Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial

Turolla et al. Journal of NeuroEngineering and Rehabilitation 2013, 10:85 http://www.jneuroengrehab.com/content/10/1/85 JNER RESEARCH JOURNAL OF NEUROENGINEERING AND REHABILITATION Open Access Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial Andrea Turolla1*, Mauro Dam1, Laura Ventura2, Paolo Tonin1, Michela Agostini1, Carla Zucconi1, Pawel Kiper1, Annachiara Cagnin1,3 and Lamberto Piron1 Abstract Background: Recent evidence has demonstrated the efficacy of Virtual Reality (VR) for stroke rehabilitation nonetheless its benefits and limitations in large population of patients have not yet been studied. Objectives: To evaluate the effectiveness of non-immersive VR treatment for the restoration of the upper limb motor function and its impact on the activities of daily living capacities in post-stroke patients. Methods: A pragmatic clinical trial was conducted among post-stroke patients admitted to our rehabilitation hospital. We enrolled 376 subjects who had a motor arm subscore on the Italian version of the National Institutes of Health Stroke Scale (It-NIHSS) between 1 and 3 and without severe neuropsychological impairments interfering with recovery. Patients were allocated to two treatments groups, receiving combined VR and upper limb conventional (ULC) therapy or ULC therapy alone. The treatment programs consisted of 2 hours of daily therapy, delivered 5 days per week, for 4 weeks. The outcome measures were the Fugl-Meyer Upper Extremity (F-M UE) and Functional Independence Measure (FIM) scales. Results: Both treatments significantly improved F-M UE and FIM scores, but the improvement obtained with VR rehabilitation was significantly greater than that achieved with ULC therapy alone. The estimated effect size of the minimal difference between groups in F-M UE and FIM scores was 2.5 ± 0.5 (P < 0.001) pts and 3.2 ± 1.2 (P = 0.007) pts, respectively. Conclusions: VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities. Trial registration: Italian Ministry of Health IRCCS Research Programme 2590412 Keywords: Stroke, Upper limb, Exercise therapy, Virtual reality, Motor recovery, Treatment outcome Background Stroke is a disorder associated with long term disability and is more common in older people [1]. The symptoms of stroke such as cognitive, motor and emotional sequalae often impact on a person’s level of independence and quality of life [2]. The purpose of neurological rehabilitation is to promote a rapid recovery from the manifold post-stroke deficits and the attainment of a lifestyle, as close as possible to the pre-morbid state [3]. * Correspondence: 1 I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy Full list of author information is available at the end of the article A large body of evidence has demonstrated that the location of the stroke lesion is strictly related to the severity of motor function impairment affecting the upper limb, thus the involvement of deep anatomical structures (i.e. corona radiata, internal capsule) is related to poorer outcomes of motor function recovery [4,5]. A recent study reported that impairment of the upper limb motor function is present in more than 80% of all stroke patients, with 30% to 40% regaining some dexterity after six months [6]. Nevertheless, the upper limb remain not functional in performing activities of daily living (ADL) in up to 66% of all stroke patients [7], representing the most disabling of all the residual impairments. © 2013 Turolla et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Turolla et al. Journal of NeuroEngineering and Rehabilitation 2013, 10:85 http://www.jneuroengrehab.com/content/10/1/85 Page 2 of 9 New scientifically based treatments have considerably increased the repertoire of therapeutic and rehabilitative strategies. Such treatments include pharmacological interventions [8,9], constraint induced movement therapy [10], treadmill training with partial body weight support [11,12], robotic-assisted therapy [13], and Virtual Reality (VR) based interventions [14,15]. Studies in computational neuroscience have demonstrated that VR technology, providing enhanced feedback about movement characteristics, improved motor task learning and execution in healthy subjects, as compared with traditional training [16-19]. Exploiting these VR features, several authors have used VR based therapy aimed at relearning motor function in post-stroke patients. A recent Cochrane review [15], assessed the effect of VR treatment on recovery of motor, gait, balance, cognitive functions and ADL in stroke patients. The conclusion was that, despite encouraging results, strong evidence of better effects in favour of VR therapy compared to conventional therapy is still lacking. However, when considering only the upper limb treatment, all the studies included in the review indicated that the VR approach yielded better motor and functional outcomes than conventional therapy. Despite this assertion, the review identified the relatively small sample size of the studies included as one of the limitations for establishing stronger evidence. The aim of this pragmatic clinical trial [20] was to further evaluate the effectiveness of VR based treatment, when provided in a routine hospital care setting, in restoring upper limb motor function and ADL capacities in a large number of post- stroke patients. Moreover, the influence of the severity of motor impairment and the distance between stroke onset and the start of the rehabilitation treatment (Stroke to Rehabilitation Interval – SRI) on motor and functional outcomes was also investigated. patients. CT/MRI scan demonstrated different combinations of brain lesions, i.e. large damage involving most of the vascular territory of the MCA or more discrete lesions of the cortical and/or subcortical areas supplied by branches of the MCA. Moreover, the patients included in the study were those with a Motor Arm sub-score between 1 and 3 on the Italian version of the National Institutes of Health Stroke Scale (It-NIHSS) [22]. This score was considered as a reliable criterion for assessing the maintenance of residual voluntary motor activation. The following conditions were considered as exclusion criteria: the presence of a moderate cognitive decline defined as a Mini Mental State Examination [23] score < 20/ 30 points; the finding of severe verbal comprehension deficit defined as a number of errors > 13 (Tau Points < 58/ 78) on the Token Test [24]; evidence of apraxia and neglect interfering with upper ar (...truncated)