Intensive virtual reality-based training for upper limb motor function in chronic stroke: a feasibility study using a single case experimental design and fMRI

Abstract

Purpose: To evaluate feasibility and neurophysiological changes after virtual reality (VR)-based training of upper limb (UL) movements. Method: Single-case A-B-A-design with two male stroke patients (P1:67 y and 50 y, 3.5 and 3 y after onset) with UL motor impairments, 45-min therapy sessions 5×/week over 4 weeks. Patients facing screen, used bimanual data gloves to control virtual arms. Three applications trained bimanual reaching, grasping, hand opening. Assessments during 2-week baseline, weekly during intervention, at 3-month follow-up (FU): Goal Attainment Scale (GAS), Chedoke Arm and Hand Activity Inventory (CAHAI), Chedoke-McMaster Stroke Assessment (CMSA), Extended Barthel Index (EBI), Motor Activity Log (MAL). Functional magnetic resonance imaging scans (FMRI) before, immediately after treatment and at FU. Results: P1 executed 5478 grasps (paretic arm). Improvements in CAHAI (+4) were maintained at FU. GAS changed to +1 post-test and +2 at FU. P2 executed 9835 grasps (paretic arm). CAHAI improvements (+13) were maintained at FU. GAS scores changed to −1 post-test and +1 at FU. MAL scores changed from 3.7 at pre-test to 5.5 post-test and 3.3 at FU. Conclusion: The VR-based intervention was feasible, safe, and intense. Adjustable application settings maintained training challenge and patient motivation. ADL-relevant UL functional improvements persisted at FU and were related to changed cortical activation patterns.

Implications for Rehabilitation

• YouGrabber trains uni- and bimanual upper motor function. Its application is feasible, safe, and intense.

• The control of the virtual arms can be done in three main ways: (a) normal (b) virtual mirror therapy, or (c) virtual following. The mirroring feature provides an illusion of affected limb movements during the period when the affected upper limb (UL) is resting.

• The YouGrabber training led to ADL-relevant UL functional improvements that were still assessable 12 weeks after intervention finalization and were related to changed cortical activation patterns.

• Motor function
• stroke
• upper limb
• virtual reality

Acknowledgements

We are grateful to our patients and would like to thank them for their time and effort in participating in the study.

Declaration of interest

Some of the authors (L. H., E. C., P. P., D. K., K. E.) have a commercial interest related to the VR system evaluated in this publication. For the remaining authors none conflicts of interest were declared. The study was partially funded by the Swiss National Centre of Competence in Research (NCCR) and the Gebert Ruef Foundation. Preliminary results were presented in a poster format at the 14th Congress of the European Federation of Neurological Societies in Geneva 2010 and at the 16th WCPT World Physical Therapy Congress in Amsterdam 2011.