Is the Combination of Robot-Assisted Therapy and Transcranial Direct Current Stimulation Useful for Upper Limb Motor Recovery? A Systematic Review with Meta-Analysis.

Stroke is the third leading cause of disability in the world, and effective rehabilitation is needed to improve lost functionality post-stroke. In this regard, robot-assisted therapy (RAT) and transcranial direct current stimulation (tDCS) are promising rehabilitative approaches that have been shown to be effective in motor recovery. In the past decade, they have been combined to study whether their combination produces adjuvant and greater effects on stroke recovery. The aim of this study was to estimate the effectiveness of the combined use of RATs and tDCS in the motor recovery of the upper extremities after stroke. After reviewing 227 studies, we included nine randomised clinical trials (RCTs) in this study. We analysed the methodological quality of all nine RCTs in the meta-analysis. The analysed outcomes were deficit severity, hand dexterity, spasticity, and activity. The addition of tDCS to RAT produced a negligible additional benefit on the effects of upper limb function (SMD -0.09, 95% CI -0.31 to 0.12), hand dexterity (SMD 0.12, 95% CI -0.22 to 0.46), spasticity (SMD 0.04, 95% CI -0.24 to 0.32), and activity (SMD 0.66, 95% CI -1.82 to 3.14). There is no evidence of an additional effect when adding tDCS to RAT for upper limb recovery after stroke. Combining tDCS with RAT does not improve upper limb motor function, spasticity, and/or hand dexterity. Future research should focus on the use of RAT protocols in which the patient is given an active role, focusing on the intensity and dosage, and determining how certain variables influence the success of RAT.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial.

TRIAL OBJECTIVE: To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke. TRIAL DESIGN: This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention. PARTICIPANTS: Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain. INTERVENTION: Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session). RESULTS: As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5). CONCLUSION: The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level. TRIALS REGISTRY: International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Effect of Doll Therapy in Behavioral and Psychological Symptoms of Dementia: A Systematic Review.

(1) Background: Behavioral and psychological symptoms of dementia (BPSD) are a threat for people with dementia and their caregivers. Doll therapy is a non-pharmacological person-centered therapy to promote attachment, company, and usefulness with the aim of minimizing challenging behaviors. However, the results are not clear. (2) Objective: To know the effectiveness of doll therapy in reducing behavioral and psychological symptoms of people with dementia at a moderate-severe phase. (3) Methodology: The systematic review was informed according to the criteria established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Searches were conducted in eight databases: Cochrane, PubMed, Web of Science, Cinahl, Embase, Lilacs, PeDro, and Scopus before October 2021. Studies were selected when they accomplished the simple majority of Consolidated Standards of Reporting Trials (CONSORT). The risk of bias was appraised with the Cochrane Collaboration Risk of Bias Tool. The review protocol was recorded in Inplasy:1539. (4) Results: The initial search strategy showed 226 relevant studies, 7 of which met the eligibility criteria. In the included studies, a total number of 295 participants (79% female) with a mean age of 85 years were enrolled. There was found to be a reduction in challenging and aggressive behaviors, the participants were less rough and irritable, and their communication skills and emotional state were also improved. (5) Conclusion: Our findings suggest that doll therapy improves the emotional state of people with dementia, diminishes disruptive behaviors, and promotes communication. However, randomized studies with a larger sample size and higher methodological rigor are needed, as well as follow-up protocols in order to reaffirm these results.

Changes in Resilience in Students of Occupational Therapy After Their First Exposure to Practice Placement Education.

Introduction: Resilience is a multidimensional and dynamic construct associated with positive growth and the capacity to transform stressful and negative factors into opportunities of personal development and self-improvement when faced with difficult experiences. The resilience process of each individual integrates multiple analysis levels, which range from genetic-environmental interactions to a complex process of adaptation between the individual and his/her family, friends, co-workers, society, and culture. Objective: To determine whether resilience improves in students of occupational therapy when exposed for the first time to practice placement education. Methodology: Quasi-experimental, prospective, observational, multi-center study with a sample composed of students from the Degree of Occupational Therapy of the public universities of Málaga (UMA) and Castilla-La Mancha (UCLM) (Spain). Two weeks prior to the beginning of the practice education period, the participants completed a questionnaire that included sociodemographic data and the area of their internships. They were also given the Spanish version of the Connor-Davidson's resilience scale (CD-RISC). All these instruments were also completed 1 week after the end of the clinical practice. Results: There were statistically significant differences between the variables that make up resilience and the different internship areas. On the other hand, there was a significant improvement of global resilience after the clinical practice period, in both women (13.85 points; p < 0.001) and men (7.72 points; p < 0.035), when the internship area was not considered. Conclusions: The results show that resilient students are more optimistic and work to improve a situation beyond doing simply what is expected of them, knowing how to control their feelings. This is beneficial for students in practice education, since, during these, they face difficult situations that require a resilient pattern, which helps reduce stress and the burnout syndrome.

Effects of Specific Virtual Reality-Based Therapy for the Rehabilitation of the Upper Limb Motor Function Post-Ictus: Randomized Controlled Trial.

This research analyzed the combined effect of conventional treatment and virtual reality exposure therapy on the motor function of the upper extremities in people with stroke. We designed a randomized controlled trial set in the rehabilitation and neurology departments of a hospital (Talavera de la Reina, Spain). The subjects included 43 participants, all randomized into experimental (conventional treatment + virtual reality exposure therapy) and control group (conventional treatment).; The main measures were Fugl-Meyer Assessment for upper extremity, Modified Ashworth Scale, and Stroke Impact Scale 3.0. The results included 23 patients in the experimental (62.6 ± 13.5 years) and 20 in the control group (63.6 ± 12.2 years) who completed the study. After the intervention, muscle tone diminished in both groups, more so in the experimental group (mean baseline/post-intervention: from 1.30 to 0.60; η2 = 0.237; p = 0.001). Difficulties in performing functional activities that implicate the upper limb also diminished. Regarding the global recovery from stroke, both groups improved scores, but the experimental group scored significantly higher than the controls (mean baseline/post-intervention: from 28.7 to 86.5; η2 = 0.633; p = 0.000). In conclusion, conventional rehabilitation combined with specific virtual reality seems to be more efficacious than conventional physiotherapy and occupational therapy alone in improving motor function of the upper extremities and the autonomy of survivors of stroke in activities of daily living.

Effects of Virtual Reality-Based Therapy on Quality of Life of Patients with Subacute Stroke: A Three-Month Follow-Up Randomized Controlled Trial.

OBJECTIVE: To evaluate the influence of conventional rehabilitation combined with virtual reality on improving quality of life related to post-stroke health. DESIGN: Randomized controlled trial. SETTING: Rehabilitation and neurology departments of a general hospital (Talavera de la Reina, Spain). SUBJECTS: A total of 43 participants with subacute stroke. INTERVENTION: Participants were randomized into experimental group (conventional treatment + virtual reality) and control (conventional treatment). MAIN MEASURES: Health-related quality of life as measured by the EuroQoL-5 dimensions instrument (EQ-5D-5L) and EuroQoL visual analog scale (EQ-VAS). RESULTS: A total of 23 patients in the experimental group (62.6 ± 13.5 years) and 20 in the control (63.6 ± 12.2 years) completed the study. In the experimental group, EQ-VAS score was 29.1 ± 12.8 at baseline, 86.5 ± 7.1 post-intervention, and 78.3 ± 10.3 at the three-month follow-up. The control group obtained scores of 25.5 ± 5.1, 57.0 ± 4.7, and 58.5 ± 5.9, respectively. We identified significant differences at the post-intervention and follow-up timepoints (p = 0.000) and a partial η2 of 0.647. In EQ-5D-5L, the severity of issues decreased after intervention in the experimental group, while pain and anxiety dimensions increased between post-intervention and follow-up. CONCLUSIONS: The conventional rehabilitative approach combined with virtual reality appears to be more effective for improving the perceived health-related quality of life in stroke survivors.

Effectiveness of virtual reality technology on functional mobility of older adults: systematic review and meta-analysis.

BACKGROUND: The accessibility, versatility and motivation provided by virtual reality technology (VRT) have fostered its rapid expansion as a rehabilitation technique to improve functional mobility. The aim of this study was to investigate the effectiveness of rehabilitation programmes using VRT, specific virtual reality technology (VRT-S) and non-specific virtual reality technology (VRT-NS), to improve functional mobility in individuals aged >60 years versus conventional treatment (CT) or no intervention. METHODS: Nine databases (Cochrane Library, Scopus, PEDro, Medline, CSIC, Web of Science, OT Seeker, NGCH and CINAHL) were searched to identify randomised trials up to December 2019. Results of clinical trials that used VRT-S and VRT-NS in rehabilitation were combined, using a random effects model with inverse variance weighting of the studies. GRADE was used to assess the quality of evidence. The protocol was registered in PROSPERO: CRD42019131630. Overall, there was moderate quality of evidence for the functional mobility results, which means that the estimate of effect is likely to change. RESULTS: Sixteen of the 18 studies selected (n = 568) provided data for the subgroup meta-analysis. VRT-NS was more effective in improving functional mobility than no intervention [standardised mean difference (SMD) = -1.02; 95% confidence interval (CI) -1,91 to -0,14). VRT-NS was also more effective than CT in improving resistance in ambulation (SMD = -1.20; 95% CI -1.93 to 0.46). No significant differences were found between VRT-S and CT or no intervention. Programmes in which >18 sessions were applied were more beneficial (SMD = -0.89; 95% CI -1.71 to -0.08; <0.001) than programmes with ≤18 sessions (SMD = 0.04; 95% CI -0.51 to 0.59) versus no intervention. CONCLUSIONS: Our results suggest that VRT is an effective intervention for improving functional mobility in older persons compared with CT. VRT-NS proved to be more effective than VRT-S. However, these results are still not conclusive due to the low methodological quality of the studies. Thus, new studies and analyses are required.

Effectiveness of Virtual Reality Systems to Improve the Activities of Daily Life in Older People.

(1) This review aims to evaluate the effectiveness of treatments with virtual reality systems (VRSs) on the functional autonomy of older adults versus conventional treatment. (3) Methods: Systematic review and meta-analysis. An electronic data search was carried out, following the PRISMA statement, up to February 2020. We combined results from clinical trials using VRSs for the improvement of basic and instrumental activities of daily living. The guidelines of the Cochrane Handbook for Systematic Reviews of Interventions were followed for calculations and risk of bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence. (4) Results: The final analysis included 23 studies with a population of 1595 participants. A moderate, but clinically significant, effect was found for basic activities of daily living (BADLs), (Standard Medium Deviation, SMD 0.61; 95% CI: -0.15-1.37; P < 0.001). A small effect was found for instrumental ADLs (Instrumental Activities of daily living, IADLs) (SMD -0.34; 95% CI: -0.82-0.15; P < 0.001). Functional ambulation was the BADL which improved the most (SMD -0.63; 95% CI: -0.86, -0.40; P < 0.001). (5) Conclusion: The use of VRSs is an innovative and feasible technique to support and improve the functional autonomy of community-dwelling older adults. Due to the very low quality of the evidence for our main outcomes, the effects of a VRS on the BADLs and IADLs are uncertain. Clinical trials of a higher methodological quality are necessary to increase the level of knowledge of its actual effectiveness.

Can exergames contribute to improving walking capacity in older adults? A systematic review and meta-analysis.

BACKGROUND: The accessibility, low cost and motivation generated by exergames has fostered its rapid expansion as a rehabilitation technique. OBJECTIVE: To estimate the effectiveness of rehabilitation programs using IVGT in improving walking capacity of people aged 60 years and over. MATERIALS AND METHODS: The electronic data research following the PRISMA Statement (Scopus, Cochrane, Web of Science, OT Seeker, National Guideline Clearinghouse, Trip Database, CSIC Spanish National Research Council) was completed in September 2018. The results of randomized clinical trials using exergames for rehabilitation of walking capacity were combined. The calculations have followed the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. The Grading of Recommendations Assessment, Development and Evaluation system was used to evaluate the quality of the evidence. RESULTS: We obtained data from 14 trials, including 11 meta-analysis studies. The size of exergames effects on walking capacity is moderate, but significant (SMD -0.56; 95 % CI: -0.90, -0.21; p = 0.002). Effectiveness was greater to recover the ability to transfer from one position or place to another (SMD -1.02; CI 95 %: -1.70, -0.35; P = 0.003). The intervention protocols, their duration and intensity varied considerably. The lack of masking, the allocation concealment, the absence of assessor blinding were the main causes of bias so the final grade of evidence has been low for walking and very low for transfers. CONCLUSIONS: Positive clinical effects of exergames have been found to improve walking capacity, but the quality of evidence to refute its effectiveness is weak with risk of bias. Further research is needed in order to know the actual magnitude of its effect.

Improving Self-Perceived Emotional Intelligence in Occupational Therapy Students Through Practical Training.

Background: In the field of healthcare, higher skills in emotional intelligence (EI) have been proven to have a positive impact on healthcare professionals in general and occupational therapists in particular and also on teamwork and patient care. The purpose of this research was to determine whether performing practical work included in the undergraduate Occupational Therapy program improves students' self-perceived EI, and whether there are any differences in the latter depending on the area in which this practical training is performed. Methods: It was conducted a multicenter, quasi-experimental, pre-post study with Occupational Therapy undergraduate students in the 2016-2017 academic year. A total of 184 students met the inclusion criteria. Of these, 10 (5.40%) declined to participate; therefore, the participation rate was 94.60% and the initial sample comprised 174 students. Mean age was 21.34 years (SD = 2.54) and 84.50% (n = 147) were women. Students' self-perceived EI was measured with the Trait Meta-Mood Scale-24 (TMMS-24). This measure was completed in the two weeks prior to the start of the practical training period and one week after the end of it. McNemar-Bowker and McNemar tests were used to analyze the differences in self-perceived EI between these two points in time. Results: After the practical training, an improvement in self-perceived EI was observed in women (Emotional Attention, Emotional Clarity, and Emotional Regulation dimensions). Regarding areas of practical training, results showed an improvement in EI in women who had received practical training in the areas of Physical Rehabilitation, Mental Health and Geriatrics and Gerontology. Conclusions: The findings contribute to a better understanding of the relation between practical training and an improvement in self-perceived EI. This insight can help make changes in the teaching methodology to enhance the emotional skills needed for a better professional performance.

Anatomical prosection practices in the Occupational Therapy degree. Student anxiety levels and academic effectiveness.

CONTEXT: The practice of anatomical dissection and/or prosection on human cadavers is an essential component of human anatomy training programmes. However, this activity can be stressful for inexperienced students when exposed to cadavers for the first time, and it may generate high anxiety levels. The aims of this study are threefold: 1) to analyse the thoughts and feelings of first-year students of the Occupational Therapy degree about prosection practices; 2) to examine their anxiety levels in relation to these practices; and 3) to evaluate how useful and effective they are as an educational tool for anatomy training. METHODS: This is a before-and-after cross-sectional study of first-year students of the Occupational Therapy degree at the Universidad de Castilla-La Mancha, Spain. These students had not previously participated in prosection practices. An anonymous questionnaire was distributed among the students before and after the practice, in order to examine their feelings and perceptions during the practice. To examine their anxiety levels, we used a State-Trait Anxiety Inventory (STAI) questionnaire. To assess their learning outcomes the students had to complete two practical tests of recognition of anatomical structures, one before attending the practice and one immediately afterwards. RESULTS: Basal anxiety levels, measured as trait anxiety (TA), remained stable and did not show significant differences during the practice (p>0.05). Their emotional anxiety, measured as state anxiety (SA), dropped from 14.7 to 10 points (p<0.05) after the practice. Before the start of the practice 11 students (19%) showed signs of anxiety, and these remained so at the end of the practical session (p>0.05). As for their academic performance, we observed that the number of students able to pass the test after attending the prosection practice increased notably (by more than 60%). Additionally, 100% of the students recommended that the practice be retained for future courses, giving it an approval rate of 9.1 out of 10. CONCLUSION: Although anatomy is usually an attractive subject for Occupational Therapy students and they value prosection practices positively, they remain a potentially complex and stressful experience. Some students find that their experiences in the dissecting room can upset their emotional balance, however, the implementation of coping mechanisms could be a very effective strategy to reduce their anxiety and also to improve their learning outcomes, helping to strengthen their practical knowledge of anatomy as we have observed in this study. The students not only value positively these practices, they also believe that they are an extremely useful tool for both teaching and learning anatomy, and they recommend their routine use as part of the training process.

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