Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke

Exploratory study on the effects of a robotic hand rehabilitation device on changes in grip strength and brain activity after stroke

BACKGROUND

The brain mechanisms underlying successful recovery of hand fuenction after stroke are still not fully understood, although functional MRI (fMRI) studies underline the importance of neuronal plasticity.

METHODS

We explored potential changes in brain activity in 7 patients with subacute to chronic stroke (69 ± 8 years) with moderate- to high-grade distal paresis of the upper limb (Motricity Index: 59.4) after standardized robotic finger-hand rehabilitation training, in addition to conventional rehabilitation therapy for 3 weeks. Behavioral and fMRI assessments were carried out before and after training to characterize changes in brain activity and behavior.

RESULTS

The Motricity Index (pre: 59.4, post: 67.2, P < .05) and grip force (pre: 7.26, post: 11.87, P < .05) of the paretic hand increased significantly after rehabilitation. On fMRI, active movement of the affected (left) hand resulted in contralesional (ie, ipsilateral) activation of the primary sensorimotor cortex prior to rehabilitation. After rehabilitation, activation appeared "normalized," including the ipsilesional primary sensorimotor cortex and supplementary motor area (SMA). No changes and no abnormalities of activation maps were seen during movement of the unaffected hand. Subsequent region-of-interest analyses showed no significant ipsilesional activation increases after rehabilitation.

CONCLUSION

Despite behavioral improvements, we failed to identify consistent patterns of functional reorganization in our sample. This warrants caution in the use of fMRI as a tool to explore neural plasticity in heterogeneous samples lacking sufficient statistical power.

Error augmentation enhancing arm recovery in individuals with chronic stroke: a randomized crossover design

BACKGROUND

Neurorehabilitation studies suggest that manipulation of error signals during practice can stimulate improvement in coordination after stroke.

OBJECTIVE

To test visual display and robotic technology that delivers augmented error signals during training, in participants with stroke.

METHODS

A total of 26 participants with chronic hemiparesis were trained with haptic (via robot-rendered forces) and graphic (via a virtual environment) distortions to amplify upper-extremity (UE) tracking error. In a randomized crossover design, the intervention was compared with an equivalent amount of practice without error augmentation (EA). Interventions involved three 45-minute sessions per week for 2 weeks, then 1 week of no treatment, and then 2 additional weeks of the alternate treatment. A therapist provided a visual cursor using a tracking device, and participants were instructed to match it with their hand. Haptic and visual EA was used with blinding of participant, therapist, technician-operator, and evaluator. Clinical measures of impairment were obtained at the beginning and end of each 2-week treatment phase as well as at 1 week and at 45 days after the last treatment.

RESULTS

Outcomes showed a small, but significant benefit to EA training over simple repetitive practice, with a mean 2-week improvement in Fugl-Meyer UE motor score of 2.08 and Wolf Motor Function Test of timed tasks of 1.48 s.

CONCLUSIONS

This interactive technology may improve UE motor recovery of stroke-related hemiparesis.

The effects of post-stroke upper-limb training with an electromyography (EMG)-driven hand robot

Loss of hand function and finger dexterity are main disabilities in the upper limb after stroke. An electromyography (EMG)-driven hand robot had been developed for post-stroke rehabilitation training. The effectiveness of the hand robot assisted whole upper limb training was investigated on persons with chronic stroke (n=10) in this work. All subjects attended a 20-session training (3-5times/week) by using the hand robot to practice object grasp/release and arm transportation tasks. Significant motor improvements were observed in the Fugl-Meyer hand/wrist and shoulder/elbow scores (p<0.05), and also in the Action Research Arm Test and Wolf Motor Function Test (p<0.05). Significant reduction in spasticity of the fingers as was measured by the Modified Ashworth Score (p<0.05). The training improved the muscle co-ordination between the antagonist muscle pair (flexor digitorum (FD) and extensor digitorum (ED)), associated with a significant reduction in the ED EMG level (p<0.05) and a significant decrease of ED and FD co-contraction during the training (p<0.05); the excessive muscle activities in the biceps brachii were also reduced significantly after the training (p<0.05).

Coordinated upper limb training assisted with an electromyography (EMG)-driven hand robot after stroke

An electromyography (EMG)-driven hand robot had been developed for post-stroke rehabilitation training. The effectiveness of the hand robot assisted whole upper limb training on muscular coordination was investigated on persons with chronic stroke (n=10) in this work. All subjects attended a 20-session training (3-5 times/week) by using the hand robot to practice object grasp/release and arm transportation tasks. Improvements were found in the muscle co-ordination between the antagonist muscle pair (flexor digitorum and extensor digitorum) as measured by muscle co-contractions in EMG signals; and also in the reduction of excessive muscle activities in the biceps brachii. Reduced spasticity in the fingers was also observed as measured by the Modified Ashworth Score.

Rehabilitation robotics

This chapter focuses on rehabilitation robotics which can be used to augment the clinician's toolbox in order to deliver meaningful restorative therapy for an aging population, as well as on advances in orthotics to augment an individual's functional abilities beyond neurorestoration potential. The interest in rehabilitation robotics and orthotics is increasing steadily with marked growth in the last 10 years. This growth is understandable in view of the increased demand for caregivers and rehabilitation services escalating apace with the graying of the population. We provide an overview on improving function in people with a weak limb due to a neurological disorder who cannot properly control it to interact with the environment (orthotics); we then focus on tools to assist the clinician in promoting rehabilitation of an individual so that s/he can interact with the environment unassisted (rehabilitation robotics). We present a few clinical results occurring immediately poststroke as well as during the chronic phase that demonstrate superior gains for the upper extremity when employing rehabilitation robotics instead of usual care. These include the landmark VA-ROBOTICS multisite, randomized clinical study which demonstrates clinical gains for chronic stroke that go beyond usual care at no additional cost.

Robotic therapy: the tipping point

The last two decades have seen a remarkable shift in the neurorehabilitation paradigm. Neuroscientists and clinicians moved away from the perception that the brain is static and hardwired to a new dynamic understanding that plasticity is a fundamental property of the adult human brain and might be harnessed to remap or create new neural pathways. Capitalizing on this innovative understanding, the authors introduced a paradigm shift in the clinical practice in 1989 when they initiated the development of the Massachusetts Institute of Technology-Manus robot for neurorehabilitation and deployed it in the clinic in 1994 (Krebs et al. 1998). Since then, the authors and others have developed and tested a multitude of robotic devices for stroke, spinal cord injury, cerebral palsy, multiple sclerosis, and Parkinson disease. Here, the authors discuss whether robotic therapy has achieved a level of maturity to justify its broad adoption in the clinical realm as a tool for motor recovery.

Portable upper extremity robotics is as efficacious as upper extremity rehabilitative therapy: a randomized controlled pilot trial

OBJECTIVE

To compare the efficacy of a repetitive task-specific practice regimen integrating a portable, electromyography-controlled brace called the 'Myomo' versus usual care repetitive task-specific practice in subjects with chronic, moderate upper extremity impairment.

SUBJECTS

Sixteen subjects (7 males; mean age 57.0 ± 11.02 years; mean time post stroke 75.0 ± 87.63 months; 5 left-sided strokes) exhibiting chronic, stable, moderate upper extremity impairment.

INTERVENTIONS

Subjects were administered repetitive task-specific practice in which they participated in valued, functional tasks using their paretic upper extremities. Both groups were supervised by a therapist and were administered therapy targeting their paretic upper extremities that was 30 minutes in duration, occurring 3 days/week for eight weeks. One group participated in repetitive task-specific practice entirely while wearing the portable robotic, while the other performed the same activity regimen manually.

MAIN OUTCOME MEASURES

The upper extremity Fugl-Meyer, Canadian Occupational Performance Measure and Stroke Impact Scale were administered on two occasions before intervention and once after intervention.

RESULTS

After intervention, groups exhibited nearly identical Fugl-Meyer score increases of ≈2.1 points; the group using robotics exhibited larger score changes on all but one of the Canadian Occupational Performance Measure and Stroke Impact Scale subscales, including a 12.5-point increase on the Stroke Impact Scale recovery subscale.

CONCLUSIONS

Findings suggest that therapist-supervised repetitive task-specific practice integrating robotics is as efficacious as manual practice in subjects with moderate upper extremity impairment.

Dose-response relationship of robot-assisted stroke motor rehabilitation: the impact of initial motor status

BACKGROUND AND PURPOSE

The increasing availability of robot-assisted therapy (RT), which provides quantifiable, reproducible, interactive, and intensive practice, holds promise for stroke rehabilitation, but data on its dose-response relation are scanty. This study used 2 different intensities of RT to examine the treatment effects of RT and the effect on outcomes of the severity of initial motor deficits.

METHODS

Fifty-four patients with stroke were randomized to a 4-week intervention of higher-intensity RT, lower-intensity RT, or control treatment. The primary outcome, the Fugl-Meyer Assessment, was administered at baseline, midterm, and posttreatment. Secondary outcomes included the Medical Research Council scale, the Motor Activity Log, and the physical domains of the Stroke Impact Scale.

RESULTS

The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment than the lower-intensity RT and control treatment groups at midterm (P=0.003 and P=0.02) and at posttreatment (P=0.04 and P=0.02). Within-group gains on the secondary outcomes were significant, but the differences among the 3 groups did not reach significance. Recovery rates of the higher-intensity RT group were higher than those of the lower-intensity RT group, particularly on the Fugl-Meyer Assessment. Scatterplots with curve fitting showed that patients with moderate motor deficits gained more improvements than those with severe or mild deficits after the higher-intensity RT.

CONCLUSIONS

This study demonstrated the higher treatment intensity provided by RT was associated with better motor outcome for patients with stroke, which may shape further stroke rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00917605.

Afferent and efferent activity control in the design of brain computer interfaces for motor rehabilitation

Stroke is a cardiovascular accident within the brain resulting in motor and sensory impairment in most of the survivors. A stroke can produce complete paralysis of the limb although sensory abilities are normally preserved. Functional electrical stimulation (FES), robotics and brain computer interfaces (BCIs) have been used to induce motor rehabilitation. In this work we measured the brain activity of healthy volunteers using electroencephalography (EEG) during FES, passive movements, active movements, motor imagery of the hand and resting to compare afferent and efferent brain signals produced during these motor related activities and to define possible features for an online FES-BCI. In the conditions in which the hand was moved we limited the movement range in order to control the afferent flow. Although we observed that there is a subject dependent frequency and spatial distribution of efferent and afferent signals, common patterns between conditions and subjects were present mainly in the low beta frequency range. When averaging all the subjects together the most significant frequency bin comparing each condition versus rest was exactly the same for all conditions but motor imagery. These results suggest that to implement an on-line FES-BCI, afferent brain signals resulting from FES have to be filtered and time-frequency-spatial features need to be used.

Effect of therapist-based versus robot-assisted bilateral arm training on motor control, functional performance, and quality of life after chronic stroke: a clinical trial

BACKGROUND

Although bilateral arm training (BAT) has been widely studied, the comparative effects of therapist-based BAT (TBAT) versus robot-assisted BAT (RBAT) remains unknown.

OBJECTIVE

This study compared the efficacy of TBAT, RBAT, and a control treatment (CT) on motor control, functional performance, and quality of life after chronic stroke.

DESIGN

A randomized, pretest-posttest, control group design was used.

METHODS

Forty-two patients (mean age=54.49 years, SD=9.69; mean length of time since stroke onset=17.62 months, SD=10.50) were randomly assigned to TBAT, RBAT, and CT groups. Each group received treatment for 90 to 105 minutes per session, 5 sessions on weekdays, for 4 weeks. Outcome measures included kinematic analyses, the Fugl-Meyer Assessment (FMA), the Motor Activity Log, and the Stroke Impact Scale (SIS).

RESULTS

Large and significant effects were found in the kinematic variables, distal part of upper-limb motor impairment, and certain aspects of quality of life in favor of TBAT or RBAT. Specifically, the TBAT group demonstrated significantly better temporal efficiency and smoothness, straighter trunk motion, and less trunk compensation compared with the CT and RBAT groups. The RBAT group had increased shoulder flexion compared with the CT and TBAT groups. On the FMA, the TBAT group showed higher distal part scores than the CT group. On the SIS, the RBAT group had better strength subscale, physical function domain, and total scores than the CT group. Limitations This study recruited patients with mild spasticity and without cognitive impairment.

CONCLUSIONS

Compared with CT, TBAT and RBAT exhibited differential effects on outcome measures. Therapist-based BAT may improve temporal efficiency, smoothness, trunk control, and motor impairment of the distal upper limb. Robot-assisted BAT may improve shoulder flexion and quality of life.

Electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength after stroke

BACKGROUND

Electromechanical and robot-assisted arm training devices are used in rehabilitation, and might help to improve arm function after stroke.

OBJECTIVES

To assess the effectiveness of electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength in patients after stroke. We will also assess the acceptability and safety of the therapy.

SEARCH METHODS

We searched the Cochrane Stroke Group's Trials Register (last searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 7), MEDLINE (1950 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011), AMED (1985 to July 2011), SPORTDiscus (1949 to July 2011), PEDro (searched August 2011), COMPENDEX (1972 to July 2011), and INSPEC (1969 to July 2011). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts and researchers in our field, as well as manufacturers of commercial devices.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for patients after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables.

MAIN RESULTS

We included 19 trials (involving 666 participants) in this update of our review. Electromechanical and robot-assisted arm training did improve activities of daily living (SMD 0.43, 95% confidence interval (CI) 0.11 to 0.75, P = 0.009, I(2) = 67%) as well as arm function (SMD 0.45, 95% CI 0.20 to 0.69, P = 0.0004, I(2) = 45%), but arm muscle strength did not improve (SMD 0.48, 95% CI -0.06 to 1.03, P = 0.08, I(2) = 79%). Electromechanical and robot-assisted arm training did not increase the risk of patients to drop out (RD 0.00, 95% CI -0.04 to 0.04, P = 0.82, I(2) = 0.0%), and adverse events were rare.

AUTHORS' CONCLUSIONS

Patients who receive electromechanical and robot-assisted arm training after stroke are more likely to improve their generic activities of daily living. Paretic arm function may also improve, but not arm muscle strength. However, the results must be interpreted with caution because there were variations between the trials in the duration and amount of training, type of treatment, and in the patient characteristics.

Resting State Changes in Functional Connectivity Correlate With Movement Recovery for BCI and Robot-Assisted Upper-Extremity Training After Stroke

Background. Robot-assisted training may improve motor function in some hemiparetic patients after stroke, but no physiological predictor of rehabilitation progress is reliable. Resting state functional magnetic resonance imaging (RS-fMRI) may serve as a method to assess and predict changes in the motor network. Objective. The authors examined the effects of upper-extremity robot-assisted rehabilitation (MANUS) versus an electroencephalography-based brain computer interface setup with motor imagery (MI EEG-BCI) and compared pretreatment and posttreatment RS-fMRI. Methods. In all, 9 adults with upper-extremity paresis were trained for 4 weeks with a MANUS shoulder-elbow robotic rehabilitation paradigm. In 3 participants, robot-assisted movement began if no voluntary movement was initiated within 2 s. In 6 participants, MI-BCI–based movement was initiated if motor imagery was detected. RS-fMRI and Fugl-Meyer (FM) upper-extremity motor score were assessed before and after training. Results. The individual gain in FM scores over 12 weeks could be predicted from functional connectivity changes (FCCs) based on the pre-post differences in RS-fMRI measurements. Both the FM gain and FCC were numerically higher in the MI-BCI group. Increases in FC of the supplementary motor area, the contralesional and ipsilesional motor cortex, and parts of the visuospatial system with mostly association cortex regions and the cerebellum correlated with individual upper-extremity function improvement. Conclusion. FCC may predict the steepness of individual motor gains. Future training could therefore focus on directly inducing these beneficial increases in FC. Evaluation of the treatment groups suggests that MI is a potential facilitator of such neuroplasticity.

Home-based therapy programmes for upper limb functional recovery following stroke

BACKGROUND

With an increased focus on home-based stroke services and the undertaking of programmes, targeted at upper limb recovery within clinical practice, a systematic review of home-based therapy programmes for individuals with upper limb impairment following stroke was required.

OBJECTIVES

To determine the effects of home-based therapy programmes for upper limb recovery in patients with upper limb impairment following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group's Specialised Trials Register (May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to May 2011), EMBASE (1980 to May 2011), AMED (1985 to May 2011) and six additional databases. We also searched reference lists and trials registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults after stroke, where the intervention was a home-based therapy programme targeted at the upper limb, compared with placebo, or no intervention or usual care. PRIMARY OUTCOMES were performance in activities of daily living (ADL) and functional movement of the upper limb. SECONDARY OUTCOMES were performance in extended ADL and motor impairment of the arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook assessment of risk of bias in terms of method of randomisation and allocation concealment (selection bias), blinding of outcome assessment (detection bias), whether all the randomised patients were accounted for in the analysis (attrition bias) and the presence of selective outcome reporting.

MAIN RESULTS

We included four studies with 166 participants. No studies compared the effects of home-based upper limb therapy programmes with placebo or no intervention. Three studies compared the effects of home-based upper limb therapy programmes with usual care.

PRIMARY OUTCOMES

we found no statistically significant result for performance of ADL (mean difference (MD) 2.85; 95% confidence interval (CI) -1.43 to 7.14) or functional movement of the upper limb (MD 2.25; 95% CI -0.24 to 4.73)).

SECONDARY OUTCOMES

no statistically significant results for extended ADL (MD 0.83; 95% CI -0.51 to 2.17)) or upper limb motor impairment (MD 1.46; 95% CI -0.58 to 3.51). One study compared the effects of a home-based upper limb programme with the same upper limb programme based in hospital, measuring upper limb motor impairment only; we found no statistically significant difference between groups (MD 0.60; 95% CI -8.94 to 10.14).

AUTHORS' CONCLUSIONS

There is insufficient good quality evidence to make recommendations about the relative effect of home-based therapy programmes compared with placebo, no intervention or usual care.

Breaking it down is better: haptic decomposition of complex movements aids in robot-assisted motor learning

Training with haptic guidance has been proposed as a technique for learning complex movements in rehabilitation and sports, but it is unclear how to best deliver guidance-based training. Here, we hypothesized that breaking down a complex movement, similar to a tennis backhand, into simpler parts and then using haptic feedback from a robotic exoskeleton would help the motor system learn the movement. We also examined how the particular form of the decomposition affected learning. Three groups of unimpaired participants trained with the target arm movement broken down in three ways: 1) elbow flexion/extension and the unified shoulder motion independently ("anatomical" decomposition), 2) three component shoulder motions in Euler coordinates and elbow flexion/extension ("Euler" decomposition), or 3) the motion of the tip of the elbow and motion of the hand with respect to the elbow, independently ("visual" decomposition). A control group practiced the same number of movements, but experienced the target motion only, achieving eight times more direct practice with this motion. Despite less experience with the target motion, part training was better, but only when the arm trajectory was decomposed into anatomical components. Varying robotic movement training to include practice of simpler, anatomically-isolated motions may enhance its efficacy.

Constraining upper limb synergies of hemiparetic patients using a robotic exoskeleton in the perspective of neuro-rehabilitation

The aim of this paper was to explore how an upper limb exoskeleton can be programmed to impose specific joint coordination patterns during rehabilitation. Based on rationale which emphasizes the importance of the quality of movement coordination in the motor relearning process, a robot controller was developed with the aim of reproducing the individual corrections imposed by a physical therapist on a hemiparetic patient during pointing movements. The approach exploits a description of the joint synergies using principal component analysis (PCA) on joint velocities. This mathematical tool is used both to characterize the patient's movements, with or without the assistance of a physical therapist, and to program the exoskeleton during active-assisted exercises. An original feature of this controller is that the hand trajectory is not imposed on the patient: only the coordination law is modified. Experiments with hemiparetic patients using this new active-assisted mode were conducted. Obtained results demonstrate that the desired inter-joint coordination was successfully enforced, without significantly modifying the trajectory of the end point.

Tracking motor improvement at the subtask level during robot-aided neurorehabilitation of stroke patients

BACKGROUND

Robot-aided neurorehabilitation can provide intensive, repetitious training to improve upper-limb function after stroke. To be more effective, motor therapy ought to be progressive and continuously challenge the patient's ability. Current robotic systems have limited customization capability and require a physiotherapist to assess progress and adapt therapy accordingly.

OBJECTIVE

The authors aimed to track motor improvement during robot-assistive training and test a tool to more automatically adjust training.

METHODS

A total of 18 participants with chronic stroke were trained using a multicomponent reaching task assisted by a shoulder-elbow robotic assist. The time course of motor gains was assessed for each subtask of the practiced exercise. A statistical algorithm was then tested on simulated data to validate its ability to track improvement and subsequently applied to the recorded data to determine its performance compared with a therapist.

RESULTS

Patients' recovery of motor function exhibited a time course dependent on the particular component of the executed task, suggesting that differential training on a subtask level is needed to continuously challenge the neuromuscular system and boost recovery. The proposed algorithm was tested on simulated data and was proven to track overall patient's progress during rehabilitation.

CONCLUSIONS

Tuning of the training program at the subtask level may accelerate the process of motor relearning. The algorithm proposed to adjust task difficulty opens new possibilities to automatically customize robotic-assistive training.

A comparison of motor adaptations to robotically facilitated upper extremity task practice demonstrated by children with cerebral palsy and adults with stroke

Nine children with cerebral palsy and nine adults with stroke were trained using 5 different upper extremity simulations using the NJIT-RAVR system for approximately nine to twelve hours over a three week period. Both groups made improvements in clinical measurements of upper extremity function and reaching kinematics. Patterns and magnitudes of improvement differ between the two groups. Responses to training required adjustment of the robotic system to accommodate the rehabilitation needs of children with cerebral palsy.

Effects of a robot-assisted training of grasp and pronation/supination in chronic stroke: a pilot study

Background

Rehabilitation of hand function is challenging, and only few studies have investigated robot-assisted rehabilitation focusing on distal joints of the upper limb. This paper investigates the feasibility of using the HapticKnob, a table-top end-effector device, for robot-assisted rehabilitation of grasping and forearm pronation/supination, two important functions for activities of daily living involving the hand, and which are often impaired in chronic stroke patients. It evaluates the effectiveness of this device for improving hand function and the transfer of improvement to arm function.

Methods

A single group of fifteen chronic stroke patients with impaired arm and hand functions (Fugl-Meyer motor assessment scale (FM) 10-45/66) participated in a 6-week 3-hours/week rehabilitation program with the HapticKnob. Outcome measures consisted primarily of the FM and Motricity Index (MI) and their respective subsections related to distal and proximal arm function, and were assessed at the beginning, end of treatment and in a 6-weeks follow-up.

Results

Thirteen subjects successfully completed robot-assisted therapy, with significantly improved hand and arm motor functions, demonstrated by an average 3.00 points increase on the FM and 4.55 on the MI at the completion of the therapy (4.85 FM and 6.84 MI six weeks post-therapy). Improvements were observed both in distal and proximal components of the clinical scales at the completion of the study (2.00 FM wrist/hand, 2.55 FM shoulder/elbow, 2.23 MI hand and 4.23 MI shoulder/elbow). In addition, improvements in hand function were observed, as measured by the Motor Assessment Scale, grip force, and a decrease in arm muscle spasticity. These results were confirmed by motion data collected by the robot.

Conclusions

The results of this study show the feasibility of this robot-assisted therapy with patients presenting a large range of impairment levels. A significant homogeneous improvement in both hand and arm function was observed, which was maintained 6 weeks after end of the therapy.

Physical activity in the prevention and treatment of stroke

The role of physical activity in the prevention of stroke is of great interest due to the high mortality and significant impact of stroke-related morbidity on the individual and on healthcare resources. The use of physical activity as a therapeutic strategy to maximise functional recovery in the rehabilitation of stroke survivors has a growing evidence base. This narrative review examines the existing literature surrounding the use of exercise and physical therapy in the primary and secondary prevention of stroke. It explores the effect of gender, exercise intensities and the duration of observed benefit. It details the most recent evidence for physical activity in improving functional outcome in stroke patients. The review summaries the current guidelines and recommendations for exercise therapy and highlights areas in which further research and investigation would be useful to determine optimal exercise prescription for effective prevention and rehabilitation in stroke.

Reversal of TMS-induced motor twitch by training is associated with a reduction in excitability of the antagonist muscle

Background

A single session of isolated repetitive movements of the thumb can alter the response to transcranial magnetic stimulation (TMS), such that the related muscle twitch measured post-training occurs in the trained direction. This response is attributed to transient excitability changes in primary motor cortex (M1) that form the early part of learning. We investigated; (1) whether this phenomenon might occur for movements at the wrist, and (2) how specific TMS activation patterns of opposing muscles underlie the practice-induced change in direction.

Methods

We used single-pulse suprathreshold TMS over the M1 forearm area, to evoke wrist movements in 20 healthy subjects. We measured the preferential direction of the TMS-induced twitch in both the sagittal and coronal plane using an optical goniometer fixed to the dorsum of the wrist, and recorded electromyographic (EMG) activity from the flexor carpi radialis (FCR) and extensor carpi radialis (ECR) muscles. Subjects performed gentle voluntary movements, in the direction opposite to the initial twitch for 5 minutes at 0.2 Hz. We collected motor evoked potentials (MEPs) elicited by TMS at baseline and for 10 minutes after training.

Results

Repetitive motor training was sufficient for TMS to evoke movements in the practiced direction opposite to the original twitch. For most subjects the effect of the newly-acquired direction was retained for at least 10 minutes before reverting to the original. Importantly, the direction change of the movement was associated with a significant decrease in MEP amplitude of the antagonist to the trained muscle, rather than an increase in MEP amplitude of the trained muscle.

Conclusions

These results demonstrate for the first time that a TMS-twitch direction change following a simple practice paradigm may result from reduced corticospinal drive to muscles antagonizing the trained direction. Such findings may have implications for training paradigms in neurorehabilitation.

Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial

OBJECTIVE

To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Stroke units in three medical centres.

SUBJECTS

Twenty patients post stroke for a mean of 22 months.

INTERVENTION

Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90-105 minutes each day, 5 days per week, for four weeks.

MAIN MEASURES

Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire.

RESULTS

The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43).

CONCLUSIONS

Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.

An economic analysis of robot-assisted therapy for long-term upper-limb impairment after stroke

BACKGROUND AND PURPOSE

Stroke is a leading cause of disability. Rehabilitation robotics have been developed to aid in recovery after a stroke. This study determined the additional cost of robot-assisted therapy and tested its cost-effectiveness.

METHODS

We estimated the intervention costs and tracked participants' healthcare costs. We collected quality of life using the Stroke Impact Scale and the Health Utilities Index. We analyzed the cost data at 36 weeks postrandomization using multivariate regression models controlling for site, presence of a prior stroke, and Veterans Affairs costs in the year before randomization.

RESULTS

A total of 127 participants were randomized to usual care plus robot therapy (n=49), usual care plus intensive comparison therapy (n=50), or usual care alone (n=28). The average cost of delivering robot therapy and intensive comparison therapy was $5152 and $7382, respectively (P<0.001), and both were significantly more expensive than usual care alone (no additional intervention costs). At 36 weeks postrandomization, the total costs were comparable for the 3 groups ($17 831 for robot therapy, $19 746 for intensive comparison therapy, and $19 098 for usual care). Changes in quality of life were modest and not statistically different.

CONCLUSIONS

The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group. However, uncertainty remains about the cost-effectiveness of robotic-assisted rehabilitation compared with traditional rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00372411.

Harnessing neuroplasticity for clinical applications

Neuroplasticity can be defined as the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections. Major advances in the understanding of neuroplasticity have to date yielded few established interventions. To advance the translation of neuroplasticity research towards clinical applications, the National Institutes of Health Blueprint for Neuroscience Research sponsored a workshop in 2009. Basic and clinical researchers in disciplines from central nervous system injury/stroke, mental/addictive disorders, paediatric/developmental disorders and neurodegeneration/ageing identified cardinal examples of neuroplasticity, underlying mechanisms, therapeutic implications and common denominators. Promising therapies that may enhance training-induced cognitive and motor learning, such as brain stimulation and neuropharmacological interventions, were identified, along with questions of how best to use this body of information to reduce human disability. Improved understanding of adaptive mechanisms at every level, from molecules to synapses, to networks, to behaviour, can be gained from iterative collaborations between basic and clinical researchers. Lessons can be gleaned from studying fields related to plasticity, such as development, critical periods, learning and response to disease. Improved means of assessing neuroplasticity in humans, including biomarkers for predicting and monitoring treatment response, are needed. Neuroplasticity occurs with many variations, in many forms, and in many contexts. However, common themes in plasticity that emerge across diverse central nervous system conditions include experience dependence, time sensitivity and the importance of motivation and attention. Integration of information across disciplines should enhance opportunities for the translation of neuroplasticity and circuit retraining research into effective clinical therapies.

Robot-aided therapy for upper limbs in patients with stroke-related lesions. Brief report of a clinical experience

This study was aimed at verifying the improvement on the motor impairment and functionality in 19 patients with chronic hemiparesis after stroke treated with a robot-aided rehabilitation protocol using the ReoGo™ system (Motorika Medical Ltd, Israel), and at evaluating the persistence of the effects after 1 month. The study also focused on the actual possibility of administering the robot-aided therapy with the ReoGo™ for the upper limbs and on the patients' degree of acceptance and compliance with the treatment. Subjects underwent an assessment prior to the start of the rehabilitation project (T-1), one at the start (T0), one at the end of the treatment (T1) and one after one month from the end of the treatment (T2). The following tests were administered: (i) Fugl-Meyer (FM) upper limb; Ashworth scale (AS); Functional Independence Measure (FIM™) (T-1 - T2); (ii) strength evaluation; Visual Analogue Scale (VAS) for pain; Frenchay Arm test (FAT); Box and Block test (BBT); Timed Up and Go (TUG) test (T0 - T2). Additionally, the Euro-QoL questionnaire and a VAS for the treatment satisfaction were administered to the subjects. Non-statistical difference of scores at T-1 and T0 on almost the entire battery of tasks suggested a stable patients' performance prior to the start of the rehabilitation. With the exception of the Medical Research Council (MRC) and the AS sub-scales measuring -as appropriate- strength and spasticity of the shoulder, triceps and wrist, all scores showed a significant increase between T0 and T1. The improvement on the pain could not be proved significant (p = 0.10). A significant increase between T0 and T2 was found for all assessment scores, with the exception of the MRC for external shoulder rotators (p = 0.05) and of the AS for shoulder (p = 0.32) and wrist (p = 0.08). Substantial stability was observed between T1 and T2. Patients were capable of completing the treatment and showed good participant satisfaction. This pilot study led to the finding of a clinical improvement and excellent patients compliance. It is possible that the learning process experienced by the patients was robot-dependent, especially in consideration of the general maintenance of the achievements observed on all activities.

Effects of Treatment Intensity in Upper Limb Robot-Assisted Therapy for Chronic Stroke

Background and Objectives. Robot-assisted therapy (RT) is a current promising intervention in stroke rehabilitation, but more research is warranted for examining its efficacy and the dose–benefit relation. The authors investigated the effects of higher intensity versus lower intensity RT on movements of forearm pronation–supination and wrist flexion–extension relative to conventional rehabilitation (CR) in patients poststroke for a mean of 21 months. Methods. In this pilot study, 18 patients with initial mean Fugl-Meyer Assessment (FMA) of 37 to 44 for the upper extremity were randomized to higher intensity RT, lower intensity RT, or CR intervention for 4 weeks. The dose of the higher intensity RT was twice the number of repetitions in the lower intensity RT. Outcome measures at pretreatment and posttreatment were administered to patients to evaluate beneficial and adverse effects of interventions. Primary outcomes were the FMA and Medical Research Council scale. Results. There were significant differences in motor function ( P = .04) and daily performance ( P = .03) among the 3 groups. The higher intensity RT group showed better improvement in motor function, muscle strength, performance of daily activities, and bimanual ability than the other 2 groups. The intensive RT intervention did not induce higher levels of an oxidative DNA biomarker. Conclusions. Higher intensity of RT that assists forearm and wrist movements may lead to greater improvement in motor ability and functional performance in stroke patients. A sample size of only 20 to 25 in each arm of a larger randomized controlled trial is needed to confirm the findings for similar subjects.

Interventions to promote upper limb recovery in stroke survivors with severe paresis: a systematic review

PURPOSE

To investigate the effect of interventions that promote upper limb (UL) recovery in stroke survivors with severe paresis.

METHODS

A systematic search of the scientific literature from January 1970 to March 2009 was conducted using CINAHL, Cochrane, PEDro, Pubmed and Web of Science. keywords used included stroke, severe, hemiplegia, UL, task-oriented, robot, non-robot and electrical stimulation. Methodological quality of the studies was assessed using the PEDro rating scale. Studies were grouped into one of three intervention categories: robotic therapy, electrical stimulation or 'other' therapy.

RESULTS

Seventeen randomised controlled trials met the inclusion criteria. A 'best evidence synthesis' indicated strong evidence that robotic therapy provides a large beneficial effect and limited evidence that electrical stimulation and 'other' interventions provide a large beneficial effect on function. There is no evidence that these interventions influence use of the arm in everyday tasks.

CONCLUSION

There are a number of newly developed interventions that enable stroke survivors with severe paresis to actively participate in task-oriented practice to promote UL recovery. While these interventions offer some promise for stroke survivors with severe paresis, ultimately, the effectiveness of these interventions will be dependent on whether they lead to restoration of function to the point at which the stroke survivor can practice everyday tasks.

The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study

Background

Few research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis.

Methods

A case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT).

Results

Muscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (p = 0.02), while a trend towards significance was found for the 9HPT (p = 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (p = 0.01, p = 0.02 respectively).

Conclusions

The results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.

Physically interactive robotic technology for neuromotor rehabilitation

Robotic technology can provide innovative responses to the severe challenges of providing cost-effective care to restore sensory-motor function following neurological and biomechanical injury. It may be deployed at several points on a continuum of care, to provide precisely controlled sensory-motor therapy to ameliorate disability and promote recovery of function, or to provide assistance to compensate for functions that cannot be recovered, or to replace limbs lost irretrievably. This chapter reviews recent progress using robotic technology to capitalize on neural plasticity and promote recovery after neurological injury such as stroke (cerebral vascular accident), research on brain-computer interfaces as a source of control signals for assistive technologies, and research on high-performance multiple-degree-of-freedom upper-extremity prosthetic limbs.

Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial

BACKGROUND AND PURPOSE

This randomized controlled trial tests the efficacy of bilateral arm training with rhythmic auditory cueing (BATRAC) versus dose-matched therapeutic exercises (DMTEs) on upper-extremity (UE) function in stroke survivors and uses functional magnetic resonance imaging (fMRI) to examine effects on cortical reorganization.

METHODS

A total of 111 adults with chronic UE paresis were randomized to 6 weeks (3×/week) of BATRAC or DMTE. Primary end points of UE assessments of Fugl-Meyer UE Test (FM) and modified Wolf Motor Function Test Time (WT) were performed 6 weeks prior to and at baseline, after training, and 4 months later. Pretraining and posttraining, fMRI for UE movement was evaluated in 17 BATRAC and 21 DMTE participants.

RESULTS

The improvements in UE function (BATRAC: FM Δ = 1.1 + 0.5, P = .03; WT Δ = -2.6 + 0.8, P < .00; DMTE: FM Δ = 1.9 + 0.4, P < .00; WT Δ = -1.6 + 0.7; P = .04) were comparable between groups and retained after 4 months. Satisfaction was higher after BATRAC than DMTE (P = .003). BATRAC led to significantly higher increase in activation in ipsilesional precentral, anterior cingulate and postcentral gyri, and supplementary motor area and contralesional superior frontal gyrus (P < .05). Activation change in the latter was correlated with improvement in the WMFT (P = .01).

CONCLUSIONS

BATRAC is not superior to DMTE, but both rehabilitation programs durably improve motor function for individuals with chronic UE hemiparesis and with varied deficit severity. Adaptations in brain activation are greater after BATRAC than DMTE, suggesting that given similar benefits to motor function, these therapies operate through different mechanisms.

Robot-assisted therapy for long-term upper-limb impairment after stroke

BACKGROUND

Effective rehabilitative therapies are needed for patients with long-term deficits after stroke.

METHODS

In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks.

RESULTS

At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported.

CONCLUSIONS

In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

A clinical study of motor imagery-based brain-computer interface for upper limb robotic rehabilitation

Non-invasive EEG-based motor imagery brain-computer interface (MI-BCI) holds promise to effectively restore motor control to stroke survivors. This clinical study investigates the effects of MI-BCI for upper limb robotic rehabilitation compared to standard robotic rehabilitation. The subjects are hemiparetic stroke patients with mean age of 50.2 and baseline Fugl-Meyer (FM) score 29.7 (out of 66, higher = better) randomly assigned to each group respectively (N = 8 and 10). Each subject underwent 12 sessions of 1-hour rehabilitation for 4 weeks. Significant gains in FM scores were observed in both groups at post-rehabilitation (4.9, p = 0.001) and 2-month post-rehabilitation (4.9, p = 0.002). The experimental group yielded higher 2-month post-rehabilitation gain than the control (6.0 versus 4.0) but no significance was found (p = 0.475). However, among subjects with positive gain (N = 6 and 7), the initial difference of 2.8 between the two groups was increased to a significant 6.5 (p = 0.019) after adjustment for age and gender. Hence this study provides evidence that BCI-driven robotic rehabilitation is effective in restoring motor control for stroke.

Do robotic and non-robotic arm movement training drive motor recovery after stroke by a common neural mechanism? Experimental evidence and a computational model

Different dose-matched, upper extremity rehabilitation training techniques, including robotic and non-robotic techniques, can result in similar improvement in movement ability after stroke, suggesting they may elicit a common drive for recovery. Here we report experimental results that support the hypothesis of a common drive, and develop a computational model of a putative neural mechanism for the common drive. We compared weekly motor control recovery during robotic and unassisted movement training techniques after chronic stroke (n = 27), as assessed with quantitative measures of strength, speed, and coordination. The results showed that recovery in both groups followed an exponential time course with a time constant of about 4-5 weeks. Despite the greater range and speed of movement practiced by the robot group, motor recovery was very similar between the groups. The premise of the computational model is that improvements in motor control are caused by improvements in the ability to activate spared portions of the damaged corticospinal system, as learned by a biologically plausible search algorithm. Robot-assisted and unassisted training would in theory equally drive this search process.

Use of a pneumatic glove for hand rehabilitation following stroke

Hand impairment is common following stroke and is often resistant to traditional therapy methods. Successful interventions have stressed the importance of repeated practice to facilitate rehabilitation. Thus, we have developed a servo-controlled glove to assist extension of individual digits to promote practice of grasp-and-release movements with the hand. This glove, the PneuGlove, permits free movement of the arm throughout its workspace. A novel immersive virtual reality environment was created for training movement in conjunction with the device. Seven stroke survivors with chronic hand impairment participated in 18 training sessions with the PneuGlove over 6 weeks. Overall, subjects displayed a significant 6-point improvement in the upper extremity score on the Fugl-Meyer assessment and this increase was maintained at the evaluation held one month after conclusion of all training (p < 0.01). The majority of this gain came from an increase in the hand/wrist score (3.8-point increase, p < 0.01). Thus, the system shows promise for rehabilitative training of hand movements after stroke.

Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: four single-cases

Background

Robot-assisted therapy offers a promising approach to neurorehabilitation, particularly for severely to moderately impaired stroke patients. The objective of this study was to investigate the effects of intensive arm training on motor performance in four chronic stroke patients using the robot ARMin II.

Methods

ARMin II is an exoskeleton robot with six degrees of freedom (DOF) moving shoulder, elbow and wrist joints. Four volunteers with chronic (≥ 12 months post-stroke) left side hemi-paresis and different levels of motor severity were enrolled in the study. They received robot-assisted therapy over a period of eight weeks, three to four therapy sessions per week, each session of one hour.

Patients 1 and 4 had four one-hour training sessions per week and patients 2 and 3 had three one-hour training sessions per week. Primary outcome variable was the Fugl-Meyer Score of the upper extremity Assessment (FMA), secondary outcomes were the Wolf Motor Function Test (WMFT), the Catherine Bergego Scale (CBS), the Maximal Voluntary Torques (MVTs) and a questionnaire about ADL-tasks, progress, changes, motivation etc.

Results

Three out of four patients showed significant improvements (p < 0.05) in the main outcome. The improvements in the FMA scores were aligned with the objective results of MVTs. Most improvements were maintained or even increased from discharge to the six-month follow-up.

Conclusion

Data clearly indicate that intensive arm therapy with the robot ARMin II can significantly improve motor function of the paretic arm in some stroke patients, even those in a chronic state. The findings of the study provide a basis for a subsequent controlled randomized clinical trial.

Motor rehabilitation after stroke, traumatic brain, and spinal cord injury: common denominators within recent clinical trials

PURPOSE OF REVIEW

Experimental studies and clinical trials that aim to improve motor function for use of the upper extremity and walking are traditionally separated by the category of neurological disease. This boundary may deter investigators from finding common denominators in the conceptual basis and deployment of rehabilitation interventions, especially across nonprogressive diseases in adults, such as stroke, brain trauma, and spinal cord injury.

RECENT FINDINGS

The results of recent randomized clinical trials for walking by treadmill training and robotic devices and for the upper extremity by constraint-induced therapy, robotics, and brain stimulation suggest that more efficient strategies are needed to devise and prove the value of new therapies.

SUMMARY

Investigators should consider working across disease platforms to develop and test the most optimal methods for training patients, the most practical trial designs, the best dose-response characteristics of interventions, the most meaningful outcome measures, and the likelihood of transfer of trained performance to real-world settings. Clinicians in the community may be more likely to adopt evidence-based practices drawn from positive trial results if these treatment strategies focus on key motor impairments and related disabilities, rather than on diseases.

[Contributions of robotic devices to upper limb poststroke rehabilitation]

INTRODUCTION

Poststroke rehabilitation care has evolved considerably over the last decade. The emergence of the concepts of brain plasticity and motor learning has led to the development of new therapeutic approaches. Most of the new strategies are based on movement therapy, which can have a real impact on neurological recovery, sometimes with significant functional benefit for the patient.

STATE OF THE ART

In this context of evolving practices, the hemiplegic arm is the subject of special attention. Considering the often unfavorable "natural" prognosis and the relatively limited impact of conventional therapies; researchers have focused work on new alternatives. Cooperation between developers of technological advances and the medical community has led to the development of innovative therapeutic options often based on the use of specific technological tools (functional electric stimulation, virtual reality, transcranial magnetic stimulation...) to solicit or facilitate movement.

PERSPECTIVES/CONCLUSION

Robot-assisted rehabilitation lies within this scope. The positive results reported in the most recent publications and the growing interest for this type of therapy in the fields of medical and engineering research should open the way for extremely promising prospects. The technological performance of new robots has nevertheless raised a large number of unanswered questions, implying a significant amount of further research.

Motor recovery after stroke: a systematic review

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

The effects of repeated rehabilitation "tune-ups" on functional recovery after focal ischemia in rats

BACKGROUND

For most stroke survivors, rehabilitation therapy is the only treatment option available. The beneficial effects of early rehabilitation on neuroplasticity and functional recovery have been modeled in experimental stroke using a combination of enriched environment and rehabilitation. However, the impact of a secondary intervention, such as a periodic return to therapy, remains unclear.

OBJECTIVE

This study examines whether a return to enriched rehabilitation (ie, "tune-up") can further promote functional recovery or produce beneficial changes in brain plasticity in the chronic phase of stroke recovery.

METHODS

Rats were exposed to focal ischemia (endothelin-1 applied to forelimb sensorimotor cortex and dorsolateral striatum) and allowed to recover either in standard housing or in a combination of enriched environment and rehabilitative reaching for 9 weeks. Animals were then exposed to rotating periods of standard housing (5 weeks) and intensive "tune-up" therapy consisting of various sensorimotor/cognitive activities (2 weeks). Functional recovery was assessed using the Montoya staircase, beam-traversing, and cylinder tests, and Golgi-Cox analysis was used to examine dendritic complexity in the contralesional forelimb motor cortex.

RESULTS

Although early enriched rehabilitation significantly improved sensorimotor function in both the beam and staircase tests, "tune-up" therapy had no effect on recovery. Golgi-Cox analysis revealed no effect of treatment on dendritic complexity.

CONCLUSIONS

This study reaffirms the benefits of early rehabilitation for functional recovery after stroke. However, "tune-up" therapy provided no benefit in ischemic animals regardless of earlier rehabilitation experience. It is possible that alternative approaches in the chronic phase may prove more effective.

Best Conventional Therapy Versus Modular Impairment-Oriented Training for Arm Paresis After Stroke: A Single-Blind, Multicenter Randomized Controlled Trial

Background. The study investigated whether passive splinting or active motor training as either individualized best conventional therapy or as standardized impairment-oriented training (IOT) would be superior in promoting motor recovery in subacute stroke patients with mildly or severely paretic arms. Methods. A total of 148 anterior circulation ischemic stroke patients were randomly assigned to 45 minutes of additional daily arm therapy over 3 to 4 weeks as either ( a) passive therapy with inflatable splints or active arm motor therapy as either ( b) individualized best conventional therapy (CONV) or ( c) standardized IOT, that is Arm BASIS training for severe paresis or Arm Ability training for mild paresis. Main outcome measures included the following: Fugl-Meyer arm motor score (severely paretic arms) and the TEMPA time scores (mildly affected arms). Pre—post (immediate effects) and pre—4 weeks follow-up analyses (long-term effects) were performed. Results. Overall improvements were documented (mean baseline and change scores efficacy: Fugl-Meyer, arm motor scores, 24.4, +9.1 points; TEMPA, 119, −26.6 seconds; P < .0001), but with no differential effects between splint therapy and the combined active motor rehabilitation groups. Both efficacy and effectiveness analyses indicated, however, bigger immediate motor improvements after IOT as compared with best conventional therapy (Fugl-Meyer, arm motor scores: IOT +12.3, CONV +9.2 points; TEMPA: IOT −31.1 seconds, CONV −20.5 seconds; P = .0363); for mildly affected patients long-term effects could also be substantiated. Conclusions. Specificity of active training seemed more important for motor recovery than intensity (therapy time). The comprehensive modular IOT approach promoted motor recovery in patients with either severe or mild arm paresis.

Multicenter randomized trial of robot-assisted rehabilitation for chronic stroke: methods and entry characteristics for VA ROBOTICS

BACKGROUND

Chronic upper extremity impairment due to stroke has significant medical, psychosocial, and financial consequences, but few studies have examined the effectiveness of rehabilitation therapy during the chronic stroke period.

OBJECTIVE

. To test the safety and efficacy of the MIT-Manus robotic device for chronic upper extremity impairment following stroke.

METHODS

. The VA Cooperative Studies Program initiated a multicenter, randomized, controlled trial in November 2006 (VA ROBOTICS). Participants with upper extremity impairment >/=6 months poststroke were randomized to robot-assisted therapy (RT), intensive comparison therapy (ICT), or usual care (UC). RT and ICT consisted of three 1-hour treatment sessions per week for 12 weeks. The primary outcome was change in the Fugl-Meyer Assessment upper extremity motor function score at 12 weeks relative to baseline. Secondary outcomes included the Wolf Motor Function Test and the Stroke Impact Scale.

RESULTS

. A total of 127 participants were randomized: 49 to RT, 50 to ICT, and 28 to UC. The majority of participants were male (96%), with a mean age of 65 years. The primary stroke type was ischemic (85%), and 58% of strokes occurred in the anterior circulation. Twenty percent of the participants reported a stroke in addition to their index stroke. The average time from the index stroke to enrollment was 56 months (range, 6 months to 24 years). The mean Fugl-Meyer score at entry was 18.9.

CONCLUSIONS

. VA ROBOTICS demonstrates the feasibility of conducting multicenter clinical trials to rigorously test new rehabilitative devices before their introduction to clinical practice. The results are expected in early 2010.

Progressive Staging of Pilot Studies to Improve Phase III Trials for Motor Interventions

Based on the suboptimal research pathways that finally led to multicenter randomized clinical trials (MRCTs) of treadmill training with partial body weight support and of robotic assistive devices, strategically planned successive stages are proposed for pilot studies of novel rehabilitation interventions. Stage 1, consideration-of-concept studies, drawn from animal experiments, theories, and observations, delineate the experimental intervention in a small convenience sample of participants, so the results must be interpreted with caution. Stage 2, development-of-concept pilots, should optimize the components of the intervention, settle on most appropriate outcome measures, and examine dose-response effects. A well-designed study that reveals no efficacy should be published to counterweight the confirmation bias of positive trials. Stage 3, demonstration-of-concept pilots, can build out from what has been learned to test at least 15 participants in each arm, using random assignment and blinded outcome measures. A control group should receive an active practice intervention aimed at the same primary outcome. A third arm could receive a substantially larger dose of the experimental therapy or a combinational intervention. If only 1 site performed this trial, a different investigative group should aim to reproduce positive outcomes based on the optimal dose of motor training. Stage 3 studies ought to suggest an effect size of 0.4 or higher, so that approximately 50 participants in each arm will be the number required to test for efficacy in a stage 4, proof-of-concept MRCT. By developing a consensus around acceptable and necessary practices for each stage, similar to CONSORT recommendations for the publication of phase III clinical trials, better quality pilot studies may move quickly into better designed and more successful MRCTs of experimental interventions.

A Comparison Between Electromyography-Driven Robot and Passive Motion Device on Wrist Rehabilitation for Chronic Stroke

Background. The effect of using robots to improve motor recovery has received increased attention, even though the most effective protocol remains a topic of study. Objective . The objective was to compare the training effects of treatments on the wrist joint of subjects with chronic stroke with an interactive rehabilitation robot and a robot with continuous passive motion. Methods. This study was a single-blinded randomized controlled trial with a 3-month follow-up. Twenty-seven hemiplegic subjects with chronic stroke were randomly assigned to receive 20-session wrist training with a continuous electromyography (EMG)-driven robot (interactive group, n = 15) and a passive motion device (passive group, n = 12), completed within 7 consecutive weeks. Training effects were evaluated with clinical scores by pretraining and posttraining tests (Fugl-Meyer Assessment [FMA] and Modified Ashworth Score [MAS]) and with session-by-session EMG parameters (EMG activation level and co-contraction index). Results. Significant improvements in FMA scores (shoulder/elbow and wrist/hand) were found in the interactive group ( P < .05). Significant decreases in the MAS were observed in the wrist and elbow joints for the interactive group and in the wrist joint for the passive group ( P < .05). These MAS changes were associated with the decrease in EMG activation level of the flexor carpi radialis and the biceps brachii for the interactive group ( P < .05). The muscle coordination on wrist and elbow joints was improved in the interactive groups in the EMG co-contraction indexes across the training sessions ( P < .05). Conclusions. The interactive treatment improved muscle coordination and reduced spasticity after the training for both the wrist and elbow joints, which persisted for 3 months. The passive mode training mainly reduced the spasticity in the wrist flexor.