Virtual Reality Training for Upper Extremity in Subacute Stroke (VIRTUES): A multicenter RCT
Brunner, I., Skouen, J. S., Hofstad, H., Aßmus, J., Becker, F., Sanders, A., . . . Verheyden, G. (2017). Virtual reality training for upper extremity in subacute stroke (VIRTUES). Neurology, doi:10.1212/WNL.0000000000004744
Objective: To compare the effectiveness of upper extremity virtual reality rehabilitation training
(VR) to time-matched conventional training (CT) in the subacute phase after stroke.
Methods: In this randomized, controlled, single-blind phase III multicenter trial, 120 participants
with upper extremity motor impairment within 12 weeks after stroke were consecutively included
at 5 rehabilitation institutions. Participants were randomized to either VR or CT as an adjunct to
standard rehabilitation and stratified according to mild to moderate or severe hand paresis,
defined as $20 degrees wrist and 10 degrees finger extension or less, respectively. The training
comprised a minimum of sixteen 60-minute sessions over 4 weeks. The primary outcome measure
was the Action Research Arm Test (ARAT); secondary outcome measures were the Box and
Blocks Test and Functional Independence Measure. Patients were assessed at baseline, after
intervention, and at the 3-month follow-up.
Results: Mean time from stroke onset for the VR group was 35 (SD 21) days and for the CT group
was 34 (SD 19) days. There were no between-group differences for any of the outcome measures.
Improvement of upper extremity motor function assessed with ARAT was similar at the
postintervention (p 5 0.714) and follow-up (p 5 0.777) assessments. Patients in VR improved
12 (SD 11) points from baseline to the postintervention assessment and 17 (SD 13) points from
baseline to follow-up, while patients in CT improved 13 (SD 10) and 17 (SD 13) points, respectively.
Improvement was also similar for our subgroup analysis with mild to moderate and severe
upper extremity paresis.
Conclusions: Additional upper extremity VR training was not superior but equally as effective as
additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative
as a supplement to standard rehabilitation.
TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients
Kho ME, Molloy AJ, Clarke FJ, et al. TryCYCLE: A prospective study of the safety and feasibility of early in-bed cycling in mechanically ventilated patients. PLOS ONE. 2016;11(12):e0167561.
The objective of this study was to assess the safety and feasibility of in-bed cycling started within the first 4 days of mechanical ventilation (MV) to inform a future randomized clinical trial.
We conducted a 33-patient prospective cohort study in a 21-bed adult academic medical-surgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult patients (≥ 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30 minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety (termination), measured as events prompting cycling termination; secondary Safety (disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the binary proportion and 95% confidence interval (CI).
From 10/2013-8/2014, we obtained consent from 34 of 37 patients approached (91.9%), 33 of whom received in-bed cycling. Of those who cycled, 16(48.4%) were female, the mean (SD) age was 65.8(12.2) years, and APACHE II score was 24.3(6.7); 29(87.9%) had medical admitting diagnoses. Cycling termination was infrequent (2.0%, 95% CI: 0.8%-4.9%) and no device dislodgements occurred. Cycling began a median [IQR] of 3 [2, 4] days after ICU admission; patients received 5 [3, 8] cycling sessions with a median duration of 30.7 [21.6, 30.8] minutes per session. During 205 total cycling sessions, patients were receiving invasive MV (150 [73.1%]), vasopressors (6 [2.9%]), sedative or analgesic infusions (77 [37.6%]) and dialysis (4 [2.0%]).
Early cycling within the first 4 days of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the effect of early cycling on patient function is warranted.