Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy
Abstract
:1. Introduction
- (a)
- the access in a safe environment to real-life situations, otherwise inaccessible to patients due to cognitive, motor and psychological limitations
- (b)
- the possibility to alter the exercises, to emphasize specific movements during patient execution, thus becoming more comfortable to perform,
- (c)
- the unique and personalized character of the exercises from one patient to another [19].
2. Materials and Methods
2.1. Study Design
2.2. Participants
- (1)
- stroke survivors after the subacute phase, at least six months post-stroke [27], and less than four years. This time frame is the best choice for functional rehabilitation and patients inside this frame time have the best status for rehabilitation, especially VR (stroke survivors with poor rehabilitation have spasticity, stiffness, tissue retraction, joint misalignments over more than four years of stroke that prevent the application of new techniques as VR and MT)
- (2)
- assessment criteria: at least 20-degree hip flexion and 10 degrees hip abduction against gravity, and at least 30-degree knee flexion against gravity.
2.3. Outcome Measures
2.4. Procedures
2.4.1. Virtual Reality Software, Device and Exergames
- (a)
- Assess AROM with a goniometer, assess MAS, MRS, FIM, FMLE and FRT
- (b)
- Assess AROM through Kinect sensor and MIRA software
- (c)
- Establish the limits of ROM performed during exergames based on the AROM assessment
- (d)
- Establish the level of technology tolerance to motion pattern and correctness (the adjustment of the tolerance levels for motion from 0 to 100%. The lower the tolerance, the higher the software’s feedback on the correctness of movement, warning the patient that he/she is not performing the task accurately). The lower level of tolerance used in our research was set to 20%, according to the manufacturer’s recommendations, excepting the first two VR sessions, when the tolerance level was set to 50% to encourage the patient and to accustom him with the technology.
- (e)
- Assigning the patient’s protocol of exergames by the results obtained from the assessments
- (i)
- The most comfortable types of exergames, for patients with only 20 degrees of hip flexion, MMT 2–3, 10 degrees of hip abduction and 30 degrees of knee flexion.
- (ii)
- The medium types of exercises, for patients with 25–60 degrees of hip flexion, 10–20 degrees of hip abduction, MMT 3, and 30–60 degrees of knee flexion.
- (iii)
- The intense level of exergames, for patients with 60–90 degrees of hip flexion, and 20–30 degrees of hip abduction, MMT-4, and 60–90 degrees of knee flexion.
2.4.2. Mirror Therapy Exercises
2.5. Statistical Analysis
3. Results
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Types of Interventions | Experimental Group | Control Group | Minutes of Therapy |
---|---|---|---|
Passive analytical exercises for each LE joint | No | Yes | 10 |
Prone or supine active analytical exercises for LE joint | No | Yes | 20 |
Active LE exercises from standing position, and proprioception | No | Yes | 20 |
Active ergometer bicycle | Yes | Yes | 10 |
Treadmill | Yes | Yes | 10 |
VR exercises | Yes | No | 32 ± 5 |
MT exercises for ankle | Yes | No | 18 ± 5 |
Total time of physiotherapy exercises (minutes) | 70 | 70 | 70 |
Characteristic | Experimental (n = 31) | Control (n = 28) | p |
---|---|---|---|
Affected side (left/right) | 16/15 | 8/20 | 0.074 |
Hemorrhagic/Ischemic stroke | 18/13 | 13/15 | 0.821 |
Gender (male/female) | 7/24 | 8/20 | 0.601 |
Age (mean/SD) | 59.03/10.12 | 60.67/8.17 | 0.767 |
Post-stroke Time (mean/SD) | 2.74/1.10 | 2.71/0.99 | 0.456 |
Mean (minutes)/SD VR Duration | 22.16/4.01 | 0 | 0.317 |
Total Physiotherapy Duration (minutes) | 70 | 70 | 1.00 |
ROM | MMT | |||||||
---|---|---|---|---|---|---|---|---|
Pre-Therapy | Post-Therapy | Pre-Therapy | Post-Therapy | |||||
Median (IR) | Median (IR) | p | Cohen’s d | Median (IR) | Median (IR) | p | Cohen’s d | |
Hip Flexion | 85.00 (5.00) | 90.00 (10.00) | 0.000 | 0.601 | 3.50 (0.75) | 3.75 (0.75) | 0.000 | 0.538 |
Hip Extension | 10.00 (5.00) | 10.00 (5.00) | 0.000 | 0.833 | 3.25 (0.50) | 3.50 (0.75) | 0.000 | 0.834 |
Hip Abduction | 30.00 (15.00) | 35.00 (10.00) | 0.000 | 0.853 | 3.25 (0.75) | 3.50 (0.75) | 0.000 | 0.718 |
Hip Adduction | 0/0 | 0 | 0.083 | 0.090 | 3.25 (0.50) | 3.50 (0.75) | 0.000 | 0.574 |
Hip Internal Rotation | 10.00 (10.00) | 10.00 (15.00) | 0.002 | 0.317 | 2.00 (1.75) | 2.50 (2.00) | 0.001 | 0.204 |
Hip External Rotation | 25.00 (15.00) | 25.00 (20.00) | 0.000 | 0.349 | 2.75 (0.75) | 3.00 (0.75) | 0.011 | 0.256 |
Knee Flexion | 80.00 (15.00) | 90.00 (15.00) | 0.000 | 0.443 | 3.25 (1.00) | 3.25 (0.50) | 0.000 | 0.573 |
Knee extension | 0 | 0 | 1.000 | NA | 3.50 (0.75) | 3.75 (0.50) | 0.000 | 0.536 |
Dorsiflexion | 15.00 (10.00) | 20.00 (12.00) | 0.000 | 0.468 | 2.75 (1.25) | 3.00 (1.25) | 0.000 | 0.302 |
Plantarflexion | 10.00 (15.00) | 15.00 (17.00) | 0.000 | 0.436 | 3.00 (2.00) | 3.00 (1.25) | 0.000 | 0.295 |
Inversion | 10.00 (24.00) | 10.00 (25.00) | 0.002 | 0.182 | 2.00 (1.75) | 2.00 (2.00) | 0.007 | 0.134 |
Eversion | 6.00 (20.00) | 10.00 (25.00) | 0.001 | 0.209 | 1.75 (2.00) | 2.00 (1.75) | 0.002 | 0.238 |
ROM | MMT | |||||||
---|---|---|---|---|---|---|---|---|
Pre-Therapy | Post-Therapy | Pre-Therapy | Post-Therapy | |||||
Median (IR) | Median (IR) | p | Cohen’s d | Median (IR) | Median (IR) | p | Cohen’s d | |
Hip Flexion | 83.00 (27.50) | 90.00 (13.75) | 0.011 | 0.324 | 3.25 (0.50) | 3.50 (0.50) | 0.000 | 0.521 |
Hip Extension | 5.00 (5.00) | 10.00 (5.00) | 0.010 | 0.419 | 3.25 (0.44) | 3.50 (0.75) | 0.001 | 0.456 |
Hip Abduction | 22.50 (10.00) | 27.50 (9.25) | 0.045 | 0.382 | 3.12 (0.50) | 3.25 (0.75) | 0.001 | 0.458 |
Hip Adduction | 0.00 (0.00) | 0.00 (0.00) | 1.000 | NA | 3.00 (0.44) | 3.25 (0.75) | 0.006 | 0.436 |
Hip Internal Rotation | 10.00 (13.75) | 12.50 (12.25) | 0.052 | 0.250 | 2.75 (1.19) | 2.87 (0.75) | 0.001 | 0.354 |
Hip External Rotation | 15.00 (16.25) | 20.00 (13.75) | 0.006 | 0.144 | 2.50 (0.94) | 2.50 (0.94) | 0.025 | 0.064 |
Knee Flexion | 75.00 (35.00) | 80.00 (25.00) | 0.000 | 0.337 | 3.00 (0.25) | 3.50 (0.44) | 0.000 | 0.814 |
Knee extension | 0 | 0 | 1.000 | NA | 3.25 (0.50) | 3.50 (0.69) | 0.000 | 0.681 |
Dorsiflexion | 15.00 (9.50) | 15.00 (25.00) | 0.005 | 0.449 | 3.00 (1.13) | 3.00 (1.19) | 0.133 | 0.111 |
Plantarflexion | 20.00 (15.00) | 20.00 (13.75) | 0.630 | 0.057 | 3.00 (1.31) | 3.00 (1.63) | 0.283 | 0.131 |
Inversion | 15.00 (10.00) | 20.00 (25.00) | 0.002 | 0.325 | 2.12 (1.44) | 2.12 (1.48) | 0.059 | 0.050 |
Eversion | 6.00 (10.00) | 10.00 (18.25) | 0.000 | 0.451 | 2.12 (1.75) | 2.12 (1.80) | 0.265 | 0.018 |
Experimental Group | Control Group | |||||||
---|---|---|---|---|---|---|---|---|
Pre-Therapy | Post-Therapy | Pre-Therapy | Post-Therapy | |||||
Median (IR) | Median (IR) | p | Cohen’s d | Median (IR) | Median (IR) | p | Cohen’s d | |
ROM (mean) | 39.17 (5.42) | 42.92 (7.42) | <0.001 | 0.645 | 37.71 (7.40) | 38.83 (8.56) | <0.001 | 0.504 |
MMT (mean) | 2.89 (1.02) | 3.05 (0.81) | <0.001 | 0.533 | 2.86 (0.73) | 3.07 (0.81) | <0.001 | 0.324 |
MAS | 2.00 (2.00) | 2.00 (2.00) | 0.157 | −0.049 | 1.00 (1.00) | 1.00 (1.00) | 1.000 | 0.00 |
MRS | 2.00 (1.00) | 2.00 (1.00) | 1.000 | 0.00 | 2.00 (0.75) | 2.00 (0.75) | 1.000 | 0 |
Motor FMLE | 24.00 (6.00) | 27.00 (7.00) | 0.000 | 0.685 | 24.50(6.75) | 25.5 (6.50) | 0.000 | 0.254 |
Passive FMLE | 17.00 (5.00) | 20.00 (2.00) | 0.136 | 0.466 | 17.50 (3.75) | 18.00 (3.75) | 0.034 | 0.121 |
Pain FMLE | 20.00 (0.00) | 20.00 (0.00) | 0.020 | 0.212 | 20.00 (4.50) | 20.00 (3.00) | 0.063 | 0.157 |
FIM | 114.00 (13.00) | 114.00 (13.00) | 1.000 | 0 | 121.00 (15.75) | 121.00 (15.75) | 0.157 | 0.010 |
TUG | 2.00 (0.00) | 2.00 (1.00) | 0.083 | 0.011 | 2.00 (0.00) | 2.00 (0.00) | 0.317 | 0.075 |
FRT | 25.00 (8.00) | 27.00 (5.30) | 0.000 | 0.573 | 23.00 (11.00) | 23.00 (12.75) | 0.470 | 0.004 |
ROM | MMT | |||||||
---|---|---|---|---|---|---|---|---|
Experimental Group | Control Group | Experimental Group | Control Group | |||||
Median (IR) | Median (IR) | p | Cohen’s d | Median (IR) | Median (IR) | p | Cohen’s d | |
Hip Flexion | 5.00 (9.00) | 0.00 (5.00) | 0.001 | 0.611 | 0.25 (0.25) | 0.25 (0.19) | 0.199 | 0.117 |
Hip Extension | 5.00 (5.00) | 0.00 (2.00) | 0.000 | 0.929 | 0.25 (0.25) | 0.25 (0.50) | 0.140 | 0.261 |
Hip Abduction | 5.00 (10.00) | 0.00 (4.50) | 0.006 | 0.518 | 0.25 (0.50) | 0.00 (0.25) | 0.030 | 0.568 |
Hip Adduction | 0.00 (0.00) | 0.00 (0.00) | 0.094 | NA | 0.25 (0.50) | 0.00 (0.75) | 0.012 | 0.610 |
Hip Internal Rotation | 0.00 (5.00) | 0.00 (2.00) | 0.593 | 0.159 | 0.00 (0.25) | 0.00 (0.25) | 0.276 | 0.031 |
Hip External Rotation | 3.00 (10.00) | 0.00 (5.00) | 0.028 | 0.761 | 0.00 (0.50) | 0.00 (0.00) | 0.011 | 0.792 |
Knee Flexion | 5.00 (13.00) | 5.00 (10.00) | 0.249 | 0.287 | 0.25 (0.50) | 0.25 (0.25) | 0.146 | 0.290 |
Knee extension | 0.00 (0.00) | 0.00 (0.00) | 1.000 | NA | 0.25 (0.50) | 0.25 (0.75) | 0.828 | 0.134 |
Dorsiflexion | 3.00 (8.00) | 0.00 (8.75) | 0.386 | 0.244 | 0.25 (0.75) | 0.00 (0.25) | 0.001 | 0.870 |
Plantarflexion | 5.00 (5.00) | 0.00 (2.00) | 0.003 | 0.752 | 0.25 (0.50) | 0.00 (0.00) | 0.002 | 0.520 |
Inversion | 0.00 (5.00) | 0.00 (5.00) | 0.354 | 0.299 | 0.00 (0.25) | 0.00 (0.00) | 0.151 | 0.439 |
Eversion | 0.00 (5.00) | 2.00 (5.00) | 0.383 | 0.346 | 0.00 (0.25) | 0.00 (0.25) | 0.223 | 0.545 |
Experimental Group | Control Group | |||||
---|---|---|---|---|---|---|
Median (IR) | Mean Rank | Median (IR) | Mean Rank | p | Cohen’s d | |
ROM | 3.75 (3.25) | 36.65 | 2.08 (2.27) | 22.64 | 0.002 | 0.693 |
MMT | 0.27 (0.35) | 36.34 | 0.10 (0.15) | 22.98 | 0.003 | 0.924 |
MAS | 0.00 (0.00) | 29.10 | 0/0 | 31.00 | 0.175 | 0.365 |
MRS | 0.00 (0.00) | 30.00 | 0/0 | 30.00 | 1.000 | NA |
Motor FMLE | 3.00 (2.00) | 38.48 | 1.00 (2.00) | 20.61 | 0.000 | 0.984 |
Passive FMLE | 0.00 (1.00) | 34.69 | 0.00 (0.00) | 33.80 | 0.008 | 0.727 |
Pain FMLE | 0/0 | 30.42 | 0.00 (0.00) | 29.54 | 0.763 | 0.155 |
FIM | 0/0 | 29.00 | 0.00 (0.00) | 31.11 | 0.133 | 0.385 |
TUG | 0/0 | 30.85 | 0.00 (0.00) | 29.05 | 0.356 | 0.243 |
FRT | 2 (2.50) | 37.15 | 0.00 (1.75) | 22.09 | 0.001 | 0.936 |
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Miclaus, R.S.; Roman, N.; Henter, R.; Caloian, S. Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy. Int. J. Environ. Res. Public Health 2021, 18, 2654. https://doi.org/10.3390/ijerph18052654
Miclaus RS, Roman N, Henter R, Caloian S. Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy. International Journal of Environmental Research and Public Health. 2021; 18(5):2654. https://doi.org/10.3390/ijerph18052654
Chicago/Turabian StyleMiclaus, Roxana Steliana, Nadinne Roman, Ramona Henter, and Silviu Caloian. 2021. "Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy" International Journal of Environmental Research and Public Health 18, no. 5: 2654. https://doi.org/10.3390/ijerph18052654