide blood to the brain Most common, comprising 85% of all strokes Hemorrhagic Arise when arteries in the brain leak blood or burst open

5 Side Effects Left Brain Paralysis on right side of the body Vision problems Quick, inquisitive behavioral style Memory Loss Right Brain Paralysis on left side of the body Speech/Language Problems Slow, cautious behavioral style Memory Loss Both types can result in hemiparesis, resulting in weaknesses in one side of the body which affects nearly 80% of all stroke victims

6 Why Upper Extremity? Approximately ¾ of acute stroke survivors lose arm and hand movement skills Approximately 65%-85% of stroke survivors will relearn to walk, but only 40% will regain complete composure of their upper limbs

7 Functional Electrical Stimulation - Functional electrical stimulation (FES) applies small electrical pulses to paralyzed or weakened muscles to restore or improve their function. - Causes muscle to contract through the use of electrical current. - May be useful for increasing arm and hand function and for preventing pain and dysfunction. - Usually paired with occupational therapy - Includes use of didactic material, such as a cone or a ball

8 Previous Research - FES - Looked at 23 different clinical trials - All Randomized-Controlled - Included combinations of - FES with repetitive task practice - FES with occupational and physical therapy - At home FES with occupational and physical therapy - Patient ages ranged from Most common treatment plan was three, three hour sessions per week for two months - All experimental groups showed increase in upper extremity motor functions

9 Virtual Reality (VR) Rehabilitation Involves computer-based technology designed to simulate real life objects and events The process of motor learning can occur as a result of watching, as well as physically performing a movement Semi-immersive or fully immersive Advantages Provides an opportunity to practice day-to-day activities that cannot always be practiced within the hospital environment More motivational Instant feedback

10 Previous Research - VR Sucar, Gesture Therapy a low-cost camera based system that tracks a hand grip held by the participant in their impaired arm Eight Games conducting task specific movements Participated in conventional therapy as well 2 groups, control and experimental, with 11 participants each Age ranging from sessions a week, 60 minutes each, for a 5 week period Provided a stronger motivation and attachment to treatment, which is vital to recovery in stroke patients Not a significant difference between control and experimental improvement

11 Previous Research - VR Comeirao, Rehabilitation Gaming System 21 acute/subacute stroke patients compared to 20 healthy control patients 3 weekly sessions of 20 minutes, in addition to conventional therapy Includes either hitting or grasping oncoming spheres Uses two data gloves to capture finger flexion, a vision-based analysis, and tracking system to coordinate player hand movements with an on-screen representation of the upper limbs Real-time modulated difficulty throughout game if the user intercepts more than seventy percent of spheres the setting is increased if the user intercepts less than fifty percent the difficulty is decreased Experimental group showed significantly faster improvement and faster movement of paretic limb over time in contrast to control group

12 Hypothesis + =

13 Proposed Research - We would conduct a randomly-controlled study - Including 30 stroke patients of both sexes - Age range from years - Participants would be randomly assigned into three equal groups: - Patients receiving FES treatment with simple task therapy - Patients receiving VR treatment - Patients receiving FES and VR treatment - In order to modulate difficulty, we will have a baseline clinical assessment. - This will ensure each patient starts at their designated difficulty level.

14 Proposed Research - Along with the prior assessment, patients will complete a motivation survey and a Fugl-Meyer Assessment to be used for later comparison. - Survey would be a simple 0-10 scale to better determine where the patient s motivational level is prior to any treatment and what they are hoping to achieve by the end of this trial. - At the end of every two weeks, an additional Fugl-Meyer Assessment will be given. This test is looking to asses five main domains: - Motor function, Sensory Function, Balance, Joint Range of Motion, and Joint Pain - Treatment for each group would be provided for 30 minutes, three times a week for 12 weeks.

15 Proposed Research - Standard re-evaluations will be given every four weeks up through their post-treatment assessment at the end of the 12 weeks. - To help keep patients engaged throughout the trail we will focus on two important aspects: - Positive Feedback - Level of difficulty - First, the system should be able to evaluate objectively the progress of the patient so it can provide feedback and motivate him or her to continue the therapy. - Second, the system should adapt according to the progress of the patient so it requires the right amount of effort.

16 Proposed Research - To produce optimal results, the games that will be provided in the groups receiving the virtual reality treatment will mimic daily activities. - Grocery shopping - Playing basketball - Cleaning the stove - Hammering a nail - As the patients engage in the games, they will be able to see their improvement at the end of each session. - The patients will be unaware of the games adaptation of difficulty which will minimize the chance of a failed score therefore eliminating negative feedback.

17 Proposed Research - The goals of this proposed clinical trial look to produce the optimal improvement in the motor functions of upper extremities in post stroke patients. - This research would provide information on the best way to treat hemiparesis while keeping patients motivated throughout the trial. - We believe that combining the FES and VR treatment will produce the greatest overall motor function improvement

18 References Alon, G., Levitt, A.F., Mccarthy, P.A., Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study. Neurorehabilitation and Neural Repair 21, doi: / Chan, M.K.-L., Tong, R.K.-Y., Chung, K.Y.-K., Bilateral Upper Limb Training With Functional Electric Stimulation in Patients With Chronic Stroke. Neurorehabilitation and Neural Repair 23, doi: / Gharib, N.M., Aboumousa, A.M., Elowishy, A.A., Rezk-Allah, S.S., Yousef, F.S., Efficacy of electrical stimulation as an adjunct to repetitive task practice therapy on skilled hand performance in hemiparetic stroke patients: a randomized controlled trial. Clinical Rehabilitation 29, doi: / Kroon, J.D., Ijzerman, M., Chae, J., Lankhorst, G., Zilvold, G., Relation Between Stimulation Characteristics And Clinical Outcome In Studies Using Electrical Stimulation To Improve Motor Control Of The Upper Extremity In Stroke. Journal of Rehabilitation Medicine 37, doi: / Ring, H., Rosenthal, N., Controlled Study Of Neuroprosthetic Functional Electrical Stimulation In Sub-Acute Post-Stroke Rehabilitation. Journal of Rehabilitation Medicine 37, doi: /

19 References Sucar, L.E., Leder, R., Hernandez, J., Sazcarate, G.: Clinical evaluation of a low-cost alternative for stroke rehabilitation. Paper presented at the rehabilitation robotics, ICORR 2009, June 2009 Cameirao, M.S., Badia, S.B., Oller, E.D., Verschure, P.F.: Neurorehabilitation using the virtual reality based Rehabilitation Gaming System: methodology, design, psychometrics, usability and validation. J. Neuroeng. Rehabil. 7, 48 (2011) Ma, M., Jain, L. C., & Anderson, P. (2014). Virtual, augmented reality and serious games for healthcare. Heidelberg: Springer.

20 Questions?

Potential for new technologies in clinical practice

Potential for new technologies in clinical practice International Neurorehabilitation Symposium University of Zurich Feb 12-13th 2009 Prof Jane Burridge Jane Burridge Feb 2009 Introduction Societal drivers