Feasibility of Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use for People With Stroke

PURPOSE: Traditional, impairment-based approaches to upper extremity hemiparesis have demonstrated improvements in motor performance but not everyday function (Van Peppen et al., 2004). A functional approach, metacognitive strategy training (MCST), has demonstrated positive improvements in task-based outcomes. Research on MCST in people with stroke has demonstrated improvement on trained and untrained tasks (McEwen et al., 2015).

MetacogVR is an intervention combining virtual reality upper extremity rehabilitation with metacognitive strategy training. The rationale for MetacogVR is that improved upper extremity motor performance may further enhance the positive effects of MCST. The purpose of this study was to evaluate the feasibility of MetacogVR in a sample of people with chronic stroke. Specifically, this study evaluated recruitment rate, retention rate, and preliminary effect on activity performance and upper extremity motor performance to inform future outcome measurement selection.

METHOD: A single-group, prospective design was used. Participants were recruited through a local stroke registry. Inclusion criteria were adults with chronic stroke, self-reported unmet functional goals, minimum of 10° active range of motion in the upper extremity, and upper extremity hemiparesis. Exclusion criteria were severe aphasia, severe cognitive impairment, and additional neurological diagnoses.

Each participant set six occupational goals using the Canadian Occupational Performance Measure (COPM; Law et al., 2014). Only five of six goals were trained. Participants received three 1-hr intervention sessions per week for 12 wk. Two weekly sessions elicited high numbers of movement repetitions through a Kinect-based virtual reality system (Microsoft, Redmond, WA). The third weekly session addressed real-world task performance through the use of metacognitive strategy training in client-chosen COPM goals.

Activity performance for trained and untrained goals was assessed via the COPM and Performance Quality Rating Scale (PQRS). Upper extremity motor performance was measured with the Fugl-Meyer Assessment (FMA). Data were first checked for normal distribution using the Shapiro–Wilks test. Mean changes, standard deviations, and Cohen’s d effect sizes were calculated comparing pre- to postintervention data and preintervention to 3-mo follow-up data. Recruitment rates and retention rates were also calculated.

RESULTS: Findings demonstrated a recruitment rate of 15% and a retention rate of 100%. Ten people with chronic stroke were recruited. At 3-mo follow-up, there were large effects on measures of upper extremity motor performance, subjective perspectives of task performance and satisfaction for trained and untrained goals, and objective measures of task performance for trained goals.

CONCLUSION: The recruitment rate in the study was low, indicating that a large sample of potential participants will be required for future studies. The 100% retention rate may reflect participant satisfaction with the intervention as demonstrated in previous studies. Large effects in outcomes on the PQRS, COPM, and FMA indicate that these measures may be sensitive to changes occurring as a result of MetacogVR; therefore, future studies should consider use of these measures. Although preliminary, findings suggest that multicomponent interventions such as MetacogVR may be critical for teaching clients to problem solve performance difficulties, thus permitting transfer and generalization of skills including improvements in upper extremity performance.

References

Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (2014). Canadian Occupational Performance Measure (5th ed.). Ottawa: CAOT Publications.

McEwen, S., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & Wolf, T. (2015). Combined cognitive-strategy and task-specific training improve transfer to untrained activities in subacute stroke: An exploratory randomized controlled trial. Neurorehabilitation and Neural Repair, 29, 526–536. https://doi.org/10.1177/1545968314558602

Van Peppen, R. P., Kwakkel, G., Wood-Dauphinee, S., Hendriks, H. J., Van der Wees, P. J., & Dekker, J. (2004). The impact of physical therapy on functional outcomes after stroke: What’s the evidence? Clinical Rehabilitation, 18, 833–862. https://doi.org/10.1191/0269215504cr843oa