Improving upper-limb and trunk kinematics by interactive gaming in individuals with chronic stroke: A single-blinded RCT.

BACKGROUND: Commercial gaming systems are increasingly being used for stroke rehabilitation; however, their effect on upper-limb recovery versus compensation is unknown. OBJECTIVES: We aimed to compare the effect of upper-limb rehabilitation using interactive gaming (Nintendo Wii) with dose-matched conventional therapy on elbow extension (recovery) and forward trunk motion (compensation) in individuals with chronic stroke. Secondary aims were to compare the effect on (1) clinical tests of impairment and activity, pain and effort, and (2) trajectory kinematics. We also explored arm and trunk motion (acceleration) during Wii sessions to understand how participants performed movements during Wii gaming. METHODS: This single-centre, randomized controlled trial compared 12 hourly sessions over 4 weeks of upper-limb Wii therapy to conventional therapy. Outcomes were evaluated at baseline and 4 weeks. The change in elbow extension and trunk motion during a reaching task was evaluated by electromagnetic sensors. Secondary outcomes were change in Fugl-Meyer assessment, Box and Block test, Action Research Arm Test, Motor Activity Log, and Stroke Impact Scale scores. Arm and trunk acceleration during Wii therapy was evaluated by using inertial sensors. A healthy control group was included for reference data. RESULTS: Nineteen participants completed Wii therapy and 21 conventional therapy (mean [SD] time post-stroke 66.4 [57.2] months). The intervention and control groups did not differ in mean change in elbow extension angle (Wii: +4.5°, 95% confidence interval [CI] 0.1; 9.1; conventional therapy: +6.4°, 95%CI 0.6; 12.2) and forward trunk position (Wii: -3.3 cm, 95%CI -6.2;-0.4]; conventional therapy: -4.1 cm, 95%CI -6.6; -1.6) (effect size: elbow, d = 0.16, p = 0.61; trunk, d = 0.13, p = 0.65). Clinical scores improved similarly but to a small extent in both groups. The amount of arm but not trunk acceleration produced during Wii sessions increased with training. CONCLUSIONS: Supervised upper-limb gaming therapy induced similar recovery of elbow extension as conventional therapy and did not enhance the development of compensatory forward trunk movement in individuals with chronic stroke. More sessions may be necessary to induce greater improvements. CLINICALTRIALS: GOV: NCT01806883.

Kinematics of the Shoulder Girdle During Pointing: Coordination Between Joints and their Contribution to the Peri-Personal Workspace.

This study explored the coordination between the components of the shoulder girdle (clavicle, scapula and humerus), and how they contribute to hand movement in the peri-personal space. Shoulder girdle motion was recorded in 10 healthy subjects during pointing movements to 9 targets in the peri-personal space, using electromagnetic sensors fixed to the trunk, scapula and upper arm. Most of the 9 degrees of freedom (DoF) of the shoulder girdle were finely scaled to target position. Principle component analysis revealed that the 6 DoF of scapula-thoracic motion were coordinated in three elementary patterns (protraction, shrug and lateral rotation). The ratio of gleno-humeral to scapulo-thoracic global motion was close to 2:1. A direct kinematic procedure showed that if no scapular motion occurred, the workspace would be reduced by 15.8 cm laterally, 13.7 cm vertically and 4.8 cm anteriorly. Scapulo-thoracic motion should be taken into account when investigating the physiology of upper-limb movements.

Influence of the side of brain damage on postural upper-limb control including the scapula in stroke patients.

Following stroke, control of both the contralesional (paretic) and ipsilesional (less affected) arms is altered. The purpose of this study was to analyse the consequences of stroke on joint rotations of both shoulder girdles, that is, glenohumeral (GH) and scapula motion. Because of hemispheric specialization, we hypothesized that changes would relate to the side of hemisphere damage. Nine stroke patients with left, and 9 with right hemisphere damage (LHD and RHD) and 9 healthy subjects were included. Reaching movements to targets positioned close, far and high in three directions were recorded using an electromagnetic system. Initial and final postures of the scapula, GH and elbow joint were evaluated. Inter-joint rotations throughout the movements were analysed using principal component analysis (PCA). The main finding was that initial and final postures of the contralesional and ipsilesional shoulders differed depending on the side of brain lesion. On the contralesional side, there was less scapula protraction and GH lateral rotation for both groups. Scapula tilt was less anterior in LHD patients, and GH elevation was greater in RHD patients. On the ipsilesional side, GH lateral rotation was reduced in both groups, and scapula protraction was reduced only for LHD patients. PCA confirmed that postures of both shoulders of the LHD group were substantially different to the healthy subjects, while only the contralesional arm of the RHD subjects differed. These results add to existing knowledge of hemispheric specialization, suggesting that the left hemisphere plays a greater role in bilateral joint postures than the right hemisphere.

The trunk as a part of the kinematic chain for reaching movements in healthy subjects and hemiparetic patients.

The aims of this study were first to further assess the role of the 3D trunk angular rotations as part of the kinematic chain for seated-reaching movements within arm's length in a large 3D workspace in healthy subjects and second, to assess if these degrees of freedom participate in the compensatory strategy in hemiparetic patients. Ten healthy subjects, eight patients with right, and eight patients with left hemiparesis following stroke were included. They performed seated reaching movements at a comfortable speed to nine targets positioned in a large 3D workspace within arm's length. An electromagnetic system was used to record kinematics of the trunk and hand. Trunk flexion, lateral flexion and torsion were analyzed as a function of target direction, distance and height. In both healthy subjects and patients, all three trunk rotations participated in the reaching movement (except for near targets in healthy subjects). Trunk flexion was greater in patients but followed a similar pattern to healthy subjects. Trunk torsion was more influenced by target distance in healthy subjects while in patients it was greatly influenced by direction. Trunk lateral flexion was similar between groups. Comparing the two patient groups, there was greater flexion to the external targets in the RHD group and different strategies in the use of torsion between groups. 3D trunk rotations thus seem to be tuned to the distance and direction of the target in the workspace in both healthy subjects and stroke patients for reaching movements within arm's length.

A methodology to quantify alterations in human upper limb movement during co-manipulation with an exoskeleton.

While a large number of robotic exoskeletons have been designed by research teams for rehabilitation, it remains rather difficult to analyse their ability to finely interact with a human limb: no performance indicators or general methodology to characterize this capacity really exist. This is particularly regretful at a time when robotics are becoming a recognized rehabilitation method and when complex problems such as 3-D movement rehabilitation and joint rotation coordination are being addressed. The aim of this paper is to propose a general methodology to evaluate, through a reduced set of simple indicators, the ability of an exoskeleton to interact finely and in a controlled way with a human. The method involves measurement and recording of positions and forces during 3-D point to point tasks. It is applied to a 4 degrees-of-freedom limb exoskeleton by way of example.

Botulinum toxin to treat upper-limb spasticity in hemiparetic patients: analysis of function and kinematics of reaching movements.

BACKGROUND: Poor control of reaching in spastic hemiparetic patients could be because of a combination of poor individuation of joints, weakness, spasticity, and/or sensory loss. OBJECTIVE: To assess the effect of botulinum toxin injections (BTIs) on spasticity, upper-limb function, and kinematics of reaching movements in patients with spastic hemiparesis caused by brain injury. METHODS: Fifteen patients with spastic hemiparesis and 9 healthy controls were included in this single-site, open-labeled study. The trajectories of reaching movements were recorded, and kinematic variables were computed. A clinical evaluation included the Motor Activity Log, the Action Research Arm Test (ARAT), and the Box and Block Test (BBT). Patients were assessed before (M0), 1 month after a first (M1), and 1 month after a second BTI (M4, at 4 months) in proximal and distal muscles. RESULTS: Significant differences were found between hemiparetic patients and healthy participants for all kinematic parameters. All parameters tended to improve after BTI. This effect was significant for velocity and smoothness. Functional scores also tended to improve. Improvements were greater at M4 than at M1, although the differences were not significant. CONCLUSIONS: Kinematic parameters improved following BTI, without significant changes in clinical outcomes such as ARAT and BBT. The decrease in spasticity alone does not seem to explain the results, which may be a result of adaptation to the decrease in hypertonicity leading to increased use of the arm and possibly an increase in antagonist muscle strength.

Effect of auditory feedback differs according to side of hemiparesis: a comparative pilot study.

BACKGROUND: Following stroke, patients frequently demonstrate loss of motor control and function and altered kinematic parameters of reaching movements. Feedback is an essential component of rehabilitation and auditory feedback of kinematic parameters may be a useful tool for rehabilitation of reaching movements at the impairment level. The aim of this study was to investigate the effect of 2 types of auditory feedback on the kinematics of reaching movements in hemiparetic stroke patients and to compare differences between patients with right (RHD) and left hemisphere damage (LHD). METHODS: 10 healthy controls, 8 stroke patients with LHD and 8 with RHD were included. Patient groups had similar levels of upper limb function. Two types of auditory feedback (spatial and simple) were developed and provided online during reaching movements to 9 targets in the workspace. Kinematics of the upper limb were recorded with an electromagnetic system. Kinematics were compared between groups (Mann Whitney test) and the effect of auditory feedback on kinematics was tested within each patient group (Friedman test). RESULTS: In the patient groups, peak hand velocity was lower, the number of velocity peaks was higher and movements were more curved than in the healthy group. Despite having a similar clinical level, kinematics differed between LHD and RHD groups. Peak velocity was similar but LHD patients had fewer velocity peaks and less curved movements than RHD patients. The addition of auditory feedback improved the curvature index in patients with RHD and deteriorated peak velocity, the number of velocity peaks and curvature index in LHD patients. No difference between types of feedback was found in either patient group. CONCLUSION: In stroke patients, side of lesion should be considered when examining arm reaching kinematics. Further studies are necessary to evaluate differences in responses to auditory feedback between patients with lesions in opposite cerebral hemispheres.

Relevance of botulinum toxin injection and nerve block of rectus femoris to kinematic and functional parameters of stiff knee gait in hemiplegic adults.

Stiff knee gait (SKG) is common in hemiplegic patients. The main focus of treatment is rectus femoris (RF) spasticity. The aims of this study were to evaluate the effect of botulinum toxin injection (BTI) in the RF muscle on peak knee flexion during swing phase and its quantitative and functional impact on gait. We also wished to evaluate the correlation between the effects of nerve block and BTI on peak knee flexion. 10 adult hemiplegic subjects (>6 months post stroke or traumatic brain injury) with SKG and inappropriate RF EMG activity during mid-swing phase were included. 3D gait analysis, clinical and functional assessments (Timed Up and Go test, 10 m walk test, 6 min walk test and the time taken to ascend and descend a flight of stairs) were performed initially, 30 min after anaesthetic block of the RF nerve and one month post BTI. After BTI, there was a significant increase in knee flexion (8 degrees average) and a tendency towards improvement in gait and functional parameters. The effect of the nerve block on peak knee flexion was significantly correlated with the effect of BTI (11 degrees average increase in peak knee flexion after nerve block). We challenge the relevance of RF nerve blocks in this population when EMG and kinematic data are available. Our results indicate that BTI is an effective treatment for SKG in adult hemiplegic subjects, with a significant increase in peak knee flexion, no reduction in hip flexion and a tendency towards functional improvements.