A low cost virtual reality system for home based rehabilitation of the upper limb following stroke:...

A low cost virtual reality system for home based rehabilitation of the upper limb

following stroke: a randomised controlled feasibility trial

PJ Standen, Kate Threapleton, Louise Connell, Andy Richardson, David Brown, Steven Battersby, Fran Platts

A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham

Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL

Development of equipment


• would increase the opportunity for the amount of therapy required to rehabilitate the upper limb and fingers following stroke

• was flexible and motivating in order to improve adherence

• the virtual glove allows capture of the position of thumb and three fingers and translates into game play. It is designed to facilitate practice of movements that underlie everyday tasks such as grasp and release

In conjunction with users we developed a low cost intervention for home use that

Development of games


• Four games each with a different levels of challenge to keep the participants motivated to continue to use the system but to ensure that they can achieve some success.

• Scores displayed on the screen at the end of a game.

• A log of when the system is in use is collected by the computer as well as what games are being played and what scores the user obtains.

Feasibility trial


First step in designing a definitive trial which would allow us to evaluate the effectiveness of the glove

• Can we recruit suitable participants? • Will they use the glove? • Can we collect outcome measures and are they appropriate?

Feasibility trial


We approached patients who • were aged 18 or over who • were recovering from a stroke • were no longer receiving any other rehabilitation • still experiencing problems with their upper limb. • Recruited from stroke wards City Hospital, ESD and Community

Support Team and Stroke Outreach Service • Randomly allocated to either the intervention (virtual glove) group

or the control group (usual care). • Intervention group had the virtual glove, games and a PC in their

homes for a period of 8 weeks . • They were advised to use the system for 20 mins 3x day (max 56

hours).

Feasibility trial


Baseline and follow up measures of upper limb function at four and eight weeks

• Wolf motor functions test a measure of upper limb functioning

• 9 hole peg test a test of fine motor co-ordination

• Motor Activity Log how well and how much they use their more impaired arm to accomplish each of a range of ADL

• Nottingham Extended Activities of Daily Living

• For intervention group only: frequency of using the equipment

Presenter

Presentation Notes

Includes 3 pilot – non randomised Withdrawals After consent – 1 health reasons, 1 changed their mind Intervention withdrawals After baseline – 1 family issues (07/JW); 1 intervention ‘wasn’t his thing’ (16/DL); 1 could not complete training due to arm pain (19/CE; 1 had seizures (AP/27); 1 arm pain and severe aphasia (JR/28) After midpoint - 1 illness (pilot 02/PB); 1 family member ill (26/LS); 1 going on long holiday so only had 4 week intervention (CP/09) Control – found the measures onerous,

Characteristics of sample at baseline


Control group (N=10) – Mean age = 63.40 (SD = 14.60; range = 35 – 79 yrs) – 8 males: 2 females – Time since stroke (weeks): mean = 24; SD = 36.26; median = 12; range = 7 - 126 – Type of stroke: 8 ischemic ; 1 haemorrhagic; 1 ‘other’ – Side of stroke: 6 left hemisphere , 3 right hemisphere, 1 bilateral – Upper limb affected – 4 left; 6 right ; 7 dominant; 3 non-dominant

• Intervention Group (N=17)

– Mean age = 58.94 (SD = 12.03; range = 40 – 82 yrs) – 8 males: 9 females – Time since stroke (weeks): mean = 38; SD = 41.28; median = 22; range = 6 - 178 – Type of stroke: 13 ischemic; 4 haemorrhagic – Side of stroke: 7 left hemisphere, 9 right hemisphere, 1 bilateral – Upper limb affected – 8 left; 9 right ; 13 dominant; 4 non-dominant

Will they use the glove?


Adherence examined in three ways:

• hours of use, • days on which it was used • how many times a day they used it



0 10 20 30 40 50 60 70 80 90

100

1 2 3 4 8 9 13 17 22 23 24 26

%

Participant ID

Percentage of Recommended Use

Percentage recommended time used Percentage recommended days used

Considerable variation between participants. No-one achieved 100% but P9 who had glove for only 4 weeks was not far off the recommended use. Two participants used the glove on every day it was with them, seven on less than half the days. Some people continued use despite many difficulties in play/psycho-social issues



0

5

10

15

20

25

30

1 2 3 4 8 9 13 17 22 23 24 26

Days

Participant ID

Sessions of use

No days max of 1 session No days max of 2 sessions No days max of 3 sessions No days 4+ sessions

Only 6 participants ever had days with three sessions. Worryingly, 5 had days with 4 or more sessions. For P9 there were days when use exceeded 90 minutes.

Can we collect outcome measures and are they appropriate?


22 participants completed outcome measures at 4 weeks and 18 at 8 weeks.

Outcome measures Wolf grip


Change from baseline in intervention group at 4 weeks significantly (p<0.05) greater than in control group

Outcome measures Nine hole peg test


Negative change scores = greater improvement. At 4 weeks slightly more improvement in intervention group but not significant because of outliers

Outcome measures Motor Activity Log: amount of use


At 4 weeks no difference in amount of improvement between the groups. At 8 weeks intervention group had a significantly (p<0.05) greater improvement than the control

30 items eg Turn on a light with a light switch, use a key to open a door, button a shirt Participants asked if they have done them during the past week with affected arm Two scores amount of use and how well they could do the item

Outcome measures Motor Activity Log : quality of movement


No difference at 4 weeks. At 8 weeks a greater change in the intervention group but this doesn’t reach significance

Outcome measures Nottingham Extended Activities of Daily Living peg test


Change from baseline in intervention group at 8 weeks greater than in control group but not

significant

“In last few weeks have you managed to feed yourself, make a hot drink, walk around outside………?” Four scales: Mobility, domestic, kitchen, leisure

Conclusion


• Identifying potential participants time consuming. Once identified, recruitment reasonable (62% of 47 approached consented).

• duration of use and on how many days participants used the glove was highly variable and could fall far short of our recommendations. No one reached the recommended use but some used the glove on almost every day it was in their homes. Only 6 participants ever used the glove three times a day but all participants had days where they used it twice.

• Adherence low but it’s low for other unsupervised rehabilitation.

• Eight weeks a long time to ask people to use kit especially if they are trying to return to their prestroke life.

• Huge variation in outcomes but inclusion criteria deliberately wide as we had no idea who this would suit. No reason to drop any of the outcome measures if going for definitive trial.

Acknowledgements


• The NIHR CLAHRC – NDL is a partnership between the University of Nottingham

and local NHS organisations and is funded by the NIHR. • Thanks to our expert users for advice on running the trial • Colleagues at NTU including Andy Burton

Date post:	18-Dec-2014
Category:	Health & Medicine
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A low cost virtual reality system for home based rehabilitation of the upper limb following stroke:...

Health & Medicine