Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial.

BACKGROUND: Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery. OBJECTIVE: The aim of this study was to directly compare virtual reality-based training with conventional therapy. METHODS: In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16x45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects. Blinded assessors tested patients twice before, once during, and twice after the intervention up to 2-month follow-up for dexterity (primary outcome: Box and Block Test), bimanual upper limb function (Chedoke-McMaster Arm and Hand Activity Inventory), and subjective perceived changes (Stroke Impact Scale). RESULTS: 54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20-81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences. CONCLUSIONS: Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT01774669.

Using mixed methods to evaluate efficacy and user expectations of a virtual reality-based training system for upper-limb recovery in patients after stroke: a study protocol for a randomised controlled trial.

BACKGROUND: In recent years, virtual reality has been introduced to neurorehabilitation, in particular with the intention of improving upper-limb training options and facilitating motor function recovery. METHODS/DESIGN: The proposed study incorporates a quantitative part and a qualitative part, termed a mixed-methods approach: (1) a quantitative investigation of the efficacy of virtual reality training compared to conventional therapy in upper-limb motor function are investigated, (2a) a qualitative investigation of patients' experiences and expectations of virtual reality training and (2b) a qualitative investigation of therapists' experiences using the virtual reality training system in the therapy setting. At three participating clinics, 60 patients at least 6 months after stroke onset will be randomly allocated to an experimental virtual reality group (EG) or to a control group that will receive conventional physiotherapy or occupational therapy (16 sessions, 45 minutes each, over the course of 4 weeks). Using custom data gloves, patients' finger and arm movements will be displayed in real time on a monitor, and they will move and manipulate objects in various virtual environments. A blinded assessor will test patients' motor and cognitive performance twice before, once during, and twice after the 4-week intervention. The primary outcome measure is the Box and Block Test. Secondary outcome measures are the Chedoke-McMaster Stroke Assessments (hand, arm and shoulder pain subscales), the Chedoke-McMaster Arm and Hand Activity Inventory, the Line Bisection Test, the Stroke Impact Scale, the MiniMentalState Examination and the Extended Barthel Index. Semistructured face-to-face interviews will be conducted with patients in the EG after intervention finalization with a focus on the patients' expectations and experiences regarding the virtual reality training. Therapists' perspectives on virtual reality training will be reviewed in three focus groups comprising four to six occupational therapists and physiotherapists. DISCUSSION: The interviews will help to gain a deeper understanding of the phenomena under investigation to provide sound recommendations for the implementation of the virtual reality training system for routine use in neurorehabilitation complementing the quantitative clinical assessments. TRIAL REGISTRATION: Cliniclatrials.gov Identifier: NCT01774669 (15 January 2013).

Length of stay in the rehabilitation center, the admission functional independence measure and the functional independence measure gain.

The decision to discharge is an important factor determining the length of stay (LOS) in a rehabilitation center and should be scrutinized. The purpose of this study was to analyse the predictive power of the individual items of the admission functional independence measure (FIM) for the LOS indicating their relevance in the decision to discharge and to expose the assumptions driving this decision. The data of all consecutive in-patients of 5 years in a rehabilitation center were analysed (n=1047). The regression analysis of FIM item values on admission and FIM item gains as independent variables and the LOS as the dependent variable showed a number of criteria operational in the decision to discharge patients with different diagnoses. The criteria were identified as 'aiming for certain standards' (for example, bed/chair/WC transfer), 'aiming for optimal improvement', 'dealing with different rates of improvement' and 'giving benefit of learning potential'. It is proposed that these criteria should be discussed and evaluated.

Chedoke-McMaster stroke assessment and modified Barthel Index self-assessment in patients with vascular brain damage.

With the conception of interdisciplinary and joint rehabilitation, and the adherence to impairment, activity and participation as rehabilitation goals, a comparison of assessment instruments that use different perspectives (professional, lay person, patient) and are employed by different professional groups addressing different issues such as in occupational therapy and in physical therapy, is required. The clinical admission-discharge assessment of the Chedoke-McMaster stroke assessment and the Barthel index data of 127 vascular brain-damaged patients, including patients with other neurological disorders, were compared. The German language version of these instruments proved highly reliable; the factorial structure indicated, with a few exceptions, the conceptualized dimensions and the Barthel index contributed to this structure with an additional dimension of drinking and eating as well as a continence factor. It takes eight items of the Barthel index to predict a substantial part of the total variance of the 15-item Chedoke-McMaster stroke assessment (r2=76), but only three Chedoke-McMaster items to predict the Barthel index total (r2=77). It is suggested that although further analyses of all instruments used in a rehabilitation centre are required, addressing their relationship to each other and their usefulness as admission-discharge measures, a rehabilitation conceptualization should proceed closely linked with the optimization of the assessment measures, thus providing a lean but comprehensive monitoring system.