Haptics in Stroke Rehabilitation

Original Editor - Rochelle Dsouza Top Contributors - Rochelle Dsouza and Ahmet Begde

Introduction[edit | edit source]

Stroke is one of the leading causes of disability that results in minor to severe impairments. Post-stroke sequelae comprise impairments such as loss of range of motion, muscle weakness and motor deficits resulting from impaired force generation[1]. The most common impairment after stroke is reduced hand function, strongly affecting the power to perform daily activities[2][3]. Neurorehabilitation attempts to reduce motor impairments after stroke [4]. It has been found that patients exhibit poor compliance with conventional physiotherapy techniques (CPT) due to their inherent monotony[5]. Owing to such limitations, a technology-aided, experience-enhancing intervention like virtual reality (VR) has garnered interest in the past decade[5][6].VR-based stroke rehabilitation promotes function by providing immediate, appropriate and accurate feedback through audio-visual cues[7][8] [9]. Although there is extensive evidence supporting the use of VR in the functional recovery of stroke patients, the inclusion of haptic feedback is poorly studied [10].

Background[edit | edit source]

Contextually, the word "haptic" is derived from the Greek verb “to touch” or "to handle". Presently, it refers to the expanding subject that is associated with the study of touch through human-computer interaction [11]. The recently emerged haptic technology has developed rapidly and has been the focal point of many research communities. Subsequently, haptic-related products have been deployed commercially, in development, and for research purposes, as well as serving as prototypes. Virtual environments are strongly associated with haptic-based applications. Such environments require the visual sensory channel to produce more realistic sensations[12]. VR simulations, can provide an engaging, realistic and motivating environment when linked with robots, movement tracking, and sensing glove systems, where the motion of the limb or tool displayed in the virtual world is a replication of the motion produced in the real world by the subject[8][7].

Theoretical Framework[edit | edit source]

Various virtual reality systems have been studied with different Haptic devices employed to restore hand function post-stroke. These devices increase immersion through the application of vibrotactile stimulation with kinaesthetic feedback[8]. This multi-modal feedback has been proposed to improve strength, motor control, and dexterity in integration with the repetitive practice of relevant motor tasks through the mechanism of neuroplasticity[6][13][14][15].

The Sensory side of Motor rehabilitation[edit | edit source]

  • One of the most relevant sources of sensory information for the motor system is Somesthesis[16]. The somatosensory system processes information and represents, several modalities of somatic sensation (i.e., touch, pain, temperature, proprioception). However, significant processing occurs even in the motor system.
  • A good example of the functional interplay between somatosensory and motor systems is the gating of sensory input for motor control. Sensory gating is exerted by integrating afferent somatosensory inputs from peripheral receptors with the motor output at several levels in the ascending sensory pathway and the cerebral cortex, consistent with serial transmission of afferent sensory activity from the spinal cord to the primary somatosensory cortex(SI), and then to primary motor cortex (MI)[16][17][18].
  • Various forms of somatosensory stimulation such as peripheral nerve stimulation, muscle-tendon vibration, paired associative stimulation and tactile learning have been shown to facilitate motor behaviour and enhance motor performance by increasing corticospinal excitability and enlarging the representation of the stimulated body part in MI[19] [20].

Relevance to Physiotherapy in Stroke Rehabilitation[edit | edit source]

Rehabilitation is an integral component of any program aimed at improving motor function in people with stroke [21] [22]. To overcome the benefits of conventional rehabilitation, novel strategies are becoming available[23]. The use of haptics interfaced with VR environments is becoming a common approach as they allow for high-intensity, high-dosage and repetitive exercise which facilitates motor learning[24]. After a stroke, motor treatment might be provided more precisely and effectively than conventional treatment approaches by using a variety of technologies such as robotics, VR and sensor-based devices [10]. In the present literature review, we found case studies and a crossover RCT. There was a significant improvement in fine motor performance[6]. Studies also showed that haptic assisted therapy significantly improved the upper limb performance in people with stroke [12][13][14][15]. Levin M F et al (2006)[12] conducted a case series to determine the efficacy of a haptic-enhanced Virtual Reality system for acquiring precision grasp. In this study, twelve subjects with chronic hemiparesis participated in a single 45 min session in which they reached and grasped 3 objects with their hemiparetic arm using the Cyberglove™ and Cybergrasp™ system for haptic feedback.

A qualitative study was carried out by Lehmann I et al (2017)[13]. In this study, five-stroke patients were interviewed over four weeks while undergoing training with the YouGrabber™ (YG) system. Considerable improvements were seen in the outcomes which evaluated the experience of YG training, perceived impact of YG training on arm function, and the role of the treating therapist. Similarly, Maris A et al (2018)[14] conducted a case series to evaluate the impact of robot-mediated adaptive I-TRAVLE training on impaired upper limb function in chronic stroke. In this case series, fourteen chronic stroke patients performed 36 sessions of 30 min duration each using the I-TRAVLE™ system. The outcomes assessed were Active shoulder ROM, handgrip strength, strength and WMFT activities. Substantial improvements were seen in muscle strength after the intervention. A crossover randomised trial by Thielbar KO et al (2019)[15]to determine the effectiveness of a home-based upper extremity stroke therapy using a multi-user virtual reality environment also showed significant improvements in upper limb functions. Twenty patients with chronic stroke were given 4 weeks of in-home treatment for 1 hour each day, using the VERGE™ system for both single and multiuser applications. The outcomes assessed were Arm displacement using Kinect skeleton data within VERGE, Fugl-Meyer Upper Extremity (FMUE). Significant improvements were seen in both the outcome measures.

References[edit | edit source]

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  2. Pérez‐Cruzado D, Merchán‐Baeza JA, González‐Sánchez M, Cuesta‐Vargas AI. Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors. Australian occupational therapy journal. 2017 Apr;64(2):91-112.
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