Background
Motor rehabilitation after stroke
Virtual reality for motor rehabilitation
Objectives of the study
Material and methods
Participants
Patient | Age (years) | Gender | Stroke | Time from stroke (months) |
---|---|---|---|---|
P1 | 43 | F | Right Sylvian ischemic | 51 |
P2 | 50 | M | Left Sylvian ischemic | 26 |
P3 | 55 | F | Right Sylvian ischemic | 108 |
P4 | 38 | F | Left rupture cerebral aneurysm Sylvian | 6 |
P5 | 64 | M | Left Sylvian ischemic | 9 |
P6 | 64 | M | Left pontine ischemic | 22 |
P7 | 72 | M | Right Sylvian sub-cortical ischemic | 72 |
P8 | 34 | F | Left Sylvian ischemic | 6 |
P9 | 68 | F | Right Sylvian ischemic | 42 |
P10 | 61 | F | Right anterior communicating artery ischemic | 54 |
Inclusion criteria | Exclusion criteria |
---|---|
• Ischemic or hemorrhagic minor-to-moderate (0 < NIHSS < 16) stroke with hemiparesis and experiencing arm motor difficulties • At least 6 months after stroke incident • Maximum 4 on the Medical Research Council Scale (MRCS) for shoulder elevation and elbow flexion/extension • 18 years and older • First ever stroke | • Participating in another movement treatment study at the time of the present study • Severe cognitive impairment (Mini Mental Status Examination score < 18 points) • Orthopedic impairment or visual disorders limiting the treatment • Unable to give informed consent form • Risk of epileptic seizures |
Experimental procedure
Virtual reality system
The rehabilitation exercises
Outcome measures
Primary outcomes
Secondary outcomes
Safety and acceptance of technology
Data analysis
Results
Primary outcomes
Rehabilitation dose and training intensity
Session #1 Median (IQR) | Session #10 Median (IQR) | Total Median (IQR) |
p-value (Session #1 vs. #10) | |
---|---|---|---|---|
Duration of training (minutes) | 26.8 (20.6 to 32.7) | 37.2 (30.9 to 45.6) | 403 (331 to 417) | 0.074 |
Effective training time (minutes) | 16.5 (12.5 to 20.1) | 32.1 (23.9 to 37.9) | 290 (246 to 329) | 0.007* |
Goal-directed Movements | 212.0 (152.0 to 301.3) | 476.5 (432.3 to 637.0) | 4713 (3669 to 5293) | 0.005* |
Goal-directed movements per minute of Effective training time | 13.2 (11.4 to 15.9) | 17.3 (16.6 to 18.7) | N/A | 0.037* |
Secondary outcomes
Upper limb function
FMA-UE | P1 | P2 | P3 | P4 | P5 | P6 | P7 | P8 | P9 | P10 |
---|---|---|---|---|---|---|---|---|---|---|
Baseline (T0) | 36 | 47 | 55 | 17 | 21 | 37 | 57 | 18 | 50 | 54 |
Post-treatment (T1) | 33 | 54 | 55 | 24 | 23 | 38 | 58 | 17 | 51 | 55 |
Follow-up (T2) | 30 | 54 | 58 | 26 | 23 | 39 | 59 | 19 | 52 | 61 |
Improvement rate at T1 | −10% | 37% | 0% | 14% | 4% | 3% | 11% | −2% | 6% | 8% |
Improvement rate at T2 | −20% | 37% | 27% | 18% | 4% | 7% | 22% | 2% | 13% | 58% |
Active range of motion
Baseline (T0) Median (IQR) | Post-treatment (T1) Median (IQR) | Follow-up (T2) Median (IQR) | Friedman test | Wilcoxon signed-rank test | ||
---|---|---|---|---|---|---|
p-value | p-value T0 to T1 | p-value T0 to T2 | ||||
FMA-UE | 42.0 (24.75 to 53.00) | 44.5 (26.25 to 54.75) | 45.5 (27.0 to 57.0) | 0.007+
| 0.131 | 0.035 |
AROM (in °) | ||||||
Shoulder flexion | 105.0 (63.8 to 118.8) | 117.5 (71.3 to 133.8) | 117.5 (77.5 to 131.3) | 0.010+
| 0.065 | 0.007* |
Elbow extension | −8.5 (−10.0 to −1.3) | −7.5 (−10.0 to 0.0) | −5.0 (−10 to 0) | 0.420 | ||
Wrist extension | 35.0 (6.3 to 55.0) | 37.5 (8.8 to 55.0) | 45.0 (22.5 to 60.0) | 0.095 | ||
Forearm supination | 62.5 (5.0 to 78.8) | 57.5 (12.5 to 83.8) | 67.5 (12.5 to 80.0) | 0.131 | ||
Forearm pronation | 62.5 (0.0 to 83.8) | 87.5 (56.3 to 90.0) | 87.5 (57.5 to 90.0) | 0.032+
| 0.027 | 0.128 |
mMRCS | ||||||
Shoulder flexion | 3 (3.0 to 3.8) | 3.5 (3.0 to 4.0) | 3.5 (3.0 to 4.0) | 0.156 | ||
Elbow extension | 2.5 (2.0 to 3.0) | 3 (2.3 to 3.8) | 3 (2.3 to 4.0) | 0.074 | ||
Wrist extension | 3 (1.5 to 4.0) | 3 (2.3 to 4.0) | 3.5 (2.3 to 4.0) | 0.174 | ||
Forearm supination | 3 (1.3 to 4.0) | 3.5 (1.5 to 4.0) | 3.5 (1.5 to 4.0) | 0.424 | ||
Forearm pronation | 3 (0.5 to 4.0) | 3.5 (2.3 to 4.0) | 3.5 (3.0 to 4.0) | 0.350 | ||
FIM | 121.5 (106.3 to 125.3) | 121 (105 to 123) | 121.5 (108.8 to 123.8) | 1 | ||
VAS | ||||||
Shoulder flexion | 0 (0 to 6) | 1 (0 to 2) | 0 (0 to 1.75) | 0.368 | ||
Elbow extension | 0 (0 to 4) | 0 (0 to 0) | 0 (0 to 0) | 0.146 | ||
Wrist extension | 0 (0 to 4) | 0 (0 to 0) | 0 (0 to 0) | 0.0498+
| 0.103 | 0.103 |
Forearm supination | 0 (0 to 0) | 0 (0 to 0) | 0 (0 to 0) | 0.135 | ||
Forearm pronation | 0 (0 to 0) | 0 (0 to 0) | 0 (0 to 0) | 0.368 |
Muscle strength
Functional independence
Pain ratings
Relationship between motor improvement and training intensity
Safety and acceptance of technology
Tolerance to VR intervention
Questions | Session # | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
Tolerance to VR intervention | ||||||||||
Q1: Before the session, how tired do you feel? | 1 (1 to 3.8) | 1 (1 to 2.5) | 1.5 (1 to 2.8) | 2 (1 to 3) | 2 (1 to 4) | 1 (1 to 4) | 3.5 (1 to 5) | 3 (1.5 to 5.8) | 1 (1 to 4.5) | 1 (1 to 2.5) |
Q3: After the session, how tired do you feel? | 1 (1 to 5.8) | 5.5 (1.5 to 6) | 1 (1.5 to 6) | 2 (1 to 5) | 2 (1 to 5) | 2 (1 to 6) | 3.5 (1 to 5.8) | 3.5 (1.3 to 6) | 2.5 (1 to 5.8) | 2 (1 to 5.8) |
Q2: Before the session, how relaxed do you feel? | 7 (5.3 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) | 7 (7 to 7) |
Q4: During the session, how relaxed did you feel? | 7 (6.3 to 7) | 7 (7 to 7) | 6 (4 to 7) | 7 (6.3 to 7) | 7 (7 to 7) | 7 (4 to 7) | 7 (6.3 to 7) | 7 (6 to 7) | 7 (5.3 to 7) | 7 (6.3 to 7) |
Adverse event monitoring | ||||||||||
Q5: During the exercises, did you feel any unusual pain (e.g. stronger) at the level of the upper limbs (arms, joints, hands) or the trunk? | 1 (1 to 1.8) | 1 (1 to 2.5) | 1 (1 to 1) | 3 (1 to 5) | 1 (1 to 3) | 2 (1 to 3) | 1.5 (1 to 5) | 3.5 (1 to 5.8) | 1 (1 to 1.8) | 1 (1 to 4.5) |
Self-evaluation | ||||||||||
Q6: After the session, do you feel any improvement of you movements (e.g., larger movements, more precise, etc.)? | 4 (1.5 to 6.3) | 4.5 (4 to 5.8) | 6 (4.3 to 7) | 6 (3.5 to 7) | 6 (5 to 7) | 6 (4.5 to 6.8) | 5.5 (5 to 6) | 6 (4.5 to 7) | 6 (4 to 6) | 7 (5.3 to 7) |
Adverse event monitoring
Self-evaluation
Questions | First Session Median(IQR) | Last Session Median(IQR) | Wilcoxon test
p-value |
---|---|---|---|
Self-evaluation | |||
Q6: After the session, do you feel any improvement of you movements (e.g., larger movements, more precise, etc.)? | 4 (1.5 to 6.3) | 7 (5.3 to 7) | 0.027* |
Acceptance of technology | |||
Q7: During the exercises, were you concentrated on the task? | 7 (7 to 7) | 7 (7 to 7) | 0.786 |
Q8: During the exercises, did you have the feeling of being in the hospital room? | 1 (1 to 1) | 1 (1 to 1.8) | 0.103 |
Q9: Did the movements of the character reflect your movements? | 6 (5.3 to 7) | 6.5 (5.3 to 7) | 0.546 |
Q10: During the exercises, did you feel comfortable with the requested movements? | 5 (4 to 7) | 7 (6 to 7) | 0.090 |
Q11: Did you like the exercises? | 7 (7 to 7) | 7 (7 to 7) | 0.317 |
Q12: Did you have the impression of doing rehabilitation exercises? | 7 (4.5 to 7) | 7 (3 to 7) | 0.706 |
Q13: Would you like the character to look more realistic? | 1 (1 to 4.8) | 4 (1.3 to 6.8) | 0.438 |
Motivation | |||
Q14: Would you like to spend more time doing the exercises at the hospital? | 6 (4 to 7) | 7 (3.3 to 7) | 0.595 |
Q15: Would you like to continue doing the exercises at home? | 7 (4.3 to 7) | 7 (5.3 to 7) | 1.000 |