Clinical potential and neuroplastic effect of targeted virtual reality based intervention for distal upper limb in post-stroke rehabilitation: a pilot observational study

Abstract

Purpose

A library of Virtual Reality (VR) tasks has been developed for targeted post-stroke rehabilitation of distal upper extremities. The objective of this pilot study was to evaluate the clinical potential of the targeted VR-based therapeutic intervention in a small cohort of patients specifically with chronic stroke. Furthermore, our aim was to explore the possible neuronal reorganizations in corticospinal pathways in response to the distal upper limb targeted VR-intervention.

Methodology

Five patients with chronic stroke were enrolled in this study and were given VR-intervention of 20 sessions of 45 min each. Clinical Scales, cortical-excitability measures (using Transcranial Magnetic Stimulation): Resting Motor Threshold (RMT), and Motor Evoked Potential (MEP) amplitude, task-specific performance metrics i.e., Time taken to complete the task (TCT), smoothness of trajectory, relative % error were evaluated pre- and post-intervention to evaluate the intervention-induced improvements.

Results

Pre-to post-intervention improvements were observed in Fugl-Meyer Assessment (both total and wrist/hand component), Modified Barthel Index, Stroke Impact Scale, Motor Assessment Scale, active range of motion at wrist, and task-specific outcome metrics. Pre-to post-intervention ipsilesional RMT reduced (mean ∼9%) and MEP amplitude increased (mean ∼29µV), indicating increased cortical excitability at post-intervention.

Conclusion

VR-training exhibited improved motor outcomes and cortical-excitability in patients with stroke. Neurophysiological changes observed in terms of improved cortical-excitability might be a consequence of plastic reorganization induced by VR-intervention.

IMPLICATIONS FOR REHABILITATION

• Post-stroke rehabilitation of distal upper extremities is crucial and needs targeted intervention to rehabilitate in the chronic phase of recovery.

• Virtual reality (VR) has emerged as a supplemental approach in post-stroke rehabilitation. However, its customization as per clinical need is still under research.

• This pilot study provides preliminary evidence of the clinical utility of the developed VR tasks targeted for distal upper extremities.

Keywords:

• Stroke
• virtual reality
• rehabilitation
• neuroplasticity
• distal upper limb
• cortical excitability

Acknowledgments

The authors would like to express sincere gratitude to the patients who agreed to participate in this study.

Informed consent statement

Written informed consent was obtained from all the patients participated in this study.

Institutional review board statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (IRB) at All India Institute of Medical Science (AIIMS), New Delhi, India, under protocol number IEC-229/11.4.2020.

Author contributions

A.M., N.S. and D.N. conceptualized and designed the study. A.M. and N.S. led the study, provided the scientific inputs, and reviewed the multiple iterations of the manuscript with D.N. D.N. performed a literature survey, developed the VR tasks, performed VR intervention, data analysis, data interpretation, and wrote the manuscript. M.S. and O.B. performed patient recruitment and clinical assessments. N.K. and M.V.P.S. provided clinical support and resources for experiments. All authors have read and agreed to the final version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets used in this study are available from the corresponding author on reasonable request.

Additional information

Funding

This research was funded by Indian Council of Medical Research (ICMR) of the Government of India [55/4/1/CARE-Disability & AT/2020/NCD-II] and Abdul Kalam Technology Innovation National Fellowship by Indian National Academy of Engineering [INAE/121/AKF/38]. Debasish Nath was supported with research fellowship from the Ministry of Human Resource and Development (MHRD), Government of India.