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Background
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

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What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.

Published version made available following 12 month embargo from the date of publication [12 Feb 2015] according to publisher policy. Accessed 10/03/2015. Published version available from 13 February 2016.

/pdf/virtual-reality-for-stroke-rehabilitation-4evwp7ler3.pdf

Virtual reality for stroke rehabilitation

THIS IS NOT THE MOST RECENT VERSION OF THIS PROTOCOL please see: http://hdl.handle.net/2328/39189 Copyright © 2011 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
This review is made available in accordance with Cochrane
Database of Systematic Review's repositories policy

/pdf/virtual-reality-for-stroke-rehabilitation-review-1d29rullyx.pdf

Virtual reality for stroke rehabilitation (review)

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

/pdf/interactive-telemedicine-effects-on-professional-practice-1xxbw8tg81.pdf

Interactive telemedicine: effects on professional practice and health care outcomes

Recent evidence has demonstrated the efficacy of Virtual Reality (VR) for stroke rehabilitation nonetheless its benefits and limitations in large population of patients have not yet been studied. To evaluate the effectiveness of non-immersive VR treatment for the restoration of the upper limb motor function and its impact on the activities of daily living capacities in post-stroke patients. A pragmatic clinical trial was conducted among post-stroke patients admitted to our rehabilitation hospital. We enrolled 376 subjects who had a motor arm subscore on the Italian version of the National Institutes of Health Stroke Scale (It-NIHSS) between 1 and 3 and without severe neuropsychological impairments interfering with recovery. Patients were allocated to two treatments groups, receiving combined VR and upper limb conventional (ULC) therapy or ULC therapy alone. The treatment programs consisted of 2 hours of daily therapy, delivered 5 days per week, for 4 weeks. The outcome measures were the Fugl-Meyer Upper Extremity (F-M UE) and Functional Independence Measure (FIM) scales. Both treatments significantly improved F-M UE and FIM scores, but the improvement obtained with VR rehabilitation was significantly greater than that achieved with ULC therapy alone. The estimated effect size of the minimal difference between groups in F-M UE and FIM scores was 2.5 ± 0.5 (P < 0.001) pts and 3.2 ± 1.2 (P = 0.007) pts, respectively. VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities. Italian Ministry of Health IRCCS Research Programme 2590412

https://link.springer.com/content/pdf/10.1186%2F1743-0003-10-85.pdf

Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial

Objective Telerehabilitation enables a remotely controlled programme to be used to treat motor deficits in post-stroke patients. The effects of this telerehabilitation approach were compared with traditional motor rehabilitation methods. Design Randomized single-blind controlled trial. Patients A total of 36 patients with mild arm motor impairments due to ischaemic stroke in the region of the middle cerebral artery. Methods The experimental treatment was a virtual reality-based system delivered via the Internet, which provided motor tasks to the patients from a remote rehabilitation facility. The control group underwent traditional physical therapy for the upper limb. Both treatments were of 4 weeks duration. All patients were assessed one month prior to therapy, at the commencement and termination of therapies and one month post-therapy, with the Fugl-Meyer Upper Extremity, the ABILHAND and the Ashworth scales. Results Both rehabilitative therapies significantly improved all outcome scores after treatment, but only the Fugl-Meyer Upper Extremity scale showed differences in the comparison between groups. Conclusion Both strategies were effective, but the experimental approach induced better outcomes in motor performance. These results may favour early discharge from hospital sustained by a telerehabilitation programme, with potential beneficial effects on the use of available resources.

/pdf/exercises-for-paretic-upper-limb-after-stroke-a-combined-4jq8aac73r.pdf

Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach.

Background. Six months after a stroke, the hemiplegic arm often remains compromised. More innovative approaches to motor rehabilitation are needed. Objective. The authors compared a motor learning—based approach in a virtual environment with more conventional upper extremity therapy in a pilot trial. Methods . This prospective, single-blinded, randomized controlled trial compared reinforced feedback in a virtual environment (RFVE; n = 27) with a control intervention (n = 20) of progressive therapy for the affected upper extremity. Both treatments were provided for 4 weeks, 5 days per week, with 1-hour treatment sessions daily. The primary outcomes were the Fugl-Meyer Upper Extremity (F-M UE) and Functional Independence Measure (FIM) scores. Kinematic outcomes included mean duration (MD), mean linear velocity (MLV), and number of submovements to measure the motor performance. Analyses of the primary outcomes were performed per protocol and by intention to treat. Results. F-M UE scores improved significantl...

https://journals.sagepub.com/doi/pdf/10.1177/1545968310362672

Motor Learning Principles for Rehabilitation: A Pilot Randomized Controlled Study in Poststroke Patients

Previous studies have shown that the motor training in a virtual-environment with the augmented feedback promotes motor learning in normal subjects and in long-term post-stroke patients. We evaluated whether this approach could be useful also for treating patients with arm motor deficits due to a recent stroke. Twenty-four patients were included in the study within 3 months from an ischemic stroke in the territory of the middle cerebral artery. Twelve subjects received virtual-environment-training (VET) therapy for the arm, and twelve patients received an equal amount of a conventional rehabilitation therapy focused to the upper limb. Before and after therapy, the autonomy of daily living activities were assessed with the Functional Independence Measure and the degree of motor impairment was measured with the Fugl-Meyer scale for the upper extremity. For both groups the therapy lasted from 5 to 7 weeks, 1 hour daily for five days a week. The VET therapy group showed 20,2% and 12,4% improvements in the Fugl-Meyer and the Functional Independence Measure scale mean scores respectively. In a comparable way, the conventional therapy determined significant, but smaller scores improvements: 11,3% and 9,1%, respectively. These data indicate that the recovery of arm motor function in patients after a recent stroke is promoted by an augmented feedback strategy applied through a virtual-environment.

The augmented-feedback rehabilitation technique facilitates the arm motor recovery in patients after a recent stroke.

Previous studies have shown that the motor training in a virtual-environment with the augmented feedback promotes motor learning in normal subjects and in long-term post-stroke patients. We evaluated whether this approach could be useful also for treating patients with arm motor deficits due to a recent stroke. Thirty-eight patients were included in the study within 3 months from an ischemic stroke in the territory of the middle cerebral artery. Twenty-five subjects received training with the Reinforced Feedback in Virtual Environment (RFVE) therapy for the arm, and thirteen patients received an equal amount of a conventional rehabilitation (CR) therapy focused to the upper limb. Before and after therapy, the autonomy of daily living activities were assessed with the Functional Independence Measure (FIM) and the degree of motor impairment was measured with the Fugl-Meyer scale for the upper extremity (FM-UE). The RFVE therapy group showed significant improvements in the FM-UE and the FIM scale mean scores. The conventional therapy determined smaller and not statistically significant scores improvements. These data indicate that the recovery of arm motor function in patients after a recent stroke appear to be speeded up by an augmented feedback provided in a virtual-environment.

Carla Zucconi

Papers

Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial

Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach.

Motor Learning Principles for Rehabilitation: A Pilot Randomized Controlled Study in Poststroke Patients

The augmented-feedback rehabilitation technique facilitates the arm motor recovery in patients after a recent stroke.

Reinforced Feedback in Virtual Environment Facilitates the Arm Motor Recovery in Patients after a Recent Stroke