SALGOT--Stroke Arm Longitudinal study at the University of Gothenburg, prospective cohort study protocol.

BACKGROUND: Recovery patterns of upper extremity motor function have been described in several longitudinal studies, but most of these studies have had selected samples, short follow up times or insufficient outcomes on motor function. The general understanding is that improvements in upper extremity occur mainly during the first month after the stroke incident and little if any, significant recovery can be gained after 3-6 months. The purpose of this study is to describe the recovery of upper extremity function longitudinally in a non-selected sample initially admitted to a stroke unit with first ever stroke, living in Gothenburg urban area. METHODS/DESIGN: A sample of 120 participants with a first-ever stroke and impaired upper extremity function will be consecutively included from an acute stroke unit and followed longitudinally for one year. Assessments are performed at eight occasions: at day 3 and 10, week 3, 4 and 6, month 3, 6 and 12 after onset of stroke. The primary clinical outcome measures are Action Research Arm Test and Fugl-Meyer Assessment for Upper Extremity. As additional measures, two new computer based objective methods with kinematic analysis of arm movements are used. The ABILHAND questionnaire of manual ability, Stroke Impact Scale, grip strength, spasticity, pain, passive range of motion and cognitive function will be assessed as well. At one year follow up, two patient reported outcomes, Impact on Participation and Autonomy and EuroQol Quality of Life Scale, will be added to cover the status of participation and aspects of health related quality of life. DISCUSSION: This study comprises a non-selected population with first ever stroke and impaired arm function. Measurements are performed both using traditional clinical assessments as well as computer based measurement systems providing objective kinematic data. The ICF classification of functioning, disability and health is used as framework for the selection of assessment measures. The study design with several repeated measurements on motor function will give us more confident information about the recovery patterns after stroke. This knowledge is essential both for optimizing rehabilitation planning as well as providing important information to the patient about the recovery perspectives. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01115348.

Virtual TeleRehab: a case study.

We examined the efficacy of a remotely based occupational therapy intervention. A 40-year-old woman who suffered a stroke participated in a telerehabilitation program. The intervention method is based on virtual reality gaming to enhance the training experience and to facilitate the relearning processes. The results indicate that Virtual TeleRehab is an effective method for motivational, economical, and practical reasons by combining game-based rehabilitation in the home with weekly distance meetings.

Virtual rehabilitation in an activity centre for community-dwelling persons with stroke. The possibilities of 3-dimensional computer games.

BACKGROUND: The main purpose of this study was to place a virtual reality (VR) system, designed to assess and to promote motor performance in the affected upper extremity in subjects after stroke, in a nonhospital environment. We also wanted to investigate if playing computer games resulted in improved motor function in persons with prior stroke. METHODS: The intervention involved 11 patients after stroke who received extra rehabilitation by training on a computer 3 times a week during a 4-week period. The control group involved 11 patients after stroke who continued their previous rehabilitation (no extra computer training) during this period. The mean age of all was 68 years (range = 47-85) and the average time after stroke 66 months (range = 15-140). The VR training consisted of challenging games, which provided a range of difficulty levels that allow practice to be fun and motivating. An additional group of 11 right-handed aged matched individuals without history of neurological or psychiatric illnesses served as reference subjects. RESULTS: All the participants reported that they were novel computer game players. After an initial introduction they learned to use the VR system quickly. The treatment group demonstrated improvements in motor outcome for the trained upper extremity, but this was not detected in real-life activities. CONCLUSIONS: The results of this research suggest the usefulness of computer games in training motor performance. VR can be used beneficially not only by younger participants but also by older persons to enhance their motor performance after stroke.

Virtual rehabilitation after stroke.

The purpose of this project was to investigate the effects of Virtual Reality technology and haptics for stroke rehabilitation. Twenty-nine stroke subjects, 17 women, and 12 men aged 44-85 years, participated in three different studies. All participants responded favorable to the use of the VR activity station. A change of attitude took place after the subjects were exposed to playing computer games. The general experience with the VR application approach suggests that this treatment concept is promising in stroke rehabilitation, with a wide range of applicability.

Assessment and training in a 3-dimensional virtual environment with haptics: a report on 5 cases of motor rehabilitation in the chronic stage after stroke.

OBJECTIVE: This exploratory study assessed the possible effectiveness of hemiparetic upper extremity training in subjects with chronic stroke with computer instrumentation (haptic force feedback) and 3-dimensional visualization applied to computer games, as well as to evaluate concurrent computer-assisted assessment of the kinematics of movements and test whether any improvement detected in the computer environment was reflected in activities of daily living (ADLs). METHODS: A single-subject repeated-measures experimental design (AB) was used. After baseline testing, 5 patients were assigned to the therapy 3 times a week for 45 min for 5 weeks. Velocity, time needed to reach, and hand path ratio (reflecting superfluous movements) were the outcome measures, along with the Assessment of Motor and Process Skills and the Box and Block test. The follow-up phase (C) occurred 12 weeks later. RESULTS: Improvements were noted in velocity, time, and hand path ratio. One patient showed improvement in occupational performance in ADLs. CONCLUSIONS: The application of this strategy of using virtual reality (VR) technologies may be useful in assessing and training stroke patients. The results of this study must be reproduced in further studies. The VR systems can be placed in homes or other nonclinical settings.

A kinematic analysis of a haptic handheld stylus in a virtual environment: a study in healthy subjects.

BACKGROUND: Virtual Reality provides new options for conducting motor assessment and training within computer-generated 3 dimensional environments. To date very little has been reported about normal performance in virtual environments. The objective of this study was to evaluate the test-retest reliability of a clinical procedure measuring trajectories with a haptic handheld stylus in a virtual environment and to establish normative data in healthy subjects using this haptic device. METHODS: Fifty-eight normal subjects; aged from 20 to 69, performed 3 dimensional hand movements in a virtual environment using a haptic device on three occasions within one week. Test-retest stability and standardized normative data were obtained for all subjects. RESULTS: No difference was found between test and retest. The limits of agreement revealed that changes in an individual's performance could not be detected. There was a training effect between the first test occasion and the third test occasion. Normative data are presented. CONCLUSION: A new test was developed for recording the kinematics of the handheld haptic stylus in a virtual environment. The normative data will be used for purposes of comparison in future assessments, such as before and after training of persons with neurological deficits.

Effects of physically active video gaming on cognition and activities of daily living in childhood brain tumor survivors: a randomized pilot study.

BACKGROUND: Physical activity can enhance cognitive functions in both animals and humans. We hypothesized that physically active video gaming could: i) improve cognitive functions and ii) improve the execution of activities of daily living among survivors of childhood brain tumors. METHODS: Children 7 to 17 years old who completed treatment, including radiotherapy, for a brain tumor 1 to 5 years earlier were randomized to either intervention or waiting list. After 10 to 12 weeks the groups crossed over. The intervention consisted of active video gaming, using a motion-controlled video console (Nintendo Wii), for a minimum of 30 minutes a day, 5 days a week and weekly Internet-based coaching sessions. Evaluations before and after each period included tests of the execution of activities of daily living, using the Assessment of Motor and Process Skills (AMPS) and cognitive tests. Test scores before and after the intervention were compared. A parallel group comparison was performed as a sensitivity analysis. RESULTS: All 13 children enrolled completed the program. Compared to baseline, the motor (P= .012) and process (P=.002) parts of AMPS improved significantly after active video gaming. In the parallel group analysis the improvement in the process part of AMPS remained statistically significant (P= .029), but not the change in AMPS motor score (P= .059). No significant change was found in cognitive tests although there were trends for improvement in sustained attention (P = .090) and selective attention (P = .078). CONCLUSION: In this pilot study, active video gaming used as a home-based intervention for childhood brain tumor survivors improved motor and process skills in activities of daily living.

Rehabilitation after stroke using virtual reality, haptics (force feedback) and telemedicine.

We have constructed a haptic immersive workbench to be placed in the patients' home for daily adjusted rehabilitation. We also propose a system for Internet based connection and communication between patients and between patients and a clinical rehabilitation center and clinical assessment/evaluation centers. The benefits of a system for rehabilitation after stroke, based on VR, Haptics and Telemedicine should be: increased quality of life, lesser isolation, feeling more secure, fewer tiring transportations, more frequent exercising, better compliance to training, lower cost for transportation. The long term recovery for a larger group of patients with motor impairments is presently under evaluation.

Active video gaming improves body coordination in survivors of childhood brain tumours.

PURPOSE: We investigated whether active video gaming (AVG) could bring about regular, enjoyable, physical exercise in children treated for brain tumours, what level of physical activity could be reached and if the children's physical functioning improved. METHODS: Thirteen children, aged 7-17 years, were randomised to either AVG or waiting-list. After 10-12 weeks they crossed-over. Weekly Internet coaching sessions were used to sustain motivation and evaluate enjoyment. Energy expenditure (EE) levels were measured as Metabolic Equivalent of Task (MET), using a multisensory activity monitor. Single-blinded assessments of physical functioning were done, using the Bruininks-Osteretsky Test of Motor Performance, second edition, evaluating participants before and after the intervention period, as well as comparing the randomisation groups after the first period. RESULTS: All patients completed the study. AVG sessions (mean duration 47 minutes) were performed on 72% of all days. Mean EE level during AVG sessions was 3.0 MET, corresponding to moderate physical activity. The Body Coordination score improved by 15% (p = 0.021) over the intervention period. CONCLUSIONS: In this group of childhood brain tumour survivors, home-based AVG, supported by a coach, was a feasible, enjoyable and moderately intense form of exercise that improved Body Coordination. Implications for Rehabilitation Childhood brain tumour survivors frequently have cognitive problems, inferior physical functioning and are less physically active compared to their healthy peers. Active video gaming (AVG), supported by Internet coaching, is a feasible home-based intervention in children treated for brain tumours, promoting enjoyable, regular physical exercise of moderate intensity. In this pilot study, AVG with Nintendo Wii improved Body Coordination.

Virtual reality and haptics as an assessment device in the postacute phase after stroke.

Virtual reality (VR) technology is altering the health care environment and is changing the options that are available to therapists. This study describes how a haptic device was used as a cinematic assessment utility. Three chronic stroke inpatients at Sahlgrenska University Hospital with left hemisphere damage were assessed. The patients were administered by the box and block manual dexterity test. For comparisons, a reference group was added to the study. Several parameters, including time, speed, and movement of the right upper extremity, were extracted and evaluated. The results indicate that the system shows potential as an assessment device. The feasibility study setup is working well, as is the assessment method. Further research, testing, refinement of the exercises, and use of VR and haptics within neurological rehabilitation are suggested.

Virtual reality and haptics as a training device for movement rehabilitation after stroke: a single-case study.

OBJECTIVE: To investigate whether training in a virtual environment with a haptic device will improve motor function in the left hemiparetic arm of a stroke subject. DESIGN: Single case, A-B-A design. SETTING: University hospital research laboratory. PARTICIPANT: A man in his late fifties (right handed), with a right-hemisphere lesion that caused a deficit in the left upper extremity. INTERVENTION: The subject trained with a 3-dimensional computer game during a 4-week period that consisted of twelve 90-minute sessions. MAIN OUTCOME MEASURES: Three tests (Purdue pegboard test, dynamometer hand-grip strength, upper-extremity test) and a subjective interview were used to evaluate motor performance. RESULTS: Improvements were found in fine manual dexterity, grip force, and motor control of the affected upper extremity. The subject reported that there was a change in his day-to-day use of the upper extremity and that he was able to use it in activities that were previously impossible for him. CONCLUSIONS: Training with virtual reality and haptics can promote motor rehabilitation.