Effect of SynPhNe Physio-neuro Platform on Hand Motor Function Rehabilitation of Acute and Subacute Stroke Patients

Stroke is a major cause of adult long term disability and the fourth leading cause of death and affects 1·8/1000 persons in Singapore. Post-stroke functional recovery of upper limb is poor with 80% of stroke survivors having some upper limb disability during the acute to subacute phase after stroke. Early rehabilitation is paramount for enhancing the survival and independence of stroke patients and inadequate supervised therapy hours is closely associated with poor rehabilitation outcome. However, high intensity and high repetition therapies, which facilitates neuroplasticity, have historically had a poor uptake because it is manpower intensive and places a high demand on stroke patients, many of whom cannot cope. High fatigue and sustained levels of effort are also generally perceived as placing the patient at risk if done at home without trained supervision.

Robotic rehabilitation system can provide high-intensity, repetitive, task-specific, interactive treatment of the impaired upper limb and can serve as an objective and reliable means of monitoring patient progress. However, robotic rehabilitation technologies have not had the wide-ranging impact that was once expected. Not only are they difficult to afford for the general population but their training options are limited, with most of them allowing basic joint movements such as wrist extension, finger extension and the like, rather than actual everyday tasks and activity level training. Those devices that provide a wider variety of everyday task training are more complex and expensive and few are designed to be used at home.

Stroke subjects also have a wide spectrum of disability which includes muscle weakness, lack of control, cognitive deficits, joint pain, and deeply embedded, maladaptive muscle couplings resulting in unconscious co-contractions and compensatory muscle use. Although these disability elements are widely acknowledged to be present, technological tools for identifying and quantifying these are missing. This technology gap affects the optimization of therapy and the patients' understanding of their condition. In many cases, patients are unable to grasp why there is no visible progress despite sincere effort, leading to discouragement and an eventual drop out of therapy. Conversely, a therapist may conclude no further improvement is feasible and place the patient on maintenance exercises. It is well known that patients may be required to follow different therapy roadmaps for hand function depending on the nature and extent of deficits. This would involve not just strength training but also co-ordination, organization, and goal-based execution. To be truly effective, a rehabilitation platform must be able to deliver a wide range of tasks and activities in a guided manner while measuring incremental as well as overall performance in a quantitative manner.

In this study, we intend to fill the gap using SynPhNe- a physio-neuro platform. It can provide an early, repetitive and task-specific hand rehabilitation with less supervision using correct muscle groups and muscle synergies of stroke patients. It also can engage physical and cognitive aspects of stroke patients. We had previously conducted a study using the SynPhNe device in chronic stroke patients and found an average of 6.3% improvement in the upper extremity component of the Fugl-Meyer score (p=0.015), and a 22% improvement in the Action Research Arm test (p=0.003) after a 4 week intervention (DSRB 2012/00521). Just as with conventional therapy, we expect that the effect will be more pronounced in the acute to sub-acute stages of stroke when there is a greater degree of neuronal plasticity. Hence, we propose this study, where we intend to explore the use of the SynPhNe to: 1) increase the time the stroke-affected hand is used in therapeutic activity; 2) improve the effectiveness of upper extremity rehabilitation; 3) reduce the length of inpatients hospital stay.

Specific study aims: 1) To investigate the feasibility and efficacy of using the SynPhNe device outside of conventional therapy time, compared with conventional occupational therapy alone, on hand motor function in acute and subacute stroke patients; 2. To evaluate the feasibility of the use of SynPhNe by acute and subacute stroke patients with minimized supervision; 3. To investigate subject and staff perceptions in terms of usability and benefit of the device; 4. To study clinical outcomes, EEG, EMG and TMS changes over the course of the study; 5. To compare the cost-benefit of SynPhNe therapy on inpatients with standard care.