A Case Series Clinical Trial of a Novel Approach Using Augmented Reality That Inspires Self-body Cognition in Patients With Stroke: Effects on Motor Function and Resting-State Brain Functional Connectivity

Fuminari Kaneko, Keiichiro Shindo, Masaki Yoneta, Megumi Okawada, Kazuto Akaboshi, Meigen Liu, Fuminari Kaneko, Keiichiro Shindo, Masaki Yoneta, Megumi Okawada, Kazuto Akaboshi, Meigen Liu

Abstract

Barring a few studies, there are not enough established treatments to improve upper limb motor function in patients with severe impairments due to chronic stroke. This study aimed to clarify the effect of the kinesthetic perceptional illusion induced by visual stimulation (KINVIS) on upper limb motor function and the relationship between motor function and resting-state brain networks. Eleven patients with severe paralysis of upper limb motor function in the chronic phase (seven men and four women; age: 54.7 ± 10.8 years; 44.0 ± 29.0 months post-stroke) participated in the study. Patients underwent an intervention consisting of therapy using KINVIS and conventional therapeutic exercise (TherEX) for 10 days. Our originally developed KiNvis™ system was applied to induce KINVIS while watching the movement of the artificial hand. Clinical outcomes were examined to evaluate motor functions and resting-state brain functional connectivity (rsFC) by analyzing blood-oxygen-level-dependent (BOLD) signals measured using functional magnetic resonance imaging (fMRI). The outcomes of motor function (Fugle-Meyer Assessment, FMA) and spasticity (Modified Ashworth Scale, MAS) significantly improved after the intervention. The improvement in MAS scores for the fingers and the wrist flexors reached a minimum of clinically important differences. Before the intervention, strong and significant negative correlations between the motor functions and rsFC of the inferior parietal lobule (IPL) and premotor cortex (PMd) in the unaffected hemisphere was demonstrated. These strong correlations were disappeared after the intervention. A negative and strong correlation between the motor function and rsFC of the bilateral inferior parietal sulcus (IPS) significantly changed to strong and positive correlation after the intervention. These results may suggest that the combination approach of KINVIS therapy and TherEX improved motor functions and decreased spasticity in the paralyzed upper extremity after stroke in the chronic phase, possibly indicating the contribution of embodied-visual stimulation. The rsFC for the interhemispheric IPS and intrahemispheric IPL and PMd may be a possible regulatory factor for improving motor function and spasticity. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01274117.

Keywords: body ownership; embodied visual feedback; kinesthetic illusion; mirror visual feedback; rehabilitation; resting-state brain functional connectivity; stroke; virtual reality.

Copyright © 2019 Kaneko, Shindo, Yoneta, Okawada, Akaboshi and Liu.

Figures

Figure 1
Figure 1
(A) Outline of the experimental plan. The experiment consisted of 10 days of intervention on weekdays and evaluations before and after the intervention. The intervention included conventional therapy for kinesthetic illusion induced by visual stimulation (KINVIS) therapy and therapeutic exercise (TherEX). KINVIS was applied for 20 min, and TherEX was applied after KINVIS therapy for 60 min by physical or occupational therapists. (B) KINVIS therapy set-up. KINVIS used the KiNvis™ System that consists of a table with two monitors, a chair for the patient to sit, both within a box to encourage concentration on the movie. Neuromuscular Electrical Stimulation was applied in combination with KINVIS. The patients’ arm was supported on a stand to avoid any somatosensory input.
Figure 2
Figure 2
Results of seed-based functional connectivity in all regions-of-interest (ROIs). ROI names are defined in Table 2. Results before and after the intervention are displayed in rows, while those in the affected and unaffected hemispheres are displayed in columns. All connectivity maps were thresholded at voxel level false-discovery-rate (FDR) corrected at p < 0.01 and at cluster level FDR corrected at p < 0.0001. (A) ROIs showing significant intrahemispheric or interhemispheric resting-state brain functional connectivity (rsFC). (B) ROIs not showing significant intrahemispheric or interhemispheric rsFC apart from the rsFC to themselves.
Figure 3
Figure 3
Scatter plots of significant correlation in Table 5, and the results of testing the significance of the correlation coefficient. This figure shows the scatter plots of the significant correlations shown in Table 5. The number (No), ROI name, and cluster location name of Columns are associated with Tables 4, 5. Stage means the assessment stage before and after the intervention. The correlation coefficient (r) and the probability value (p) shows above the scatter plot. The column of “Difference of CC (correlation coefficient) between before and after” shows the result of testing of the significance of the correlation coefficient (Z, Z-score; p, probability value). The significance probability defined p = 0.05/6 because a total of six tests were required. Values were marked *if they were below this threshold. Abbreviations: FMA upper extremity motor, the score of Fugl-Meyer assessment upper extremity motor function; ARAT total, Total score of Action research arm test; SMG, supramarginal gyrus; AG, angular gyrus; SPL, superior parietal lobule; MidFG, middle frontal cortex; PreCG, precentral gyrus; PC, cingulate gyrus posterior division.

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