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Technological advancements in stroke rehabilitation

Authors:
Arshad Nawaz Malik
Arshad Nawaz Malik
Arshad Nawaz Malik
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Hina Tariq at Texas Tech University
Hina Tariq
Ayesha Afridi at Riphah International University
Ayesha Afridi
Farooq Azam Rathore at National University of Medical Sciences
Farooq Azam Rathore
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Abstract

Early, coordinated, and multidisciplinary rehabilitation plays a major part in motor recovery after stroke. The conventional stroke rehabilitation primarily includes physical therapy, occupational therapy, and speech therapy. However, with these conventional methods, many stroke survivors still have a residual functional disability which impairs their ability to perform activities of daily living. This could be attributed to the insufficient therapy dose, low engagement and motivation of the patient, and lack of objective feedback to achieve significant improvements in function. Various technology-based stroke rehabilitation interventions have been developed in the last few decades which have shown promising results in improving stroke patients' functional mobility and independence. The use of technology promotes repetitive, task-specific training, active engagement of patients, integrating constructive and concurrent feedback, and accurately measuring functional improvement. This review summarizes the important technological advances in stroke rehabilitation, including exergames, telerehabilitation, robotic-assisted systems, virtual and augmented reality, wearable sensors, and smartphone applications.
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Open Access Vol. 72, No. 8, August 2022
1672
REHABILATION SCIENCES
Technological advancements in stroke rehabilitation
Arshad Nawaz Malik,1 Hina Tariq,2 Ayesha Afridi,3 Farooq Azam Rathore4
Abstract
Early, coordinated, and multidisciplinary rehabilitation
plays a major part in motor recovery after stroke. The
conventional stroke rehabilitation primarily includes
physical therapy, occupational therapy, and speech
therapy. However, with these conventional methods,
many stroke survivors still have a residual functional
disability which impairs their ability to perform activities
of daily living. This could be attributed to the insufficient
therapy dose, low engagement and motivation of the
patient, and lack of objective feedback to achieve
significant improvements in function.
Various technology-based stroke rehabilitation
interventions have been developed in the last few
decades which have shown promising results in
improving stroke patients' functional mobility and
independence. The use of technology promotes
repetitive, task-specific training, active engagement of
patients, integrating constructive and concurrent
feedback, and accurately measuring functional
improvement.
This review summarizes the important technological
advances in stroke rehabilitation, including exergames,
telerehabilitation, robotic-assisted systems, virtual and
augmented reality, wearable sensors, and smartphone
applications
Keywords: Rehabilitation, Robotics, Stroke, Virtual Reality.
DOI: https://doi.org/10.47391/JPMA.22-90
Introduction
Stroke is the most common cause of mortality and adult
neurological disability worldwide. The estimated global
prevalence in 2019 was 101 million1 while in Pakistan an
incidence of 250 per 100,000 has been reported.2
Along with the neurological impairment, stroke also has
long-term adverse effects on the physical, emotional, and
social well-being of the stroke survivor. It reduces
patients' overall activity level, participation, and active
involvement in the community. After being discharged
from the rehabilitation centers, 65% of the individuals still
do not make full motor recovery and cannot actively
engage the affected limbs in the activities of daily living,
indicating a need for further intensive intervention.3
Stroke rehabilitation services vary significantly across the
globe. Although developed and high-income countries
are gradually shifting towards advanced technology-
based stroke rehabilitation, conventional rehabilitation
(i.e., physical and occupational therapy) remains the
standard practice worldwide.4 Although conventional
rehabilitative approaches help restore motor function
and body movement, most stroke survivors are still left
with a long-term residual functional disability.5 The
growing body of evidence on stroke rehabilitation
suggests that neuroplasticity and optimum motor
recovery depends on several elements such as repetitions
and intensity of training, task-specificity, objective
feedback, and motivation during therapy.5
Repetitions and Intensity of Training
The literature suggests that the stroke patients should be
engaged in task-specific training. However, the outcomes
of the task-oriented training will depend upon dosage
and intensity of the exercise for optimum neuromotor
recovery. Conventional rehabilitation practices often
cannot fulfill the intensity and dosage requirement for
stroke rehabilitation. The higher the dose of exercise the
better are the results for stroke recovery.6
Task-specificity
Recent evidence has shown that technologies in stroke
rehabilitation such as augmented reality and robot-
assisted systems have the potential to provide a safe
environment for intensive task-specific training. Task-
specific training elicits cortical reorganization, which is
difficult to achieve with conventional rehabilitation
approaches.7,8
Objective Feedback and Motivation
Feedback and subsequent motivation play an essential
role in motor learning. Post-stroke sensory and motor
impairments make it difficult for the individual to detect
and correct movement errors. Objective feedback is vital
to learning references of correctness which allows the
individuals to detect errors from sensory information.
1,3Faculty of Rehabilitation and Allied Health Sciences, Riphah International
University, Islamabad, Pakistan, 2Bournemouth University, UK, 4Armed Forces
Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan.
Correspondence: Farooq Azam Rathore. E-mail; farooqrathore@gmail.com
Some recent technological advances in stroke
rehabilitation are designed to provide feedback that
helps stroke patients track their progress accurately, set
further goals for themselves, and ultimately improve their
functional performance.9 It has been demonstrated that
patients who were provided daily objective feedback on
their walking speed could walk faster than those who did
not receive any objective feedback.10 Lack of objective
feedback followed by subsequent lack of motivation is
one of the significant causes of failure to benefit from
rehabilitation programmes. Patients receiving
conventional stroke rehabilitation have reported
boredom and low motivation as one of the primary
reasons for lack of adherence to exercise programmes.9
Introducing games in stroke rehabilitation through
technologies such as virtual reality and tele-rehabilitation
increases patient engagement, adherence to training
programmes, and better clinical outcomes.9
Technologies in Stroke Rehabilitation
Exer-Gaming
Gamification in stroke rehabilitation significantly
motivates patients to adhere to exercise programmes.
The patient uses hands or body motions to play the
games, providing repeated practice to paretic limbs with
consistent feedback and cues.11,12 In addition, the games
provide a source of enjoyment for the patient, ultimately
increasing motivation, duration, and intensity of
training.11 Commercial games are affordable and readily
available, but most are not custom-designed according to
patient needs (speed, movement, and measurement).5
Various games have already been trialed with stroke
survivors, including 2D, 3D, and natural user interfaces
like Nintendo Wii Sport, PlayStation, Wii Balance, Xbox,
Kinect, and Armeo-Senso showed positive outcomes.12,13
Tele-rehabilitation
In tele-rehabilitation, the service users can access the
interventions remotely through video conferencing or
telephone calls. It is cost-effective, reduces hospital stay,
and addresses transportation issues and the non-
availability of rehabilitation centers in the patients'
locality. It is a useful approach to engage stroke patients
in training at home remotely through constant guidance
and feedback. One of the limitations of tele-rehabilitation
is however the lack of physical interaction of patients with
the clinicians.11,12
Robotic Rehabilitation
The robotic devices, also known as an exoskeleton,
provide assistance to a part of the body to achieve motor
control and movement after stroke.12,13 Research on
robotics in stroke rehabilitation, has demonstrated
significant improvements in functional outcomes. Some
of the most used robotic exoskeleton systems include
Saebo Mobile Arm Support (SaeboMAS), Haptic Master,
Hand Mentor Pro (HMP), Hand Mentor, and Myomo
mPower 100.13 Powered robotic exoskeletons have
recently been designed for gait rehabilitation in stroke. It
is strapped onto the legs and has electrical motors that
can control the joint movement to provide intensive
repetitive walking practice.14
Virtual and Augmented Reality
Virtual reality: Virtual reality (VR) is a computer-based
technology that creates a virtual, interactive,
motivational, and multi-sensory environment where
patients can interact and engage with computer-
generated activities.5 VR applications and games can
provide repetitive, intensive, and task-specific training,
essential elements of neuroplasticity.13 They include non-
immersive, semi-immersive, and immersive technologies
depending on the level of isolation of the user from the
surroundings during training.13 Various non-immersive
video games have been designed for home, making it a
widely available, safe, and affordable option for clinicians
and stroke patients.5
Augmented reality: Augmented reality (AR) allows users
to interact with computer-generated activities with real
objects.7 Compared to VR, which provides a virtual
experience, AR enhances the real environment with
images, sounds, or text through devices such as head-
mounted displays, smartphones, tablets, and AR glasses.7
An added advantage of AR is that it allows users to
practice occupations and skills safely in an appropriate
environment, eliminating real risks associated with them.9
Wearable Sensors
Wearable sensors detect the human body motion, assess
the movement, and provide immediate feedback to
patients for correction or modification of movement. The
sensors provide objective data even in the absence of a
therapist, potentially reducing diagnostic errors, which
helps clinicians customize therapy and make appropriate
adjustments. For example, EMG sensors providing muscle
activity data can be used to monitor stroke patients'
motor function, allowing customization of their
intervention. Kinect and Wii mote are commonly used
sensors in stroke rehabilitation.14
Smartphone and Tablets
Handheld devices such as smartphones and tablets are
beneficial for stroke survivors in home-based
rehabilitation programmes. Smartphone and tablet
applications are affordable, easy to use, and easily
accessible at home. Several applications have been
J Pak Med Assoc Open Access
A. N. Malik, H. Tariq, A. Afridi, et al 1673
Open Access Vol. 72, No. 8, August 2022
Technological advancements in stroke rehabilitation
1674
developed specifically for stroke patients, e.g.,
phonology-free application to help patients with aphasia
in communication and interaction.15
Clinical Implementation of Technology-
Based Stroke Rehabilitation
The new technologies have the potential to overcome the
shortcomings of conventional rehabilitation approaches
by providing intensive, repetitive, motivational, goal-
oriented massed practice required for cortical
reorganization. However, several barriers and limitations
hinder its implementation in regular clinical practice,
especially in developing countries like Pakistan. These
include lack of financial resources for equipment,
technical expertise and training, patient education, and
patient compliance. Additionally, not all technologies will
be compatible for individuals with cognitive impairments
and severe movement limitations. In Pakistan, it is also
important to consider the language barriers, especially for
illiterate individuals.
Conclusion
Emerging technologies in stroke rehabilitation offer
several advantages over conventional rehabilitation
approaches like high repetitions and intensity, task
specificity, objective feedback, increased user
engagement, and motivation. The clinicians should
consider the barriers and limitations associated with
technology before designing a stroke patient training
programme. Customized games and applications should
be designed to meet individual patient rehabilitation
needs and goals.
Acknowledgement: None.
Disclaimer: None.
Conflict of Interest: No conflict of interest
Funding Disclosure: No funding.
References
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  • Nov 2019
  • J NEUROENG REHABIL
Stroke is one of the main causes of long-term disability worldwide, placing a large burden on individuals and society. Rehabilitation after stroke consists of an iterative process involving assessments and specialized training, aspects often constrained by limited resources of healthcare centers. Wearable technology has the potential to objectively assess and monitor patients inside and outside clinical environments, enabling a more detailed evaluation of the impairment and allowing the individualization of rehabilitation therapies. The present review aims to provide an overview of wearable sensors used in stroke rehabilitation research, with a particular focus on the upper extremity. We summarize results obtained by current research using a variety of wearable sensors and use them to critically discuss challenges and opportunities in the ongoing effort towards reliable and accessible tools for stroke rehabilitation. Finally, suggestions concerning data acquisition and processing to guide future studies performed by clinicians and engineers alike are provided.
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Exercise Training Guidelines for Multiple Sclerosis, Stroke, and Parkinson Disease: Rapid Review and Synthesis
Article
Full-text available
  • Mar 2019
  • AM J PHYS MED REHAB
The translation of knowledge from exercise training research into the clinical management of multiple sclerosis (MS), stroke, and Parkinson's disease (PD) requires evidence-based guidelines that are uniformly recognizable by healthcare practitioners and patients/clients with these diseases. This paper synthesized resources that reported aerobic and resistance training guidelines for people with MS, stroke, and PD. Systematic searches yielded 25 eligible resources from electronic databases and websites or textbooks of major organizations. Data were extracted (exercise frequency, intensity, time, and type) and synthesized into recommendations per disease. Exercise guidelines for MS consistently recommended 2-3 days/week of aerobic training (10-30 minutes at moderate-intensity) and 2-3 days/week of resistance training (1-3 sets between 8-15 repetition maximum (RM)). Exercise guidelines for stroke recommended 3-5 days/week of aerobic training (20-40 minutes at moderate-intensity) and 2-3 days/week of resistance training (1-3 sets between 8-15 repetitions between 30-50% 1-RM). Exercise guidelines for PD recommended 3-5 days/week of aerobic training (20-60 minutes at moderate-intensity), and 2-3 days/week of resistance training (1-3 sets of 8-12 repetitions between 40-50% of 1-RM). This harmonization of exercise guidelines provides a prescriptive basis for healthcare providers, exercise professionals, and people with these diseases regarding disease-specific exercise programming.
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The effect of frequency of feedback on overground temporal gait asymmetry post stroke
Article
  • Jul 2021
  • TOP STROKE REHABIL
Background and objectives: Temporal gait asymmetry (TGA) affects 55% of people with stroke. This study investigated the effects of augmented feedback during overground gait training, on TGA. Methods: Eighteen people with chronic stroke were randomized to receive one of two feedback displays (A or B) and one of three feedback frequencies; no feedback (0%), after alternate walking trials (50%) or after every trial (100%). Display A depicted the TGA ratio as a vertical line along a horizontal axis with perfect symmetry in the middle. Display B depicted single limb stance duration of each leg as a bar graph. Participants completed 25 repetitions of 30 second trials with their assigned feedback (acquisition). Participants completed 10 repetitions of 30 second trials without feedback 24 hours later (retention). A pressure sensitive mat recorded TGA and speed. Changes in TGA and speed were investigated by plotting individual motor learning curves and fitting a curve with locally estimated scatterplot smoothing (LOESS) for each feedback group. An effect of feedback was defined a priori as a LOESS fitted curve with a decreasing slope from acquisition to retention. Results: LOESS curve exhibited a decreasing slope for TGA in the 100B group only and for speed in the 50A and 0FB groups. Discussion: This study provides preliminary evidence that visual feedback delivered at a high frequency during a single session of overground walking can change TGA post-stroke without reducing gait speed. An overground gait intervention with high frequency visual feedback to improve TGA post-stroke is worthwhile to investigate.
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The State of Stroke Services across the Globe: Report of World Stroke Organization-World Health Organization Surveys
Article
  • May 2021
Background: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization (WSO)-World Health Organisation (WHO)-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle income countries (LMICs) compared to high income countries (HICs). Methods: Using a validated WSO comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across WHO regions and economic strata. The WHO also conducted a survey of non-communicable diseases in 194 countries in 2019. Results: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys and participation in research) were reported in low-income countries (LICs) than HICs. The overall global score for prevention was 40.2%. Stroke units were present in 91% of HICs in contrast to 18% of LICs (p<0.001). Acute stroke treatments were offered in ~60% of HICs compared to 26% of LICs (p=0.009). Compared to HICs, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. Conclusions: There is an urgent need to improve stroke services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.
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Task-oriented training and exer-gaming for improving mobility after stroke: A randomized trial
Article
  • Oct 2020
  • J Pakistan Med Assoc
Objective: To evaluate the effects of task-oriented training and to compare it with virtual reality training on the mobility, physical performance and balance in stroke patients. Methods: The randomised controlled trial was conducted from January 2016 to March 2017 at the Physical Rehabilitation Department of Pakistan Railways General Hospital, Rawalpindi, Pakistan, and comprised patients 40-70 years with stroke history of at least 3 months who had the ability to stand unaided. The subjects were randomised into virtual reality training group A and task-oriented training group B. Task oriented training was provided for 3 days per week over 8 weeks to both groups with each session lasting 40-45 minutes, while additional 15-20 minutes of exer-gaming was provided only to group A. Fugl-Meyer Assessment-Lower Extremity, Berg Balance Test, Timed Up and Go Test and Dynamic Gait Index were used for assessment which was done at baseline, and at 2, 4, 6 and 8 weeks of training. Data was analysed using SPSS 21. Results: Of the 52 subjects, there were 26(50%) in each of the two groups. The overall sample had 36(69.2%) males and 16(30.7%) females. Group A showed significant difference in Fugl-Meyer Assessment-Lower Extremity and Berg Balance Test scores at 04 weeks of training compared to group B (p<0.05). Timed Up and Go Test significantly improved in group A at 6 weeks (p<0.05). Both groups showed significant improvement in Dynamic Gait Index after 8 weeks of training (p>0.05). Conclusions: Virtual reality combined with task-oriented training improved the physical performance, mobility and balance outcome in stroke patients. However, virtual reality and task-oriented trainings had similar effect on gait performance of the patients.
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The use of augmented reality for rehabilitation after stroke: a narrative review
Article
  • Jul 2020
Purpose To explore research relating to the use of Augmented Reality (AR) technology for rehabilitation after stroke in order to better understand the current, and potential future application of this technology to enhance stroke rehabilitation. Methods Database searches and reference list screening were conducted to identify studies relating to the use of AR for stroke rehabilitation. These studies were then reviewed and summarised. Results Eighteen studies were identified where AR was used for upper or lower limb rehabilitation following stroke. The findings of these studies indicate the technology is in the early stages of development and application. No clear definition of AR was established, with some confusion between virtual and augmented reality identified. Most AR systems engaged users in rote exercises which lacked an occupational focus and contextual relevance. User experience was mostly positive, however the poor quality of the studies limits generalisability of these findings to the greater stroke survivor population. Conclusion AR systems are currently being used for stroke rehabilitation in a variety of ways however the technology is in its infancy and warrants further investigation. A consistent definition of AR must be developed and further research is required to determine the possibilities of using AR to promote practice of occupations in a more contextually relevant environment to enhance motor learning and generalisation to other tasks. This could include using AR to bring the home environment into the hospital setting to enhance practice of prioritised occupations before returning home. • IMPLICATIONS FOR REHABILITATION • There is a developing body of evidence evaluating the use of various forms of AR technology for stroke rehabilitation. • User motivation and engagement in rehabilitation may improve with the use of AR. • A clear and consistent definition for AR must be developed. • Ongoing work could explore how AR systems support engagement in, and promote motor learning that links to, meaningful occupations.
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Exploring serious games for stroke rehabilitation: a scoping review
Article
  • Jun 2020
Aims and Objectives: Stroke is the main cause of long-term disabilit and happens mostly in the older population. Stroke affected patients experience either of the cognitive, visual or motor losses and recovery requires time and patience as they have to do physical exercises every day and at times repetitively. There are various types of stroke rehabilitation exercises focussing on technological solutions that include therapies performed using games. Motion-based games are popular in encouraging participants to perform repetitive tasks without being getting bored. Therefore, in this study, we have explored studies that included the use of games for stroke rehabilitation to understand the design principles and characteristics of the games used for these purposes. Method: A number of medical respositories were searched for relevant articles in a window of 2008-2018. 18 studies were chosen for the scoping review depending on the inclusion criteria, and design principles used in these studies are analysed and evaluated. Results and Conclusion: We present main findings from our review concerning the attributes of existing games for stroke rehabilitation such as meaningful play, handling of failures, emphasising challenge, and the value of feedback. We conclude with a list of design recommendations that future serious game developers can consider while designing interfaces for stroke patients. • Implications for Rehabilitation • This review exhibits that the usage of gaming technologies is a very effective interactive mechanism for stroke based rehabilitation. • Further our review also shows that serious games provide an avenue and opportunity for customized and highly contextualized gameplay • Our review also suggests that effective features to incorporate into serious games for rehabilitation includes; facilitating challenge and recovery from errors.
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