A randomized controlled trial of Cognitive Sensory Motor Training Therapy on the recovery of arm function in acute stroke patients.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of Cognitive Sensory Motor Training Therapy (Perfetti's method) vis-à-vis conventional occupational therapy in the recovery of arm function after acute stroke. DESIGN: Prospective randomized controlled trial. SETTING: Two rehabilitation centers in Bangkok, Thailand. SUBJECTS: Forty first-time acute stroke patients without severe cognitive or language impairment. INTERVENTION: All subjects were randomly divided into two groups; one was treated using Perfetti's method and the other using conventional occupational therapy. Each group underwent therapy for 30 minutes, five times a week for four weeks. MAIN MEASURES: The primary variable was arm function as assessed by the Action Research Arm Test; secondary variables were the extended Barthel Index and the box and block test score. RESULTS: The intention-to-treat analysis revealed no statistically significant differences between the two groups at the end of treatment for any variable. CONCLUSIONS: There was no evidence of a difference between Cognitive Sensory Motor Training Therapy of Perfetti's method and conventional occupational therapy with respect to the restoration of hand and arm function after a stroke.

External lid loading for the temporary treatment of paresis of the M. orbicularis oculi: a case report.

This clinical note re-introduces external lid loading with the help of a lead weight for the temporary treatment of lagophthalmos. Although simple and effective, the technique is rarely used. Instead of wearing a monoculus, the patient uses an individually tailored lead weight (0.8-mm thickness, 1.0-2.0g) stuck on the lid to enable its closure. Spontaneous ptosis indicates a too-heavy weight. With the musculus (M.) levator palpebrae intact, lid lifting is possible. The effect is gravity dependent; therefore, the patient has to wear the monoculus at night. To minimize the risk for lead intoxication, the surface of the weight is varnished. In the case of persistent M. orbicularis oculi paresis, internal lid loading can follow. Since 1997, a total of 152 lagophthalmos cases have been treated. All patients could close the lid immediately. Almost half the patients had to readjust the weight several times per day because of hooded eyelids. Compliance was high, and partial or complete restoration of M. orbicularis oculi function occurred in 60% of cases. In some subjects, restoration of the M. orbicularis oculi was faster than for the M. orbicularis orbis. External lid loading for the temporary treatment of lagophthalmos is simple and effective. Compared with a monoculus, vision is unimpaired and the aesthetic is more appropriate for most patients. Faster restoration of the M. orbicularis oculi hints at a potentially facilitatory effect of the weight.

Treadmill training with partial body weight support after stroke.

Treadmill therapy with partial BWS is a promising new approach to improve gait ability after stroke. This task-specific approach enables nonambulatory patients the repetitive practice of complex gait cycles instead of single-limb gait-preparatory maneuvers. Patients walk more symmetrically with less spasticity and better cardiovascular efficiency on the treadmill than with floor walking. Several controlled, clinical studies have shown the potential of treadmill training as a therapeutic intervention for nonambulatory patients with chronic stroke-related hemiplegia. Furthermore, controlled trials in acute stroke survivors have shown that treadmill training is as effective as other physiotherapy approaches that stress the repetitive practice of gait. Controlled multicenter trials comparing locomotor training with conventional therapy will be forthcoming. An electromechanical gait trainer that relieves the strenuous effort of the therapists and provides control of the trunk in a phase-dependent manner is a new technical alternative for gait training in severely impaired stroke patients.

A new orthosis for subluxed, flaccid shoulder after stroke facilitates gait symmetry: a preliminary study.

OBJECTIVE: The aims of this study were: (i) to evaluate the immediate effects on subluxation and gait pattern of a new shoulder orthosis, developed for treatment of painful shoulder syndrome in subacute stroke patients; and (ii) to evaluate patients' and therapists' opinions about its fit and benefits after 4 weeks. METHODS: A total of 40 subacute in-rehabilitation stroke patients with non-functional arm and painful shoulder were included in the study. Of these, 12 subjects underwent shoulder radiography and gait analysis with and without the orthosis to determine the immediate effects of the orthosis. All 40 patients wore the orthosis during the daytime for 4 weeks before completing a survey. Outcome measures were: repositioning of the humeral head, gait cycle parameters, and qualitative lower limb muscle activation patterns. Patients and therapists rated wearing comfort, odour nuisance, effect on pain and performing gait and mobility-related activities. RESULTS: When using the shoulder orthosis the humeral head was repositioned in 10 of 12 patients, patients walked more symmetrically due to a prolonged hemiparetic stance phase (p < 0.01), and the paretic quadriceps muscle activity was higher and more appropriately timed. The majority of patients and therapists rated the wearing comfort positive, the odour nuisance minimal, and that the orthosis helped with performing activities. However, less than half of patients and therapists reported improvement in pain. CONCLUSION: The well-tolerated shoulder orthosis improved gait quality and repositioned the subluxated humeral head, offered a good fit, and eased performing activities, but did not reduce pain. This preliminary study does not warrant any definite conclusions on the effectiveness of the orthosis; more studies are needed to compare its effect with other models.

Robot-assisted practice of gait and stair climbing in nonambulatory stroke patients.

A novel gait robot enabled nonambulatory patients the repetitive practice of gait and stair climbing. Thirty nonambulatory patients with subacute stroke were allocated to two groups. During 60 min sessions every workday for 4 weeks, the experimental group received 30 min of robot training and 30 min of physiotherapy and the control group received 60 min of physiotherapy. The primary variable was gait and stair climbing ability (Functional Ambulation Categories [FAC] score 0-5); secondary variables were gait velocity, Rivermead Mobility Index (RMI), and leg strength and tone blindly assessed at onset, intervention end, and follow-up. Both groups were comparable at onset and functionally improved over time. The improvements were significantly larger in the experimental group with respect to the FAC, RMI, velocity, and leg strength during the intervention. The FAC gains (mean +/- standard deviation) were 2.4 +/- 1.2 (experimental group) and 1.2 +/- 1.5 (control group), p = 0.01. At the end of the intervention, seven experimental group patients and one control group patient had reached an FAC score of 5, indicating an ability to climb up and down one flight of stairs. At follow-up, this superior gait ability persisted. In conclusion, the therapy on the novel gait robot resulted in a superior gait and stair climbing ability in nonambulatory patients with subacute stroke; a higher training intensity was the most likely explanation. A large randomized controlled trial should follow.

Upper and lower extremity robotic devices for rehabilitation and for studying motor control.

PURPOSE OF REVIEW: The successful motor rehabilitation of stroke, traumatic brain-injured and spinal cord-injured patients requires an intensive and task-specific therapy approach. Budget constraints limit a hand-to-hand therapy approach, so that intelligent machines may offer a solution to promote motor recovery and obtain a better understanding of motor control. This new field of automated or robot-assisted motor rehabilitation has emerged since the 1990s. RECENT FINDINGS: This article will present clinically viable devices for upper and lower extremity rehabilitation. The MIT-Manus and the Mirror-Image Motion Enabler robot, which enable unrestricted unilateral or bilateral shoulder and elbow movement, consistently proved superior on the motor impairment level. The ARM guide, which assisted reaching in a straight-line trajectory, and the Bi-Manu-Track, which enabled the bilateral practice of a forearm and wrist movement, are currently being tested. For gait rehabilitation after stroke, the electromechanical gait trainer, GT I, has proved effective compared with treadmill training with body weight support. The Lokomat, consisting of a treadmill and a powered exoskeleton, lessened the therapeutic effort compared with manually assisted treadmill training in spinal cord-injured patients. Future developments will see more degrees of freedom, improved man-machine interaction and the implementation of virtual reality. SUMMARY: Technical possibilities are one aspect, but multi-centre trials and a consideration of the unsubstantiated fears among therapists of being replaced by machines will decide on the successful implementation of this most promising field to the benefit of patients.

Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects.

OBJECTIVE: To determine whether use of a robotic arm trainer for bilateral exercise in daily repetitive training for a 3-week period reduced spasticity and improved motor control in the arm of severely affected, chronic hemiparetic subjects. DESIGN: Before-after trial. SETTING: Community rehabilitation center in Germany. PARTICIPANTS: Consecutive sample of 12 chronic hemiparetic patients; minimum stroke interval 6 months; patients could maximally protract the affected shoulder, hold the extended arm, or slightly flex and extend the elbow. INTERVENTIONS: Additional daily therapy of 15 minutes with the arm trainer for 3 weeks; the 1 degree of freedom trainer enabled the bilateral passive and active practice of a forearm pronation and supination and wrist dorsiflexion and volarflexion; impedance control guaranteed a smooth movement. MAIN OUTCOME MEASURES: Patients' impressions, the Modified Ashworth Scale (MAS) score (range, 0-5) to assess spasticity, and the arm section of the Rivermead Motor Assessment (RMA) score (range, 0-15) to assess motor control were rated before therapy, after each 3-week interval, and at follow-up 3 months later. RESULTS: All patients had favorable impressions: the extremity felt more vivid, and 8 subjects noticed a reduction in spasticity, an ease of hand hygiene, and pain relief. The MAS score of the wrist and fingers joints decreased significantly (P<.0125) from a median of 3 (2-3) and 3 (3-4) to 2 (1-2) and 2.5 (2-3). The RMA score minimally increased in 5 cases without improvement in functional tasks. The median RMA score before therapy was 2.0 (1-2) and 2.0 (1-3.75) after therapy. There were no side effects. At follow-up, the effects had waned. CONCLUSIONS: The arm trainer made possible intensive bilateral elbow and wrist training of severely affected stroke patients. Future studies should address the treatment effect in subacute stroke patients and determine the optimum treatment intensity.