Rodríguez-Hernández et al. (2023)

Virtual Reality Training for Improving Hand Motor Function Post-Stroke

This trial compared two ways to improve hand motor function post-stroke

Virtual reality was used to improve the learning experience in the intervention group

Differences were in favor of the intervention but may emphasize within-group differences which may be misleading

Introduction

People experiencing a stroke often remain with significant difficulties in using the limb. Less than fifteen percent of people achieve full recovery and up to 80% of stroke survivors have impairments of the upper limb, leading to limitations in activity and participation in daily activities. Of the impairments, post-stroke hand motor function is debilitating since it impairs people in everyday basic activities like eating, writing, handling objects, and many more. Conventional stroke rehabilitation offers people specific training, targeted at their individual needs but a lot of people get demotivated when they are not improving as they would want to. This can lead to frustration, demotivation, and possibly to people giving up on trying to use their stroke limb (nonuse). To overcome this or avoid this happening, virtual reality might be a game changer since it lets people engage in a simulated environment without feeling they are endlessly repeating movements and completing tasks such as gripping. Therefore, the current study aimed to investigate the effectiveness of virtual reality combined with conventional rehabilitation for improving hand motor function post-stroke.

 

Methods

This prospective randomized controlled trial compared conventional rehabilitation (control group) to conventional rehabilitation plus virtual reality training (experimental group). Participants were recruited from a Neurology department and eligible when they were between 18-85 years old. They suffered a stroke no longer than 6 months before inclusion and had stroke-related motor impairments in the upper limb, objectified using the Fugl-Meyer Assessment, Ashworth Scale, and Action Research Arm Test.

The impairments could include:

  • Fugl-Meyer Assessment:
    • scarce or no reflex activity, absence or limitation of voluntary movements in flexion and extension synergies,
    • limitations in shoulder flexion-extension and adduction-abduction and wrist flexion-extension and stabilization,
    • difficulty grasping and gripping with the most affected hand, trembling or dysmetria
  • Ashworth Scale:
    • slight or substantial increase in muscle tone
  • Action Research Arm Test:
    • difficulties in pinching, gripping, or handling objects and making larger-scale movements, for example, placing the hand behind their head

No minimum or maximum scores were set for these impairments and as such, the authors tried to include people experiencing (movement) limitations affecting their functional independence.

A total of 15 treatment sessions of 150 minutes were completed on five consecutive days for 3 weeks. The conventional rehabilitation for the control group consisted of 75 minutes of physiotherapy and 75 minutes of occupational therapy with a 15-minute break in between both.

The conventional rehabilitation in the control group consisted of:

  • manual therapy techniques (massage);
  • passive and active assisted mobilization of the upper and lower limbs;
  • walking on level surfaces, slopes, and stairs;
  • exercises with resistance or assistance from balls, elastic bands, and dumbbells in therapeutic cages and trellises;
  • active assisted mobility exercises of the upper limb and fingers in a sitting position;
  • moving objects horizontally on a table; elevation and superposition of objects in the vertical plane;
  • biomechanical tasks that simulated flexion-extension and abduction–adduction of the shoulder and flexion-extension of the wrist and fingers

People in the experimental group received conventional rehabilitation for 100 minutes per session and a 50-minute specific virtual reality rehabilitation. A device called the HandTutor © was used together with a computer screen. The virtual reality program creates tasks that simulate everyday activities in a virtual environment. Motion is tracked and feedback can be provided.

hand motor function post-stroke
From: Rodríguez-Hernández et al., J Neuroeng Rehabil. (2023)

 

The primary outcome was hand motor function and objectified using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) which evaluates the motor function of the upper limb, the Ashworth Scale measuring the resistance to passive movement (spasticity), and the Action Research Arm Test (ARAT) which objectifies the ability to manipulate small and large objects using grasp, grip, pinch and gross movements. These measurements were obtained at baseline, following the 3-week intervention period, and at a 3-month follow-up.

Participants with other neurological conditions and severe hemineglect were excluded from participating.

 

Results

Forty-six participants were included in this study and equally divided into the experimental and control groups. The groups were similar at baseline.

hand motor function post-stroke
From: Rodríguez-Hernández et al., J Neuroeng Rehabil. (2023)

 

The authors describe the differences from baseline to postintervention and follow-up (within-group differences), but not the between-group differences.

hand motor function post-stroke
From: Rodríguez-Hernández et al., J Neuroeng Rehabil. (2023)

 

Questions and thoughts

Is it possible to organize rehabilitation sessions of 150 minutes per day, for 5 days in a row? I assume that this is mostly possible in specialized multidisciplinary clinics. However, this would be very costly to organize for standard private physiotherapy practices. On the other hand, the device that was used in this research is an affordable tool, so it should be doable to implement part of the rehabilitation at home. This wasn’t studied, however, but seems an interesting research question for future studies. If this would be achievable to combine these intensive physiotherapist-led exercises with supplemented home-based exercise sessions, it could lead to better outcomes in the first (crucial) months post-stroke.

 

Talk nerdy to me

The authors described their results using within-group differences. That is, they compared the baseline result to the post-intervention result in each group and then looked at how large this difference was in each group to determine the group yielding the largest difference. That is not how it should have been done. In a randomized controlled trial, you’d want to know the difference between the groups, to determine which treatment is superior and thus best suited for the studied population. Here, a between-group difference is the only way to compare both groups.

From Bland et al. (2011), we quote: “When we randomise trial participants into two or more groups, we do this so that they will be comparable in every respect except the intervention which they then receive. The essence of a randomised trial is to compare the outcomes of groups of individuals that start off the same. We expect to see an estimate of the difference (the “treatment effect”) with a confidence interval and, often, a P value. However, rather than comparing the randomised groups directly, researchers sometimes look within groups at the change between the outcome measure from pre-intervention baseline to the final measurement at the end of the trial. They then perform a test of the null hypothesis that the mean difference is zero, separately in each randomised group. They may then report that in one group this difference is significant but not in the other and conclude that this is evidence that the groups, and hence the treatments, are different. … Using separate paired tests against baseline and interpreting only one being significant as indicating a difference between treatments is a frequent practice. It is conceptually wrong, statistically invalid, and consequently highly misleading.”

 

Take-home messages

Conventional therapy paired with a specific virtual reality technology system can be more effective than traditional programs alone in improving hand motor function post-stroke and voluntary movement. It could also help to normalize muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion improve; resistance to movement (spasticity) lessens and remains at a low level. The analysis, however, emphasizes the within-group differences, leaving the question of the effective clinical relevance open.

 

Reference

Rodríguez-Hernández M, Polonio-López B, Corregidor-Sánchez AI, Martín-Conty JL, Mohedano-Moriano A, Criado-Álvarez JJ. Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial. J Neuroeng Rehabil. 2023 Apr 4;20(1):38. doi: 10.1186/s12984-023-01170-3. PMID: 37016408; PMCID: PMC10071242. 

 

Interesting read

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Podcast

Episode 039: Neurosport & Physiotherapy rehab With Katie Mitchell

ATTENTION THERAPISTS WHO WANT TO IMPROVE THEIR SHOULDER & WRIST GAME

WATCH TWO 100% FREE WEBINARS ON SHOULDER PAIN AND ULNA-SIDE WRIST PAIN

Improve your Clinical Reasoning for Exercise Prescription in the Active Person with Shoulder pain with Andrew Cuff and Navigate Clinical Diagnosis & Management featuring a Case Study of Golfer with Thomas Mitchell

 

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