Gloreha Research Study

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EFFECTS OF PASSIVE REHABILITATION OF THE UPPER LIMB

WITH ROBOTIC DEVICE GLOREHA®

ON VISUAL-SPATIAL AND ATTENTIVE EXPLORATION CAPACITIES

OF PATIENTS WITH STROKE ISSUES.

RESEARCH CARRIED OUT BY:

Neuromotor and Cognitive Rehabilitation Research Center

University of Verona

Neurological Rehabilitation Department

Hospital University of Verona

directed by Prof. Nicola Smania

March 2013

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1. PURPOSE OF THE STUDY

The purpose of the current study is to assess the effects of the paradigm “spatial-motor-cueing”

on the recovery of the visual-spatial exploration capacities of patients who show neglect after a

right brain lesion. On the basis of previous studies (Halligan&Marshall 1989; Robertson&North,

1992; Robertson et al., 1992; Fujii et al., 1996) we intend to research if the motor activation of the

contralesional limb helps to run the attention to the contralateral hemisphere (left), reduce the

hemiinattention deficit and improve the visual-spatial and attentive capacities of the patient.

Furthermore, with the current study, we intend to assess in general the effects of motor

rehabilitation of the upper limb on the attentive capacities of the patients with cerebral stroke

issues. It has been highlighted firstly how impairment of the global attentive capacities could cut

down the cognitive capacities even when the other cognitive functions are well conserved and

secondly how they are important for learning of motor abilities (Collo et al., 2009).

The study indeed has involved patients, with or without left neglect, who have had general

attentive diseases.

From the existing literature it is still not clear if the simple passive movement of the contralesional

limb could have a specific effect on the cognitive capacities of the patient with stroke issues. For

this reason, the project contemplates the use of the robotic device Gloreha usually used for the

passive rehabilitation of the upper limb. The robot, besides being equipped with a specific glove

for the movement, enables the patient to see the movements of the upper limb on a display that

shows the hand and its actions in a detailed way. So Gloreha leads the patient to pay attention to

the contralesional limb’s movements both in terms of proprioceptive level and in terms of visual

control level.

This device, through the passive movement of the left hand, could train the visual-spatial attention

to the contralateral hemifield, besides the general attentive capacities, because the patient must

make an effort to be attentive.

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2. MATERIALS AND METHODS

Selection of the patients

The collection of the data and the intended treatment in this project took place at the

Neurorehabilitation Department in the Hospital “G.B. Rossi” in Verona.

For this study we have engaged patients, who have the following inclusion criteria:

• Cerebral stroke of the right hemisphere (documented through CAT and/or brain RM)

• Aged from 18 to 85

• Low level spasticity of the upper limb (pt<3 Modified Ashworth Scale).

On the other hand, patients with the following characteristics have been excluded:

• Other vascular cerebral events in anamnesis (i.e. previous stroke) and/or other

neurological diseases (Parkinson, Multiple Sclerosis, etc.)

• Dementia (pt>23,80 in MMSE1)

• Psychiatric diseases

• Aphasia of medium-high level (endangered comprehension and very limited production or

no production)

• Abuse of alcohol and/or drugs

• Important spasticity (pt≥3 Modified Ashworth Scale).

Rating’s procedures

General clinical evaluation

Demographic and clinical data of each patient have been collected according to a specific data

sheet.

In order to decide the inclusion/exclusion of the patients in the study and their neurological status,

a clinical evaluation (screening evaluation) has been run through the use of the following tests and

1 Mini Mental State Examination (Folstein et al., 1975).

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scales: Mini Mental State Examination (to rate the global cognitive state), Modified Ashworth

Scale (to rate the level of spasticity), European stroke scale2 (to rate the neurological gravity).

Outcome measures evaluation

After the screening evaluation, the patients who have achieved the standards of inclusion and

exclusion, have been submitted to cognitive and motor tests before and after the training with

Gloreha, with the purpose to evaluate the eventual effects of the passive motor treatment of the

upper limb on the patient’s capacities.

Training

The patients involved in the study have followed a

passive rehabilitation training of the contralesional

upper limb through using the robotic device

Gloreha.

The training was made up of 10 rehabilitation

sessions of 25 minutes each, that have run during 2

weeks (5 sessions per week). During the training the

patients had to perform exercises of passive

movement, which were saved in the device Gloreha. During the performance of the exercises the

patient looked at an image on the display of the computer that replayed the same movements

that their hand performed. A variant of this exercise was to name the fingers looking directly at

the proper hand. This exercise had the purpose to enhance the awareness of the patient regarding

the performed movement. Alternatively, asking the patient to perform this task with closed eyes,

we have tried to research and to improve the proprioceptive capacities of the patient to the

moving limb.

During the training a high level of concentration was required for the exercise period.

2 European Stroke Scale (Hantson et al., 1994).

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3. RESULTS

For this study we have recruited 4 patients with issues of cerebral stroke who showed right

hemispheric lesions.

Pa

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Modified Ashworth Scale

Sh

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Fin

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B.A. F 69 5 13 Ischemic 23,9 80 0 0 0 0

B.M. F 66 8 35 Ischemic 25 63 0 2 1 1/2

F.M. F 64 5 4 Hemorrhagyc 24,9 69 0 0 0 0

M.S. F 85 7 9 Ischemic 23,8 41 0 0 1 0

Chart 1. Demographic and clinical data of the patients.

Before and after the treatment with Gloreha, an evaluation regarding cognitive tests, tests of manual

dexterity and motor tests was done to the patients:

• Line Crossing Test or “Albert’s Test” (BIT; Wilson et al., 1987)

• Bells Test (Gauthier at al., 1989)

• Line Bisection Test (BIT; Wilson et al., 1987)

• Saccadic Training (RehaCom, Hasomed)

• Computerized Test for the assessment of unilateral stimuli

• SART (Sustained Attention to Response Task) Test

• Fugl Meyer Assessment (Fugl-Meyer et al., 1975)

• Motricity Index (Demeurisse et al., 1980)

• Nine Hole Peg Test (Kellor et al., 1971)

• Purdue PegBoard Test (Tiffin, 1948).

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Cognitive evaluation

At the pre-treatment evaluation, the patients B.A and F.M. showed neglect during each of the three

performed tests: Line Crossing Test, Bells Test, Line Bisection Test.

All the patients have showed difficulties in the Test for the assessment of unilateral stimuli, both in terms of

accuracy (less on the left side), and in terms of latency during the test of the Saccadic Training, mostly in

the relevation of the contralesional stimuli.

The diseases of visual attention have been confirmed by the SART test.

Manual dexterity evaluation

At the evaluation pre-treatment, the patients B.A. and F.M. showed difficulties to use the left hand during

the tests of manual dexterity, not justifiable with the presence of motor deficit (hemiplegia).

The patients B.M. and M.S. showed hemiplegia of the contralesional upper limb with mild spasticity that

did not let them perform the test of dexterity with this limb.

Motor evaluation

At the pre-treatment evaluation, the patients B.A. and F.M. showed mild difficulties in performing

movements with the left upper limb, whist the patients B.M and M.S. showed left hemiplegia.

These difficulties have been confirmed by the motor tests.

The study has involved 4 patients , two with left neglect and two without, who showed general attentive

disease.

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After the treatment with Gloreha we have registered:

a) An improvement of the capacities of visual-spacial exploration in one of the patients with neglect

(F.M).

At the pre-treatment evaluation, the patient showed a deficit of visuo-spatial elaboration (neglect)

in most of the performed tests. After the treatment with Gloreha, the patient F.M. showed an

improvement in the Line Crossing Test, Bells Test, Line Bisection Test.

Chart 2. Line Crossing Test, 18 items (patient F.M.)

Chart 3. Bells Test, 17 items (patient F.M.)

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Chart 4. Line Bisection Test (patient F.M.)

b) An escalation of the speed of relevation of visual stimuli in the left hemifield (Saccadic Training)

with all the patients.

Patient B.A.: In the tests of relevation of stimuli, a decrease of the reaction time has been

highlighted in the test of the Saccadic Training; both contralesional and ipsilesional. In particular,

after the treatment, the difference between the reaction time for the relevation of right stimuli and

the reaction time for the relevation of left stimuli is lower than that identified in the pre-treatment

evaluation.

Patient F.M.: In the test of Saccadic Training a reduction of the reaction time was noticed in the

relevation of contralesional stimuli and a mild exacerbation of the speed to answer to ipsilesional

visual stimuli.

Patient B.M.: The test of Saccadic Training revealed a reduction of reaction time in the relevation of

stimuli - both contralesional and ipsilesional.

Patient M.S.: The test of Saccadic Training showed a reduction of reaction time in the relevation of

contralesional stimuli and an increase of the ipsilesional ones.

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Chart 5. Saccadic training: reaction time (contralesional stimuli).

c) An important reduction of the reaction time about the supported attention (SART) on two out of

four treated patients.

Patient B.A.: Performing the attentive test (SART) after the treatment, a reduction of the reaction

time (average_T0=565; average _T1=450) and of the omissions has been identified. Using the

Wilcoxon test, the statistical analysis has shown an important difference in the reaction time

between pre- and post-treatment (Z= -5.587, p<.001).

Patient M.S.: Performing the attentive test SART we can note a reduction of the reaction time

(average_T0=993; average _T1=711; Z=-7.045, p>.001) and of the omissions.

Chart 6. SART (Sustained Attention to Response Task) Test: reaction time (patients B.A. and M.S.)

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d) An increase of the capacities of manual dexterity in one out of two patients, who were able to be

evaluated (F.M.).

At the pre-treatment evaluation, the patient showed a high difficulty in using the left hand in

performing excercises that require good capacities of manual dexterity.

After the treatment, a small improvement in both the tests has been identified.

Chart 7. Purdue Peg Board Test (patient F.M.)

Chart 8. Nine Hole Peg Test (patient F.M.)

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4. CONCLUSIONS

Our results seem to confirm the validity of the issue about the motor cueing on neglect (Robertson et al.,

1992; Robertson, 1998; Robertson et al., 2002), even if only on one patient.

The improvement, according to Robertson and his colleagues, would be for an increase of attentive

resources to the contralesional hemifield after the action of the contralateral limb that is usually neglected.

Another explanation about the improvement of the heminattentive deficit could came from the most

recent studies of Corbetta et al. These authors show how the improvement of neglect is due to an

interhemispheric rebalancing of the neural activity (Corbetta et al. 2005, 2009). They show indeed that

the retriev of the heminattentive disease is related to a reduction of activity in areas of the contralateral

hemisphere associated with an increase of activity in the right hemispheric areas. The passive motor

activity of the contralesional limb in this sense could simplify this re-balance, since these patients have an

hemiparetic left limb or they often do not use it spontaneously.

It has been noted, indeed, how after a rehabilitative motor treatment there is a change of activation of the

cerebral areas. This change would imply an increase of the activation of some areas and a reduction of

others (Patel et al. , 2012).

The inter-hemispheric rebalancing could be furthermore the basis of the retrivial of other cognitive

capacities, as the attention ability and the speed in reaction.

Literature explains that the motor activity would have in general an effect on the cognitive capacities of the

neurological patient (Heyn et al., 2004; Prakash et al., 2010). On the basis of our results, and of the present

data in the literature, an integration between cognitive capacities and motor capacities is probable. In this

sense an adequate evaluation of both the domains is necessary for the development of an adequate

rehabilitative intervention.

These observations remain nevertheless as foreplay. The collected data in the current study are meager

because of the low quantity of the sampling. For this reason it will be necessary in the future to increase

the size of the survey. Furthermore it must be carried out with evaluation of follow-up to ensure the

maintenance of the effects. It would be interesting to support our theories through neurophysiological

investigations in order to evaluate the inter-hemispheric activation before and after motor treatment.

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5. BIBLIOGRAPHY

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