The assistive potential of functional electrical stimulation to support object manipulation in functional upper extremity movements after stroke: A randomized cross-over study.

Background: After standard care, 55%-75% of patients after stroke show a persistent paresis of the upper limb (UL). Assistive devices are developed to increase the patients' level of independence in daily life. Objectives: To investigate the potential of Functional Electrical Stimulation (FES) to assist object manipulation in activities of daily life. Design: Seventeen patients after stroke were tested and analyzed in a randomized cross-over design. Methods: Functional grasping was assessed by means of the Action Research Arm Test (ARAT) and the modified Box and Block Test (mBBT), in one session with and another without FES assistance. The order of sessions was randomized. Patients' motivation was assessed after each session. Task performance and motivation were compared between conditions using the Wilcoxon test and subgroup analyses were performed for impairment severity by distribution-based mixed-factor analyses. Results: When analyzing the total ARAT, FES did not effectively assist the overall performance (P = .142), but did assist the performance of objects of the Grasp category (P = .020). Impairment severity showed an interaction with the orthotic effect (P = .012), as severely impaired patients profited from FES assistance and mild-moderately impaired did not. When focusing on the more functional items of the ARAT (i.e., excluding scores from thumb-middle and thumb-ring finger combinations), there was a significant orthotic effect of FES on task performance (P = .023). Further, there was an orthotic effect for the number of transported blocks in the mBBT (P = .033), exclusively prominent in the group of severely impaired patients. Functional Electrical Stimulation did not increase the patients' motivation (P = .959), which was high after both conditions. Conclusion: Functional Electrical Stimulation has the potential to support object manipulation, but is dependent on impairment severity and object type. To observe a consistent orthotic effect, features of the stimulator should be further developed to generate appropriate grasps and forces across subjects and objects. Trial Registration: The trial was registered with the German Clinical Trials Register (DRKS00025889).

Lateropulsion in Right-Sided Stroke: Brain Anatomical Correlates of Severity and Duration.

BACKGROUND AND PURPOSE: Lateropulsion (LP) is a profound disorder of postural control that has a significant impact on neurorehabilitation. Knowledge of relevant brain areas could guide decisions on appropriate intervention methods. Although LP severity and duration are highly variable in individuals with LP, imaging studies on LP have not sufficiently considered these aspects. The aim of this study was to investigate the lesion location in individuals after stroke and the correlation with LP duration and severity. METHODS: A retrospective case-control study using voxel lesion symptom mapping (VLSM) in 74 individuals with right-sided brain lesion (49 with and 25 without LP) was performed to analyze the correlation between lesion location and LP severity. Duration was investigated in a subsample of 22 individuals with LP. LP was diagnosed by means of the Scale for Contraversive Pushing. RESULTS: Individuals with LP showed significantly larger lesion sizes compared with the individuals with no LP. VLSM analysis of LP severity did not reveal statistically significant results. VLSM analysis showed a statistically significant association with longer LP duration for the inferior frontal gyrus, the hippocampus, the inferior parietal gyrus, the supramarginal gyrus, the angular gyrus, the temporal cortex, the sagittal stratum, and the superior longitudinal fasciculus. DISCUSSION AND CONCLUSION: LP-relevant areas are located in the multisensory network. Areas of the frontoparietal network, which are related to spatial cognition, memory, and attention, were found to be relevant for duration and severity. The findings, especially those regarding duration involving the middle temporal cortex, could explain the better intervention outcomes for methods based more on implicit than on explicit knowledge of verticality.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A433 ).

The efficacy of hybrid neuroprostheses in the rehabilitation of upper limb impairment after stroke, a narrative and systematic review with a meta-analysis.

BACKGROUND: Paresis of the upper limb (UL) is the most frequent impairment after a stroke. Hybrid neuroprostheses, i.e., the combination of robots and electrical stimulation, have emerged as an option to treat these impairments. METHODS: To give an overview of existing devices, their features, and how they are linked to clinical metrics, four different databases were systematically searched for studies on hybrid neuroprostheses for UL rehabilitation after stroke. The evidence on the efficacy of hybrid therapies was synthesized. RESULTS: Seventy-three studies were identified, introducing 32 hybrid systems. Among the most recent devices (n = 20), most actively reinforce movement (3 passively) and are typical exoskeletons (3 end-effectors). If classified according to the International Classification of Functioning, Disability and Health, systems for proximal support are expected to affect body structures and functions, while the activity and participation level are targeted when applying Functional Electrical Stimulation distally plus the robotic component proximally. The meta-analysis reveals a significant positive effect on UL functions (p < 0.001), evident in a 7.8-point Mdiff between groups in the Fugl-Meyer assessment. This positive effect remains at the 3-month follow-up (Mdiff = 8.4, p < 0.001). CONCLUSIONS: Hybrid neuroprostheses have a positive effect on UL recovery after stroke, with effects persisting at least three months after the intervention. Non-significant studies were those with the shortest intervention periods and the oldest patients. Improvements in UL functions are not only present in the subacute phase after stroke but also in long-term chronic stages. In addition to further technical development, more RCTs are needed to make assumptions about the determinants of successful therapy.

Hybrid Functional Electrical Stimulation and Robotic Assistance for Wrist Motion Training After Stroke: Preliminary Results.

This work presents preliminary results of a clinical study with sub-acute stroke patients using a hybrid system for wrist rehabilitation. The patients trained their wrist flexion/extension motion through a target tracking task, where electrical stimulation and robotic torque assisted them proportionally to their tracking error. Five sub-acute stroke patients have completed the training for 3 sessions on separate days. The preliminary results show hybrid assistance improves tracking performance and motion smoothness in most participants. In each session, patients' tracking performances before and after training were evaluated in unassisted tracking trials, without assistance. Their unassisted performance was compared across sessions and the results suggest that moderately to severely impaired patients might benefit more from hybrid training with our system than mildly impaired patients. Subjective assessments from all sessions show that the patients found the use of the device very comfortable and the training enjoyable. More data is being collected and future work will aim at verifying these trends.

Sham-controlled randomized multicentre trial of transcranial direct current stimulation for prolonged disorders of consciousness.

BACKGROUND AND PURPOSE: Transcranial direct current stimulation (tDCS) has been shown to improve signs of consciousness in a subset of patients with disorders of consciousness (DoC). However, no multicentre study confirmed its efficacy when applied during rehabilitation. In this randomized controlled double-blind study, the effects of tDCS whilst patients were in rehabilitation were tested at the group level and according to their diagnosis and aetiology to better target DoC patients who might repond to tDCS. METHODS: Patients received 2 mA tDCS or sham applied over the left prefrontal cortex for 4 weeks. Behavioural assessments were performed weekly and up to 3 months' follow-up. Analyses were conducted at the group and subgroup levels based on the diagnosis (minimally conscious state [MCS] and unresponsive wakefulness syndrome) and the aetiology (traumatic or non-traumatic). Interim analyses were planned to continue or stop the trial. RESULTS: The trial was stopped for futility when 62 patients from 10 centres were enrolled (44 ± 14 years, 37 ± 24.5 weeks post-injury, 18 women, 32 MCS, 39 non-traumatic). Whilst, at the group level, no treatment effect was found, the subgroup analyses at 3 months' follow-up revealed a significant improvement for patients in MCS and with traumatic aetiology. CONCLUSIONS: Transcranial direct current stimulation during rehabilitation does not seem to enhance patients' recovery. However, diagnosis and aetiology appear to be important factors leading to a response to the treatment. These findings bring novel insights into possible cortical plasticity changes in DoC patients given these differential results according to the subgroups of patients.

Online detection of compensatory strategies in human movement with supervised classification: a pilot study.

Introduction: Stroke survivors often compensate for the loss of motor function in their distal joints by altered use of more proximal joints and body segments. Since this can be detrimental to the rehabilitation process in the long-term, it is imperative that such movements are indicated to the patients and their caregiver. This is a difficult task since compensation strategies are varied and multi-faceted. Recent works that have focused on supervised machine learning methods for compensation detection often require a large training dataset of motions with compensation location annotations for each time-step of the recorded motion. In contrast, this study proposed a novel approach that learned a linear classifier from energy-based features to discriminate between healthy and compensatory movements and identify the compensating joints without the need for dense and explicit annotations. Methods: Six healthy physiotherapists performed five different tasks using healthy movements and acted compensations. The resulting motion capture data was transformed into joint kinematic and dynamic trajectories. Inspired by works in bio-mechanics, energy-based features were extracted from this dataset. Support vector machine (SVM) and logistic regression (LR) algorithms were then applied for detection of compensatory movements. For compensating joint identification, an additional condition enforcing the independence of the feature calculation for each observable degree of freedom was imposed. Results: Using leave-one-out cross validation, low values of mean brier score (<0.15), mis-classification rate (<0.2) and false discovery rate (<0.2) were obtained for both SVM and LR classifiers. These methods were found to outperform deep learning classifiers that did not use energy-based features. Additionally, online classification performance by our methods were also shown to outperform deep learning baselines. Furthermore, qualitative results obtained from the compensation joint identification experiment indicated that the method could successfully identify compensating joints. Discussion: Results from this study indicated that including prior bio-mechanical information in the form of energy based features can improve classification performance even when linear classifiers are used, both for offline and online classification. Furthermore, evaluation compensation joint identification algorithm indicated that it could potentially provide a straightforward and interpretable way of identifying compensating joints, as well as the degree of compensation being performed.

Contralaterally EMG-triggered functional electrical stimulation during serious gaming for upper limb stroke rehabilitation: a feasibility study.

Introduction: Virtual Reality/serious games (SG) and functional electrical stimulation (FES) therapies are used in upper limb stroke rehabilitation. A combination of both approaches seems to be beneficial for therapy success. The feasibility of a combination of SG and contralaterally EMG-triggered FES (SG+FES) was investigated as well as the characteristics of responders to such a therapy. Materials and methods: In a randomized crossover trial, patients performed two gaming conditions: SG alone and SG+FES. Feasibility of the therapy system was assessed using the Intrinsic Motivation Inventory (IMI), the Nasa Task Load Index, and the System Usability Scale (SUS). Gaming parameters, fatigue level and a technical documentation was implemented for further information. Results: In total, 18 patients after stroke (62.1 ± 14.1 years) with a unilateral paresis of the upper limb (MRC ≤4) were analyzed in this study. Both conditions were perceived as feasible. Comparing the IMI scores between conditions, perceived competence was significantly increased (z = -2.88, p = 0.004) and pressure/tension during training (z = -2.13, p = 0.034) was decreased during SG+FES. Furthermore, the task load was rated significantly lower for the SG+FES condition (z = -3.14, p = 0.002), especially the physical demand (z = -3.08, p = 0.002), while the performance was rated better (z = -2.59, p = 0.010). Responses to the SUS and the perceived level of fatigue did not differ between conditions (SUS: z = -0.79, p = 0.431; fatigue: z = 1.57, p = 0.115). For patients with mild to moderate impairments (MRC 3-4) the combined therapy provided no or little gaming benefit. The additional use of contralaterally controlled FES (ccFES), however, enabled severely impaired patients (MRC 0-1) to play the SG. Discussion: The combination of SG with ccFES is feasible and well-accepted among patients after stroke. It seems that the additional use of ccFES may be more beneficial for severely impaired patients as it enables the execution of the serious game. These findings provide valuable implications for the development of rehabilitation systems by combining different therapeutic interventions to increase patients' benefit and proposes system modifications for home use. Clinical trial registration: https://drks.de/search/en, DRKS00025761.

Influence of stance width on standing balance in healthy older adults.

Posturography is an objective way to systematically interpret postural control. Recent evidence suggests self-selected stance width when conducting posturography in healthy young participants, as it is easy to perform yet standardized. It is unclear, if this is similarly applicable to healthy older adults which can better serve as comparison group for persons with specific impairments, like Parkinson's disease, who might have problems with set foot distances. The aim of this study was to investigate the influence of different stance widths on a set of parameters in healthy older adults. Twenty-four healthy elderly (65.6 ± 5.0 years, BMI 26.2 ± 4.5 kg/m2) participated in the study. Posturographic measurement consisted of two tests (body sway, BS; limits of stability, LoS) each assessed in five stance widths on a force platform. A series of time domain and frequency domain parameters, such as BS and LoS range, sample entropy, mean velocity, and balance functional reserve were calculated. Anthropometric parameters and self-selected stance width (mean 17.7 ± 4.7 cm) showed positive correlation. One-way repeated measures MANOVA revealed significant differences between all parameters and foot positions. Except for sample entropy in A-P dimension, univariate analysis showed significant effects of stance widths on the parameters with stronger effects on M-L dimensions. Outcomes acquired in self-selected stance width provide comparable results to standardized stance widths 20 and 30 cm. The recommendation of self-selected stance width can be adopted to older healthy subjects. Furthermore, it reflects a natural stance and includes individual body composition.

The scale for retropulsion: Internal consistency, reliability and construct validity.

BACKGROUND: Retropulsion is an impairment of body orientation against gravity in the sagittal plane. In a Delphi study, the Scale for Retropulsion (SRP) was developed with a high level of expert agreement. OBJECTIVE: To assess the clinimetric properties of the German SRP in patients with neurological disorders. METHODS: The SRP was applied to 70 hospitalized patients with neurological disorders (stroke, critical illness neuropathy and/or myopathy, Parkinson syndromes). Internal consistency was determined with the Cronbach ɑ. Test-retest and interrater reliabilities were evaluated with the weighted kappa, intraclass correlation coefficient (ICC), and Bland-Altman plots. The construct validity was evaluated with Spearman correlation. RESULTS: The median (interquartile range) SRP score was 5 (3-8) and ranged from 0 to 22 (total scale range: 0 to 24). The SRP had excellent internal consistency (Cronbach ɑ=0.875) and good to excellent test-retest reliability (weighted kappa=0.957, ICC=0.957) and interrater reliability (weighted kappa=0.837, ICC=0.837). Analysis of construct validity resulted in good correlations with other clinical balance scales (rSp>0.80), and fair to moderate correlations with posturographic measures (rSp=0.27-0.56) and the subjective postural vertical error in the sagittal plane (rSp=-0.325, P=0.012) as well as the range in the frontal plane (rSp=0.359, P=0.007). The SRP discriminated between patients classified with and without retropulsion by an independent clinical expert (P<0.001). CONCLUSION: The SRP provides a valid and reliable bedside test to quantify retropulsion in individuals with neurological disorders.

Influence of footwear on postural sway: A systematic review and meta-analysis on barefoot and shod bipedal static posturography in patients and healthy subjects.

BACKGROUND: Bipedal static posturography is widely used to assess postural control. However, standardized methods and evidence on the influence of footwear on balance in comparison to barefoot stance is sparse. RESEARCH QUESTIONS: Is bipedal static posturography applied in a standardized way with respect to demographics and the experimental set-up (systematic review)? Does habitual footwear influence postural control in comparison to barefoot condition during bipedal static posturography in adult patients and healthy subjects (meta-analysis)? METHODS: For this systematic review and meta-analysis, a comprehensive follow-up literature search was conducted from March 2009 until January 2020 according to the PRISMA guidelines. Original, research articles reporting on bipedal, unsupported, static posturography in adults (≥18 years) were included according to inclusion criteria (age, sex, height, weight, duration, repetitions, visual/foot condition, sampling frequency). Studies comparing habitual footwear with barefoot condition during bipedal static posturography were included for the meta-analysis. Center of pressure parameters (sway velocity, range, root mean square, paths lengths) with subjects having eyes closed (EC) or open (EO) were analyzed using random effects models. RESULTS: For this systematic review and meta-analysis, 207 and eight out of 5189 studies with 12'341 and 156 subjects, respectively, were eligible. Most studies (89%) reported barefoot, 5% shod, and 6% barefoot and shod measurements. Less than half of studies (44%) included patients of which the minority (13%) suffered from neurological disease. Sway velocity in the anterior-posterior direction was higher in habitual shoes compared to barefoot with EC (SMD: 1.08; 95% CI: 0.68-1.48; p < 0.01; I2 = 0%), with EO (SMD: 0.68; 95% CI: 0.11-1.26; p = 0.02; I2 = 1%), and in the medio-lateral direction with EC (SMD: 1.30; 95% CI: 0.76-1.85, p < 0.01; I2 = 37%). SIGNIFICANCE: Methodical heterogeneity of bipedal static posturography hampers studies' comparability. Thus, we provide a standardized approach to increase knowledge whether habitual footwear decrease postural control in comparison to barefoot stance.

Improvement of Apraxia With Augmented Reality: Influencing Pantomime of Tool Use via Holographic Cues.

Background: Defective pantomime of tool use is a hall mark of limb apraxia. Contextual information has been demonstrated to improve tool use performance. Further, knowledge about the potential impact of technological aids such as augmented reality for patients with limb apraxia is still scarce. Objective: Since augmented reality offers a new way to provide contextual information, we applied it to pantomime of tool use. We hypothesize that the disturbed movement execution can be mitigated by holographic stimulation. If visual stimuli facilitate the access to the appropriate motor program in patients with apraxia, their performance should improve with increased saliency, i.e., should be better when supported by dynamic and holographic cues vs. static and screen-based cues. Methods: Twenty one stroke patients and 23 healthy control subjects were randomized to mime the use of five objects, presented in two Environments (Screen vs. Head Mounted Display, HMD) and two Modes (Static vs. Dynamic) resulting in four conditions (ScreenStat, ScreenDyn, HMDStat, HMDDyn), followed by a real tool demonstration. Pantomiming was analyzed by a scoring system using video recordings. Additionally, the sense of presence was assessed using a questionnaire. Results: Healthy control participants performed close to ceiling and significantly better than patients. Patients achieved significantly higher scores with holographic or dynamic cues. Remarkably, when their performance was supported by animated holographic cues (e.g., striking hammer), it did not differ significantly from real tool demonstration. As the sense of presence increases with animated holograms, so does the pantomiming. Conclusion: Patients' performance improved with visual stimuli of increasing saliency. Future assistive technology could be implemented upon this knowledge and thus, positively impact the rehabilitation process and a patient's autonomy.

The impact of visuospatial perception on distance judgment and depth perception in an Augmented Reality environment in patients after stroke: an exploratory study.

BACKGROUND: Augmented Reality (AR)-based interventions are applied in neurorehabilitation with increasing frequency. Depth perception is required for the intended interaction within AR environments. Until now, however, it is unclear whether patients after stroke with impaired visuospatial perception (VSP) are able to perceive depth in the AR environment. METHODS: Different aspects of VSP (stereovision and spatial localization/visuoconstruction) were assessed in 20 patients after stroke (mean age: 64 ± 14 years) and 20 healthy subjects (HS, mean age: 28 ± 8 years) using clinical tests. The group of HS was recruited to assess the validity of the developed AR tasks in testing stereovision. To measure perception of holographic objects, three distance judgment tasks and one three-dimensionality task were designed. The effect of impaired stereovision on performance in each AR task was analyzed. AR task performance was modeled by aspects of VSP using separate regression analyses for HS and for patients. RESULTS: In HS, stereovision had a significant effect on the performance in all AR distance judgment tasks (p = 0.021, p = 0.002, p = 0.046) and in the three-dimensionality task (p = 0.003). Individual quality of stereovision significantly predicted the accuracy in each distance judgment task and was highly related to the ability to perceive holograms as three-dimensional (p = 0.001). In stroke-survivors, impaired stereovision had a specific deterioration effect on only one distance judgment task (p = 0.042), whereas the three-dimensionality task was unaffected (p = 0.317). Regression analyses confirmed a lacking impact of patients' quality of stereovision on AR task performance, while spatial localization/visuoconstruction significantly prognosticated the accuracy in distance estimation of geometric objects in two AR tasks. CONCLUSION: Impairments in VSP reduce the ability to estimate distance and to perceive three-dimensionality in an AR environment. While stereovision is key for task performance in HS, spatial localization/visuoconstruction is predominant in patients. Since impairments in VSP are present after stroke, these findings might be crucial when AR is applied for neurorehabilitative treatment. In order to maximize the therapy outcome, the design of AR games should be adapted to patients' impaired VSP.  Trial registration: The trial was not registered, as it was an observational study.

Comparison of two methods based on one psychophysical paradigm to measure the subjective postural vertical in standing.

The perception of verticality can be altered with age or due to neurological diseases. Different procedures have been described to measure the subjective postural vertical (SPV). A deviation from the earth vertical was either described as a single position or as a sector defined by two positions representing the edges of the perceived verticality. In this study, for the first time, we investigated if these two methods produce equal values, and consequently can be merged to set normative values. SPV in standing was tested in 24 healthy young adults (28.4 (5.2) years of age, 12 women). Each participant performed both methods in the sagittal and the frontal plane. Absolute and constant error values were found to be similar for both methods in both planes with a mean difference of less than 0.3° (p > 0.148). The mean width of the SPV sector was 3.9° (0.9°) in the sagittal and 3.7° (1.4°) in the frontal plane, ranging in the mean from -5.5° to 8.1° in the sagittal and -5.3° to 4.3° in the frontal plane. SPV values significantly differed in range between both methods in both planes with a mean difference of more than 3.1° (p<0.002). Results show that both methods, SPVposition and SPVsector, produce equal error values when applied with otherwise similar methodological settings and can therefore be used alternatively or within the same meta-analysis. The SPVsector, however, led to wider range values and was less frequently rated as the preferred method to represent the participants' subjective verticality.

[Proprioception - The Sixth Sense And Its Disorders]. / Propriozeption ­ Der "sechste Sinn" und seine Störungen.

Vision, hearing, smell, taste, touch - and the sixth sense, the perception of one's own body, allow for comprehensive interaction with our surroundings. This article provides an overview of physiological structures and diagnostic methods relevant for proprioception. In addition, the contribution of the proprioceptive function to the pathology of sensorimotoric disorders is described, and associated therapeutic approaches in neurorehabilitation are addressed.

A new cutoff score for the Burke Lateropulsion Scale improves validity in the classification of pusher behavior in subactue stroke patients.

BACKGROUND: Pusher behavior substantially hampers balance during sitting, standing, and posture transitions in stroke patients. The Burke Lateropulsion Scale (BLS) was recommended to evaluate pusher behavior. However, its cutoff score has not been validated and recent studies found evidence for a need to modify it. As there is no gold standard for the diagnosis of pusher behavior, functions that are typically disturbed in these patients should be used for the validation of the cutoff score. RESEARCH QUESTION: To investigate whether pusher behavior correlates with balance performance during sitting, standing and posture transitions, and to validate the BLS cutoff score. METHODS: 44 subacute stroke patients with pusher behavior (BLS ≥ 2) were included in this study. The BLS and the Performance-Oriented Mobility Assessment Balance subscale (POMA-B) were assessed several times at intervals of two weeks resulting in a total of 137 data sets. RESULTS: Correlation analysis between the BLS score and the POMA-B score revealed a moderate negative correlation (rSp=-0.602, p < 0.001): The lower the BLS score, the higher the balance performance. The maximum Youden Index (J=0.864) was found for a cutoff score ≥2.5. Patients with a BLS score ≥2 scored ≥1 on the POMA-B, while patients with a BLS score ≥3 scored at no item or only at the sitting balance task. SIGNIFICANCE: In line with previous findings, the results of this study support using a BLS cutoff score of ≥3 instead of ≥2 to diagnose PB for research purposes and intervention planning. A score ≥3 correlates with severe balance impairments and with an impaired verticality perception in the frontal plane, and it improves the agreement with the Scale for Contraversive Pushing.

Robot-assisted gait training to reduce pusher behavior: A randomized controlled trial.

OBJECTIVE: To determine the effects of 2 weeks of intensive robot-assisted gait training (RAGT) on pusher behavior compared to nonrobotic physiotherapy (nR-PT). METHODS: In a single-blind, randomized, controlled trial with 2 parallel arms, we compared 2 weeks of daily RAGT (intervention group) with the same amount of nR-PT (control group). Patients with subacute stroke who had pusher behavior according to the Scale for Contraversive Pushing (SCP) were included. The primary research questions were whether changes in pusher behavior would differ between groups post intervention, and at a follow-up 2 weeks afterward (SCP and Burke Lateropulsion Scale, Class II evidence). Secondary outcomes included the Performance-Oriented Mobility Assessment, the Functional Ambulation Classification, and the Subjective Visual Vertical. RESULTS: Thirty-eight patients were randomized. Thereof, 30 patients received the allocated intervention and were included in the analyses. RAGT led to a larger reduction of pusher behavior than nR-PT at post test (SCP: U = 69.00, r = -0.33, p = 0.037; Burke Lateropulsion Scale: U = 47.500, r = -0.50, p = 0.003) and at follow-up (SCP: U = 54.00, r = -0.44, p = 0.008). Pusher behavior had ceased in 6 of 15 participants in the intervention group and 1 of 15 participants in the control group at post test. At follow-up, 9 of 15 and 5 of 15 participants, respectively, no longer exhibited the behavior. CONCLUSIONS: Two weeks of RAGT seems to persistently reduce pusher behavior, possibly by recalibrating the disturbed inner reference of verticality. The potential benefits of RAGT on pusher behavior and verticality perception require further investigation. TRIAL REGISTRATION: German Clinical Trials Register (registration number: DRKS00003444). CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that RAGT is beneficial to reduce pusher behavior in patients with stroke.

Movement Sonification in Stroke Rehabilitation.

Stroke often affects arm functions and thus impairs patients' daily activities. Recently, several studies have shown that additional movement acoustics can enhance motor perception and motor control. Therefore, a new method has been developed that allows providing auditory feedback about arm movement trajectories in real-time for motor rehabilitation after stroke. The present article describes the study protocol for a randomized, controlled, examiner, and patient blinded superiority trial (German Clinical Trials Register, www.drks.de, DRKS00011419), in which the method will be applied to 13 subacute stroke patients with hemiparesis during 12 sessions of 30 min each as additional feedback during the regular movement therapy. As primary outcome, a significant pre-post-change in the Box and Block Test is expected that exceeds the performance increase of 13 patients who will be provided with sham-acoustics. Possible limitations of the method as well as the study design are discussed.

Virtual reality to augment robot-assisted gait training in non-ambulatory patients with a subacute stroke: a pilot randomized controlled trial.

BACKGROUND: Active performance is crucial for motor learning, and, together with motivation, is believed to be associated with a better rehabilitation outcome. Virtual reality (VR) is an innovative approach to engage and motivate patients during training. There is promising evidence for its efficiency in retraining upper limb function. However, there is insufficient proof for its effectiveness in gait training. AIM: To evaluate the acceptability of robot-assisted gait training (RAGT) with and without VR and the feasibility of potential outcome measures to guide the planning of a larger randomized controlled trial (RCT). DESIGN: Single-blind randomized controlled pilot trial with two parallel arms. SETTING: Rehabilitation hospital. POPULATION: Twenty subacute stroke patients (64±9 years) with a Functional Ambulation Classification (FAC) ≤2. METHODS: Twelve sessions (over 4 weeks) of either VR-augmented RAGT (intervention group) or standard RAGT (control group). Acceptability of the interventions (drop-out rate, questionnaire), patients' motivation (Intrinsic Motivation Inventory [IMI], individual mean walking time), and feasibility of potential outcome measures (completion rate and response to interventions) were determined. RESULTS: We found high acceptability of repetitive VR-augmented RAGT. The drop-out rate was 1/11 in the intervention and 4/14 in the control group. Patients of the intervention group spent significantly more time walking in the robot than the control group (per session and total walking time; P<0.03). In both groups, motivation measured with the IMI was high over the entire intervention period. The felt pressure and tension significantly decreased in the intervention group (P<0.01) and was significantly lower than in the control group at the last therapy session (r=-0.66, P=0.005). The FAC is suggested as a potential primary outcome measure for a definitive RCT, as it could be assessed in all patients and showed significant response to interventions (P<0.01). We estimated a sample size of 44 for a future RCT. CONCLUSIONS: VR-augmented RAGT resulted in high acceptability and motivation, and in a reduced drop-out rate and an extended training time compared to standard RAGT. This pilot trial provides guidance for a prospective RCT on the effectiveness of VR-augmented RAGT. CLINICAL REHABILITATION IMPACT: VR might be a promising approach to enrich and improve gait rehabilitation after stroke.