Stroke Rehabilitation: Therapy Robots and Assistive Devices

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

The Effect of Diagonal Exercise Training for Neurorehabilitation on Functional Activity in Stroke Patients: A Pilot Study

Functional movements of the human body occur multifacetedly. This pilot study investigated the effects of neurorehabilitation training, including diagonal movements, balance, gait, fall efficacy, and activities of daily living in stroke patients. Twenty-eight patients diagnosed with stroke by a specialist were divided into experimental groups applying diagonal exercise training and control groups applying sagittal exercise training. The five times sit-to-stand test (FTSST), timed up and go (TUG) test, and Berg balance scale (BBS) were used to evaluate balance ability, the falls efficacy scale (FES) was used to evaluate fall efficacy, and the modified Barthel index (MBI) was used to evaluate activities of daily living. All evaluations were conducted once prior to intervention implementation and again six weeks after the final intervention. In the study results, the experimental group to which the diagonal exercise training was applied had statistically significant changes in FTSST, BBS, and FES compared to the control group. In conclusion, the rehabilitation program, including diagonal exercise training, increased the patient's balance and reduced the fear of falling.

Effects of trunk stabilization exercises using laser pointer visual feedback in patients with chronic stroke: A randomized controlled study

BACKGROUND

Many previous studies have cited the importance of trunk stabilization exercises in patients with stroke. However, the evidence for optimal trunk stabilization exercises for patients with stroke is still lacking.

OBJECTIVE

To investigate the effects of laser pointer visual feedback in trunk stabilization exercises that are important for improving trunk dysfunction in patients with stroke.

METHODS

In total, 30 patients with chronic stroke were randomly assigned to experimental and control groups. The experimental group underwent a traditional stroke rehabilitation program and trunk stabilization exercises using laser pointer visual feedback. The control group underwent a traditional stroke rehabilitation program and trunk stabilization exercises without visual feedback. Pre- and postintervention results after 6 weeks were evaluated using the Berg Balance Scale, static and dynamic plantar pressure, 10-m walk test, and the Korean version of the Fall Efficacy Scale. The results were analyzed using a general linear repeated measurement model.

RESULTS

Both groups showed significant improvements in BBS scores, static plantar pressure, dynamic plantar pressure, 10 MWT, and K-FES scores after 6 weeks of intervention (P< 0.05). Compared to the control group, significant improvements were observed in the experimental group in the Berg Balance Scale scores, dynamic paretic posterior plantar pressure, 10-m walk test, and Korean version of the Fall Efficacy Scale scores (P< 0.025).

CONCLUSION

Our results demonstrated the effectiveness of visual feedback during trunk stabilization exercises for resolving trunk dysfunction in patients with stroke. Trunk stabilization exercises using laser pointer visual feedback have been found to be more effective in balance, walking, and fall efficacy in patients with stroke.

The willingness and influencing factors to choose smart senior care among old adults in China

Background

Population aging has become an escalating issue in China resulting in increasing healthcare demand. Smart senior care has the potential to help older adults live independently and relieve the pressure of healthcare including home-based care. This study aimed to explore Chinese older adults’ preferred access models and service content of smart senior care and factors affecting their willingness to choose smart senior care.

Methods

This was a cross-sectional study. A total of 760 community-dwelling older adults from Xuzhou, China were included in this study. Their demographics, family support, health status, smart senior care use, and willingness to choose smart senior care were collected. The Chi-square test was used for single factor analysis of each variable. The statistically significant variables were included in the logistics regression model to analyze factors influencing older adults’ willingness to choose smart senior care. The chi-square goodness of fit test was used to analyze the preferred content and access models of smart senior care; the Bonferroni method was used to correct the results.

Results

The finding indicated that participants’ age, number of children, frequency of children visiting parents, adequate senior care, self-reported health, chronic diseases, smartphone use, and attitude toward smart senior care were significantly associated with their willingness to choose the smart senior care (p < 0.05). For smart senior care access models, participants preferred the remote monitoring model, telephone call model, and the community site model over the health smart home model and the smart application platform model. There was no statistical difference among these three preferred access models (p’ > 0.005). Regarding service content, participants desired medical care service the most (p’ < 0.005).

Conclusions

Chinese older adults’ willingness to choose smart senior care is affected by personal, family, health, and other factors. To develop China’s senior care, we should consider their demand and preference for smart senior care. It is important to enrich the content of smart senior care, especially on medical care services, and maintain the dynamic balance between supply and demand using a diverse supply approach.

Robotic Biofeedback for Post-Stroke Gait Rehabilitation: A Scoping Review

This review aims to recommend directions for future research on robotic biofeedback towards prompt post-stroke gait rehabilitation by investigating the technical and clinical specifications of biofeedback systems (BSs), including the complementary use with assistive devices and/or physiotherapist-oriented cues. A literature search was conducted from January 2019 to September 2022 on Cochrane, Embase, PubMed, PEDro, Scopus, and Web of Science databases. Data regarding technical (sensors, biofeedback parameters, actuators, control strategies, assistive devices, physiotherapist-oriented cues) and clinical (participants' characteristics, protocols, outcome measures, BSs' effects) specifications of BSs were extracted from the relevant studies. A total of 31 studies were reviewed, which included 660 stroke survivors. Most studies reported visual biofeedback driven according to the comparison between real-time kinetic or spatiotemporal data from wearable sensors and a threshold. Most studies achieved statistically significant improvements on sensor-based and clinical outcomes between at least two evaluation time points. Future research should study the effectiveness of using multiple wearable sensors and actuators to provide personalized biofeedback to users with multiple sensorimotor deficits. There is space to explore BSs complementing different assistive devices and physiotherapist-oriented cues according to their needs. There is a lack of randomized-controlled studies to explore post-stroke stage, mental and sensory effects of BSs.

Neuroimaging Techniques as Potential Tools for Assessment of Angiogenesis and Neuroplasticity Processes after Stroke and Their Clinical Implications for Rehabilitation and Stroke Recovery Prognosis

Stroke as the most frequent cause of disability is a challenge for the healthcare system as well as an important socio-economic issue. Therefore, there are currently a lot of studies dedicated to stroke recovery. Stroke recovery processes include angiogenesis and neuroplasticity and advances in neuroimaging techniques may provide indirect description of this action and become quantifiable indicators of these processes as well as responses to the therapeutical interventions. This means that neuroimaging and neurophysiological methods can be used as biomarkers—to make a prognosis of the course of stroke recovery and define patients with great potential of improvement after treatment. This approach is most likely to lead to novel rehabilitation strategies based on categorizing individuals for personalized treatment. In this review article, we introduce neuroimaging techniques dedicated to stroke recovery analysis with reference to angiogenesis and neuroplasticity processes. The most beneficial for personalized rehabilitation are multimodal panels of stroke recovery biomarkers, including neuroimaging and neurophysiological, genetic-molecular and clinical scales.

Global Trends and Hotspots in Research on Rehabilitation Robots: A Bibliometric Analysis From 2010 to 2020

Background: In recent years, with the development of medical science and artificial intelligence, research on rehabilitation robots has gained more and more attention, for nearly 10 years in the Web of Science database by journal of rehabilitation robot-related research literature analysis, to parse and track rehabilitation robot research hotspot and front, and provide some guidance for future research.

Methods: This study employed computer retrieval of rehabilitation robot-related research published in the core data collection of the Web of Science database from 2010 to 2020, using CiteSpace 5.7 visualization software. The hotspots and frontiers of rehabilitation robot research are analyzed from the aspects of high-influence countries or regions, institutions, authors, high-frequency keywords, and emergent words.

Results: A total of 3,194 articles were included. In recent years, the research on rehabilitation robots has been continuously hot, and the annual publication of relevant literature has shown a trend of steady growth. The United States ranked first with 819 papers, and China ranked second with 603 papers. Northwestern University ranked first with 161 publications. R. Riener, a professor at the University of Zurich, Switzerland, ranked as the first author with 48 articles. The Journal of Neural Engineering and Rehabilitation has the most published research, with 211 publications. In the past 10 years, research has focused on intelligent control, task analysis, and the learning, performance, and reliability of rehabilitation robots to realize the natural and precise interaction between humans and machines. Research on neural rehabilitation robots, brain–computer interface, virtual reality, flexible wearables, task analysis, and exoskeletons has attracted more and more attention.

Conclusions: At present, the brain–computer interface, virtual reality, flexible wearables, task analysis, and exoskeleton rehabilitation robots are the research trends and hotspots. Future research should focus on the application of machine learning (ML), dimensionality reduction, and feature engineering technologies in the research and development of rehabilitation robots to improve the speed and accuracy of algorithms. To achieve wide application and commercialization, future rehabilitation robots should also develop toward mass production and low cost. We should pay attention to the functional needs of patients, strengthen multidisciplinary communication and cooperation, and promote rehabilitation robots to better serve the rehabilitation medical field.

Objective assessment of the functional status of stroke patients: Can comprehensive rehabilitation treatment improve their functional efficiency?

Study aim: To check if the short rehabilitation treatment (3 weeks) complemented by complex rehabilitation on advanced equipment improves the functional status of chronic stroke patients; and which clinical and objective parameters can be used to assess the efficacy of such treatment.

Material and methods: 28 patients 3 to 6 months after the stroke. They participated in 3 weeks rehabilitation program in Rehabilitation Hospital. This program was supplemented by rehabilitation on: Zebris treadmill, ALFA and GAMMA platform, Biodex Balance System SD, the Balance Tutor treadmill. Their functional status was assessed by: Scandinavian Stroke Scale (SSS), Timed-Up-And-Go test (TUG), balance tests on Zebris, instrumented gait analysis on BTS system.

Results: The positive changes of the patients’ functional status were found in time of TUG test, in case of balance test for 95% of the ellipsoid area, lengths of major and minor axes of the ellipsoid, average sway speed, sway path length, total ground reaction force for left and right leg, and Gillette Gait Index in case of the gait analysis.

Conclusions: The improvement of the functional status of chronic stroke patients after relatively short rehabilitation treatment was achieved, due to the addition to the standard rehabilitation treatment the program on the advanced technologically equipment.

Efficiency of Leg Exoskeleton Use in Rehabilitation of Cerebral Stroke Patients

The study aimed to evaluate the effectiveness of functional and motor activity restoration, including the walking function, in patients after an ischemic stroke using the ExoAtlet lower limb exoskeleton.

Patients and methods. A clinical study was carried out on 42 patients who had undergone a cerebral infarction in the mid cerebral artery system with a post-stroke paresis of the leg, and who had undergone a rehabilitation course in a round-theclock hospital during the early recovery period. Patients were randomized into two equal groups comparable in terms of the stroke severity: the patients in group 1 were receiving a standard rehabilitation program (control group), the patients in group 2 were additionally receiving a course of gait rehabilitation using the ExoAtlet exoskeleton - 10 sessions, 5 sessions per week for 14 days.

Results. The study demonstrated the effectiveness of the ExoAtlet exoskeleton used in the rehabilitation of stroke patients over the standard course of rehabilitation. The advantages include a decrease in the hemiparesis degree, an increase in the muscle strength of the paretic limb, an improvement in balance, an improvement and acceleration of the walking process. The obtained results of the instrumental study confirmed the benefits of physical training on the Exoskeleton, which was demonstrated through an increase in stability and balance, as well as through a decrease in the energy consumption index for maintaining the stable verticalization.

Conclusion. The usage of the ExoAtlet exoskeleton increases the effectiveness of rehabilitation measures and improves motor and functional activities of patients who have suffered a cerebral stroke.

Effects of Combining Online Anodal Transcranial Direct Current Stimulation and Gait Training in Stroke Patients: A Systematic Review and Meta-Analysis

Objective: Combining transcranial direct current stimulation (tDCS) and repetitive gait training may be effective for gait performance recovery after stroke; however, the timing of stimulation to obtain the best outcomes remains unclear. We performed a systematic review and meta-analysis to establish evidence for changes in gait performance between online stimulation (tDCS and repetitive gait training simultaneously) and offline stimulation (gait training after tDCS). Methods: We comprehensively searched the electronic databases Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature, and included studies that combined cases of anodal tDCS with motor-related areas of the lower limbs and gait training. Nine studies fulfilled the inclusion criteria and were included in the systematic review, of which six were included in the meta-analysis. Result: The pooled effect estimate showed that anodal tDCS significantly improved the 10-m walking test (p = 0.04; I ² = 0%) and 6-min walking test (p = 0.001; I ² = 0%) in online stimulation compared to sham tDCS. Conclusion: Our findings suggested that simultaneous interventions may effectively improve walking ability. However, we cannot draw definitive conclusions because of the small sample size. More high-quality studies are needed on the effects of online stimulation, including various stimulation parameters.

Internet+Continuing Nursing (ICN) Program Promotes Motor Function Rehabilitation of Patients With Ischemic Stroke

BACKGROUND AND PURPOSE

Ischemic stroke is a severe disorder with high rates of death and recurrence that causes disability in patients and for which there is currently no effective treatment. Internet-based rehabilitation helps patients with disability recover at home with the help of their household or family members in a nonclinical setting. However, the effects of the internet+continuing nursing (ICN) program on the recovery of patients after ischemic stroke remains unknown.

METHODS

In the present study, patients were treated with an ICN-based rehabilitation training program; subsequently, the Self-efficacy Scale for Chronic Disease, Questionnaire of Exercise Adherence, Motor Assessment Scale, Activities of Daily Living, and Stroke-specific Quality of Life were performed to evaluate the effects of the ICN program on patient self-confidence to persist with rehabilitation, functional exercise compliance, motor function, ability to live independently and quality of life following ischemic stroke.

RESULTS

We observed that, after the ICN intervention for 6 weeks and 3 months, the scores of Self-efficacy Scale for Chronic Disease, Questionnaire of Exercise Adherence, Motor Assessment Scale, Activities of Daily Living, and Stroke-specific Quality of Life in the ICN-treated group were significantly higher compared with those in the control group.

CONCLUSION

These results suggested that the ICN program may promote the recovery of patients after ischemic stroke.

Incidence and Prevalence of Poststroke Shoulder Pain Among Different Regions of the World: A Systematic Review and Meta-Analysis

Objectives: Poststroke shoulder pain (PSSP) is a common complication after stroke. This review aimed to provide updated information on the epidemiological characteristics of PSSP, reveal their trends over time and region. Study Design and Setting: We searched the PubMed, Embase, Cochrane Library and Web of Science databases from inception until Dec 31, 2020. Data were extracted from the eligible studies, and their quality was assessed. The pooled incidence and prevalence estimates of PSSP and their 95% confidence intervals (CIs) were calculated. We analyzed the incidence and prevalence of PSSP by different geographical regions and countries and separately calculated the annual incidence and prevalence (and 95% CIs) of PSSP. Results: A total of 21 studies were eligible for the meta-analysis. Eleven cohort studies were included to analyze the incidence of PSSP, and the estimated pooled incidence in 3,496 stroke patients was 0.29 (95% CI 0.21-0.36). Ten cross-sectional studies were included to analyze the prevalence of PSSP, and the pooled prevalence in 3,701 stroke patients was 0.33 (95% CI 0.22-0.43). In addition, we found that there were significant differences in the incidence and prevalence of PSSP between different geographical regions and different countries. Additionally, the incidence of PSSP fluctuated around 30%, and the prevalence had a downward trend over time. Conclusions: Current evidence suggests that the incidence and prevalence of PSSP are high and may be influenced by geographical region and time.

Psychometric properties of the Psychosocial Impact of Assistive Devices Scale (PIADS): A systematic review

BACKGROUND

The Psychosocial Impact of Assistive Devices Scale (PIADS) is commonly used to assess the psychosocial effects of an assistive device. Given its growing use, an appraisal of the evidence regarding its psychometric properties is required.

PURPOSE

To conduct a systematic review using validated critical appraisal scales to analyze both the quality and content of the evidence on the psychometric properties of the PIADS.

METHODS

PubMed/Medline, Embase and CINAHL were systematically searched for identification of studies. Two independent reviewers appraised the retrieved studies using MacDermid and COSMIN-RoB checklists, and extracted data regarding the psychometric measurements reported.

RESULTS

MacDermid scores showed that 8 out of 11 studies were at least of good methodological quality. COSMIN-RoB scores ranged from inadequate to very good. Except criterion and construct validity, which have presented a moderate level of evidence, the other psychometric properties assessed have demonstrated a high level of evidence. Cross-cultural validity, measurement error and responsiveness have not been studied.

CONCLUSION

Few studies have yet evaluated the psychometric properties of the PIADS. However, the quality of the evidence that they provide is mostly adequate. Therefore, this review supports the use of the PIADS which has overall good psychometric properties.

Clinical Evaluation of Different Treatment Strategies for Motor Recovery in Poststroke Rehabilitation during the First 90 Days

Background: Motor recovery after stroke is based on neuronal plasticity and the structural reorganization of the brain. Questions are debated about the proper moment to start rehabilitation in the acute period of stroke, the significance of rehabilitation interventions during the so-called “plastic window”, and the advantages of modern and traditional programs. The aims of this study were to evaluate the role of different rehabilitation strategies and their combinations for motor recovery and the impact on functional disability by way of neurological and functional outcomes 3 months after ischemic stroke. Methods: We used three rehabilitation approaches: early rehabilitation from the first day of stroke (Phase I), traditional exercise programs (Phase II), and an author’s new method of biofeedback rehabilitation using motion sensors and augmented reality (AR) rehabilitation (Phase III). Clinical and functional outcomes were measured on the 90th day after stroke. We developed algorithms for quantifying the quality of movements during the execution of tasks in the motor domains of the AR rehabilitation program. Results: Phase I of rehabilitation led to an improvement in functional independence, and the recovery of motor functions of the extremities with an absence of mortality and clinical deterioration. AR rehabilitation led to significant improvement both with respect to clinical and functional scores on scales and to variables reflecting the quality of movements. Patients who were actively treated during Phases II and III achieved the same final level of motor recovery and functional outcomes as that of participants who had only received AR rehabilitation during Phase III. Patients who underwent outpatient observation after Phase I showed a deficit of spontaneous motor recovery on the 90th day after stroke. Conclusions: Early rehabilitation was successful but was not enough; rehabilitation programs should be carried out throughout the entire “sensitive period” of poststroke plasticity. The newly developed AR biofeedback motion training is effective and safe as a separate rehabilitation method in the early recovery period of moderately severe, hemiparalytic, and ischemic stroke. These two rehabilitation approaches must be applied together or after each other, not instead of each other, as shown in clinical practice.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Customizing Robot-Assisted Passive Neurorehabilitation Exercise Based on Teaching Training Mechanism

Passive movement is an important mean of rehabilitation for stroke survivors in the early stage or with greater paralysis. The upper extremity robot is required to assist therapists with passive movement during clinical rehabilitation, while customizing is one of the crucial issues for robot-assisted upper extremity training, which fits the patient-centeredness. Robot-assisted teaching training could address the need well. However, the existing control strategies of teaching training are usually commanded by position merely, having trouble to achieve the efficacy of treatment by therapists. And deficiency of flexibility and compliance comes to the training trajectory. This research presents a novel motion control strategy for customized robot-assisted passive neurorehabilitation. The teaching training mechanism is developed to coordinate the movement of the shoulder and elbow, ensuring the training trajectory correspondence with human kinematics. Furthermore, the motion trajectory is adjusted by arm strength to realize dexterity and flexibility. Meanwhile, the torque sensor employed in the human-robot interactive system identifies movement intention of human. The goal-directed games and feedbacks promote the motor positivity of stroke survivors. In addition, functional experiments and clinical experiments are investigated with a healthy adult and five recruited stroke survivors, respectively. The experimental results present that the suggested control strategy not only serves with safety training but also presents rehabilitation efficacy.

Robotic-assisted gait rehabilitation following stroke: a systematic review of current guidelines and practical clinical recommendations

INTRODUCTION

Stroke is the third leading cause of adult disability worldwide, and lower extremity motor impairment is one of the major determinants of long-term disability. Although robotic therapy is becoming more and more utilized in research protocols for lower limb stroke rehabilitation, the gap between research evidence and its use in clinical practice is still significant. The aim of this study was to determine the scope, quality, and consistency of guidelines for robotic lower limb rehabilitation after stroke, in order to provide clinical recommendations.

EVIDENCE ACQUISITION

We systematically reviewed stroke rehabilitation guideline recommendations between January 1, 2010 and October 31, 2020. We explored electronic databases (N.=4), guideline repositories and professional rehabilitation networks (N.=12). Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and brief syntheses were used to evaluate and compare the different recommendations, considering only the most recent version.

EVIDENCE SYNTHESIS

From the 1219 papers screened, ten eligible guidelines were identified from seven different regions/countries. Four of the included guidelines focused on stroke management, the other six on stroke rehabilitation. Robotic rehabilitation is generally recommended to improve lower limb motor function, including gait and strength. Unfortunately, there is still no consensus about the timing, frequency, training session duration and the exact characteristics of subjects who could benefit from robotics.

CONCLUSIONS

Our systematic review shows that the introduction of robotic rehabilitation in standard treatment protocols seems to be the future of stroke rehabilitation. However, robot assisted gait training (RAGT) for stroke needs to be improved with new solutions and in clinical practice guidelines, especially in terms of applicability.

Systematic review of guidelines to identify recommendations for upper limb robotic rehabilitation after stroke

INTRODUCTION

Upper limb motor impairment is one of the most frequent stroke consequences. Robot therapy may represent a valid option for upper limb stroke rehabilitation, but there are still gaps between research evidence and their use in clinical practice. The aim of this study was to determine the quality, scope, and consistency of guidelines clinical practice recommendations for upper limb robotic rehabilitation in stroke populations.

EVIDENCE ACQUISITION

We searched for guideline recommendations on stroke published between January 1st, 2010 and January 1st, 2020. Only the most recent guidelines for writing group were selected. Electronic databases (N.=4), guideline repertories and professional rehabilitation networks (N.=12) were searched. We systematically reviewed and assessed guidelines containing recommendation statements about upper limb robotic rehabilitation for adults with stroke (PROSPERO registration number: CRD42020173386).

EVIDENCE SYNTHESIS

Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and textual syntheses were used to appraise and compare recommendations. From 1324 papers that were screened, eight eligible guidelines were identified from six different regions/countries. Half of the included guidelines focused on stroke management, the other half on stroke rehabilitation. Rehabilitation assisted by robotic devices is generally recommended to improve upper limb motor function and strength. The exact characteristics of patients who could benefit from this treatment as well as the correct timing to use it are not known.

CONCLUSIONS

This systematic review has identified many opportunities to modernize and otherwise improve stroke patients' upper limb robotic therapy. Rehabilitation assisted by robot or electromechanical devices for stroke needs to be improved in clinical practice guidelines in particular in terms of applicability.

Breaking the ice to improve motor outcomes in patients with chronic stroke: a retrospective clinical study on neuromodulation plus robotics

BACKGROUND

Stroke is one of the main causes of impairment affecting daily activities and quality of life. There is a growing effort to potentiate the recovery of functional gait and to enable stroke patients to walk independently.

AIM

To estimate the effects of dual-site transcranial direct current stimulation (dstDCS) on gait recovery in chronic stroke patients provided with robot-aided gait training (RAGT).

METHODS

Thirty-seven patients were included in this retrospective clinical study. Nine patients were provided with dstDCS during the first 10 min of RAGT by using Lokomat®Pro (on-RAGT), 15 patients immediately after RAGT (post-RAGT), and 13 patients immediately before RAGT (pre-RAGT).

RESULTS

Each group improved over time concerning disability burden and lower limb strength. on-RAGT and post-RAGT experienced better improvement in balance (p < 0.001) and, moderately, gait endurance (p = 0.04) as compared to pre-RAGT. Furthermore, all treatments decreased the facilitation of the unaffected hemisphere (p < 0.001) and the inhibition of the affected hemisphere (p < 0.001). The duration of such aftereffects was found to be greater for post-RAGT.

DISCUSSION AND CONCLUSION

This is the first trial with dstDCS coupled with RAGT in chronic stroke patients with gait impairment. When timely coupled with RAGT, dstDCS may be considered an effective tool for the recovery of lower limb function in patients with first unilateral stroke in the chronic phase. Moreover, our data suggest the ductility of dstDCS concerning RAGT timing, thus making this intervention suitable in a neurorehabilitation setting and well adaptable to patients' needs.

Wearable Biofeedback Improves Human-Robot Compliance during Ankle-Foot Exoskeleton-Assisted Gait Training: A Pre-Post Controlled Study in Healthy Participants

The adjunctive use of biofeedback systems with exoskeletons may accelerate post-stroke gait rehabilitation. Wearable patient-oriented human-robot interaction-based biofeedback is proposed to improve patient-exoskeleton compliance regarding the interaction torque’s direction (joint motion strategy) and magnitude (user participation strategy) through auditory and vibrotactile cues during assisted gait training, respectively. Parallel physiotherapist-oriented strategies are also proposed such that physiotherapists can follow in real-time a patient’s motor performance towards effective involvement during training. A preliminary pre-post controlled study was conducted with eight healthy participants to conclude about the biofeedback’s efficacy during gait training driven by an ankle-foot exoskeleton and guided by a technical person. For the study group, performance related to the interaction torque’s direction increased during (p-value = 0.07) and after (p-value = 0.07) joint motion training. Further, the performance regarding the interaction torque’s magnitude significantly increased during (p-value = 0.03) and after (p-value = 68.59 × 10⁻³) user participation training. The experimental group and a technical person reported promising usability of the biofeedback and highlighted the importance of the timely cues from physiotherapist-oriented strategies. Less significant improvements in patient–exoskeleton compliance were observed in the control group. The overall findings suggest that the proposed biofeedback was able to improve the participant-exoskeleton compliance by enhancing human-robot interaction; thus, it may be a powerful tool to accelerate post-stroke ankle-foot deformity recovery.

[Robotic recovery of walking function in patients in the early recovery period of stroke]

OBJECTIVE

To compare the efficacy of walking function recovery in patients in the early recovery period of ischemic stroke (IS) using an exoskeleton for the lower extremities and an active-passive pedal exercise bike.

MATERIAL AND METHODS

An open randomized study of 47 patients in the early recovery period of IS was conducted. The rehabilitation course included exercises on an ExoAtlet exoskeleton in group 1 and exercises on a pedal simulator for active-passive training (5 days a week for 2 weeks) in group 2. Several tests were used to evaluate treatment results, including the Hauser walking index, the 10-meter walking test, the Berg balance scale, stabilometry, and biomechanics of walking. The complete training course was completed by 20 patients of group 1 and 21 of group 2.

RESULTS

There was a significant increase in strength in paretic muscles, postural stability, functional level and walking speed in patients of both groups, but in patients of group 1, the dynamics of recovery was more pronounced (p<0.05). In group 1, there was a significant decrease in the level of disability and an increase in daily activity, which was higher compared to group 2. An analysis of the main indicators of the statokinesiogram showed the more pronounced positive shifts in patients of group 1, but significant differences were found only in the dynamics of the length and area of the curve in the test with eyes open. When studying the biomechanics of walking, it was found that the function of walking was changed: there was a significant decrease in the speed of movement by 2.2 times, the length of a double step by 1.6 times, and the pace of walking by 1.3 times compared to normal indicators. After the end of exercises, a significant increase in the length of the double step, speed and pace of walking as well as a decrease in the period of the locomotor cycle were found in group 1.

CONCLUSION

The study revealed a positive impact of hardware rehabilitation on locomotion, both with the use of an exoskeleton and an active-passive pedal simulator. The use of an exoskeleton, have the advantages resulting in a significantly greater recovery of strength, stability, speed and symmetry of walking over the same period of training. A significant increase in postural stability in vertical position was revealed.