Domiciliary VR-Based Therapy for Functional Recovery and Cortical Reorganization: Randomized Controlled Trial in Participants at the Chronic Stage Post Stroke

Abstract

BackgroundMost stroke survivors continue to experience motor impairments even after hospital discharge. Virtual reality-based techniques have shown potential for rehabilitative training of these motor impairments. Here we assess the impact of at-home VR-based motor training on functional motor recovery, corticospinal excitability and cortical reorganization.ObjectiveThe aim of this study was to identify the effects of home-based VR-based motor rehabilitation on (1) cortical reorganization, (2) corticospinal tract, and (3) functional recovery after stroke in comparison to home-based occupational therapy.MethodsWe conducted a parallel-group, controlled trial to compare the effectiveness of domiciliary VR-based therapy with occupational therapy in inducing motor recovery of the upper extremities. A total of 35 participants with chronic stroke underwent 3 weeks of home-based treatment. A group of subjects was trained using a VR-based system for motor rehabilitation, while the control group followed a conventional therapy. Motor function was evaluated at baseline, after the intervention, and at 12-weeks follow-up. In a subgroup of subjects, we used Navigated Brain Stimulation (NBS) procedures to measure the effect of the interventions on corticospinal excitability and cortical reorganization.ResultsResults from the system’s recordings and clinical evaluation showed significantly greater functional recovery for the experimental group when compared with the control group (1.53, SD 2.4 in Chedoke Arm and Hand Activity Inventory). However, functional improvements did not reach clinical significance. After the therapy, physiological measures obtained from a subgroup of subjects revealed an increased corticospinal excitability for distal muscles driven by the pathological hemisphere, that is, abductor pollicis brevis. We also observed a displacement of the centroid of the cortical map for each tested muscle in the damaged hemisphere, which strongly correlated with improvements in clinical scales.ConclusionsThese findings suggest that, in chronic stages, remote delivery of customized VR-based motor training promotes functional gains that are accompanied by neuroplastic changes.Trial RegistrationInternational Standard Randomized Controlled Trial Number NCT02699398 (Archived by ClinicalTrials.gov at https://clinicaltrials.gov/ct2/show/NCT02699398?term=NCT02699398&rank=1)

Adaptive conjunctive cognitive training (ACCT) in virtual reality for chronic stroke patients: a randomized controlled pilot trial

“…The data generated through the interaction with the system was automatically stored in a remote secured database at the experimenter's institution. RGS has been validated in several clinical studies to be effective in functional motor recovery [32,44,64,67]. With this pilot study, we extended the RGS framework of embodied training, where the patient controls a virtual avatar on a computer screen, with conjunctive cognitive training scenarios which we call ACCT.…”

“…It is also the primary rationale behind the Rehabilitation Gaming System (RGS) [41,42], a VR rehabilitation tool on which the development of the training program presented here is based. RGS promotes functional recovery at all stages post-stroke [43] and cortical reorganization [44] through an integrated approach that combines action execution and observation [45] with goal-oriented integrated tasks. In RGS the patient controls an avatar on a computer screen and observes the avatar's movement from a firstperson perspective.…”

“…However, the exact relationship between adherence and motivation as well as the factors which in turn define and affect internal states need to be investigated. Ultimately, VRbased systems are apt to increase training time and intensity and can extend the training to the patient's home after discharge from the hospital [44], as they operate in an automated fashion, require less personnel, and are more cost-effective than traditional rehabilitation methods [52]. It is, therefore, worthwhile to investigate the effectiveness of science and evidence-based VR systems for cognitive recovery as they can overcome current limitations in cognitive rehabilitation, such as labour-intensiveness, isolated treatment of cognitive deficits and missing knowledge of the active ingredients in treatments [14].…”

Revealing an extended critical window of recovery post-stroke

“…This work builds on previous research conducted with the RGS, a VR-based tool that promotes functional recovery post-stroke through goal-oriented embodied sensorimotor stimulation. A number of studies suggest the effectivity of RGS protocols for overcoming upper limb motor deficits (Cameirão et al, 2012 da Silva Cameirão et al, 2011; Ballester et al, 2016, 2015, 2017). These protocols rest on principles that are derived from the Distributed Adaptive Control theory of mind and brain (Verschure, 2012), which places recovery in the context of the acquisition and expression of goal-oriented voluntary behavior driven by perception, memory, value and goals and the optimization of perceptual and behavioral prediction.…”

Safety, Feasibility, and Acceptability of a New Virtual Rehabilitation Platform: A Supervised Pilot Study

“…12,22 Moderate improvement in motor skills have been reported in chronic stroke patients who were administered high-intensity therapy. [23][24][25][26][27] In countries with weak health systems, stroke survivors rarely receive therapy with the opportunity and frequency necessary to obtain the best possible recovery. This is due to the saturation of rehabilitation centers, a shortage of specialized therapists, and the socioeconomic situation of patients which makes it difficult for them to attend their appointments.…”