Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a randomised-clinical-trial

The Effect of Robot-Assisted Training on Arm Function, Walking, Balance, and Activities of Daily Living After Stroke: A Systematic Review and Meta-Analysis

This meta-analysis aimed to compare the effects of robot-assisted training (RAT) with those of conventional therapy (CT), considering the potential sources of heterogeneity in the previous studies. We searched three international electronic databases (MEDLINE, Embase, and the Cochrane Library) to identify relevant studies. Risk of bias assessment was performed using the Cochrane's Risk of Bias 1.0 tool. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations method. The meta-analyses for each outcome of the respective domains were performed using 24 randomized controlled trials (RCTs) on robot-assisted arm training (RAAT) for arm function, 7 RCTs on RAAT for activities of daily living (ADL), 12 RCTs on robot-assisted gait training (RAGT) for balance, 6 RCTs on RAGT for walking, and 7 RCTs on RAGT for ADL. The random-effects model for the meta-analysis revealed that RAAT has significant superiority over CT in improving arm function, and ADL. We also showed that RAGT has significant superiority over CT in improving balance. Our study provides high-level evidence for the superiority of RAT over CT in terms of functional recovery after stroke. Therefore, physicians should consider RAT as a therapeutic option for facilitating functional recovery after stroke.

Robotic arm training in neurorehabilitation enhanced by augmented reality - a usability and feasibility study

BACKGROUND

Robotic therapy and serious gaming support motor learning in neurorehabilitation. Traditional monitor-based gaming outputs cannot adequately represent the third dimension, whereas virtual reality headsets lack the connection to the real world. The use of Augmented Reality (AR) techniques could potentially overcome these issues. The objective of this study was thus to evaluate the usability, feasibility and functionality of a novel arm rehabilitation device for neurorehabilitation (RobExReha system) based on a robotic arm (LBR iiwa, KUKA AG) and serious gaming using the AR headset HoloLens (Microsoft Inc.).

METHODS

The RobExReha system was tested with eleven adult inpatients (mean age: 64.4 ± 11.2 years; diagnoses: 8 stroke, 2 spinal cord injury, 1 Guillain-Barré-Syndrome) who had paretic impairments in their upper limb. Five therapists administered and evaluated the system. Data was compared with a Reference Group (eleven inpatients; mean age: 64.3 ± 9.1 years; diagnoses: 10 stroke, 1 spinal cord injury) who trained with commercially available robotic therapy devices (ArmeoPower or ArmeoSpring, Hocoma AG). Patients used standardized questionnaires for evaluating usability and comfort (Quebec User Evaluation of Satisfaction with assistive technology [QUEST]), workload (Raw Task Load Index [RTLX]) and a questionnaire for rating visual perception of the gaming scenario. Therapists used the QUEST, the System Usability Scale and the short version of the User Experience Questionnaire.

RESULTS

Therapy with the RobExReha system was safe and feasible for patients and therapists, with no serious adverse events being reported. Patients and therapists were generally satisfied with usability. The patients' usability ratings were significantly higher in the Reference Group for two items of the QUEST: reliability and ease of use. Workload (RTLX) ratings did not differ significantly between the groups. Nearly all patients using the RobExReha system perceived the gaming scenario in AR as functioning adequately despite eight patients having impairments in stereoscopic vision. The therapists valued the system's approach as interesting and inventive.

CONCLUSIONS

We demonstrated the clinical feasibility of combining a novel robotic upper limb robot with an AR-serious game in a neurorehabilitation setting. To ensure high usability in future applications, a reliable and easy-to-use system that can be used for task-oriented training should be implemented.

TRIAL REGISTRATION

Ethical approval was obtained and the trial was registered at the German Clinical Trials Register (DRKS00022136).

Spasticity evaluation with the Amadeo Tyromotion device in patients with hemispheric stroke

Objective

The objective of this study is to verify the reliability and the concurrent and discriminant validity of the measurements of spasticity offered by the robotic device, quantifying the (1) test-retest reliability, (2) correlation with the clinical evaluation using the Modified Ashworth Scale (MAS), (3) inter-rater reliability between the two physiotherapists, and (4) ability to discriminate between healthy and stroke patients.

Methods

A total of 20 stroke patients and 20 healthy volunteers participated in the study. Two physical therapists (PT1 and PT2) independently evaluated the hand spasticity of stroke subjects using the MAS. Spasticity was assessed, both in healthy and stroke patients, with the Amadeo device at three increasing velocities of passive movement for three consecutive repeated assessments, while raw data of force and position were collected through an external program.

Data analysis

The intraclass correlation coefficient (ICC) and the weighted kappa were computed to estimate the reliability of the Amadeo device measurements, the inter-rater reliability of MAS, and the correlation between the MAS and Amadeo device measurements. The discriminant ability of the Amadeo device was assessed by comparing the stroke and healthy subjects' spasticity measurements with the percentage of agreements with 0 in MAS for healthy subjects.

Results

The test-retest reliability of the Amadeo device was high with ICC at all three velocities (ICC = 0.908, 0.958, and 0.964, respectively) but lower if analyzed with weighted kappa correlation (0.584, 0.748, and 0.749, respectively) as mean values for each velocity. The correlation between Amadeo and the clinical scale for stroke patients with weighted kappa correlation was poor (0.280 ± 0.212 for PT1 and 0.290 ± 0.155 for PT2). The inter-rater reliability of the clinical MAS was high (ICC = 0.911).

Conclusion

Both MAS and Amadeo spasticity scores showed good reliability. The Amadeo scores did not show a strong clinical correlation with the MAS in stroke patients. Hitherto, Amadeo evaluation shows trends that are consistent with the characteristics of spasticity, such as an increase in spasticity as the speed of muscle stretching increases. The ability of the device to discriminate between stroke patients and healthy controls is low. Future studies adopting an instrumental gold standard for spasticity may provide further insight into the validity of these measurements.

Upper limb intelligent feedback robot training significantly activates the cerebral cortex and promotes the functional connectivity of the cerebral cortex in patients with stroke: A functional near-infrared spectroscopy study

Background

Upper limb intelligence robots are widely used to improve the upper limb function of patients with stroke, but the treatment mechanism is still not clear. In this study, functional near-infrared spectroscopy (fNIRS) was used to evaluate the concentration changes of oxygenated hemoglobin (oxy-Hb) and deoxyhemoglobin (deoxy-Hb) in different brain regions and functional connectivity (FC) of the cerebral cortex in patients with stroke.

Method

Twenty post-stroke patients with upper limb dysfunction were included in the study. They all received three different types of shoulder joint training, namely, active intelligent feedback robot training (ACT), upper limb suspension training (SUS), and passive intelligent feedback robot training (PAS). During the training, activation of the cerebral cortex was detected by fNIRS to obtain the concentration changes of hemoglobin and FC of the cerebral cortex. The fNIRS signals were recorded over eight ROIs: bilateral prefrontal cortices (PFC), bilateral primary motor cortices (M1), bilateral primary somatosensory cortices (S1), and bilateral premotor and supplementary motor cortices (PM). For easy comparison, we defined the right hemisphere as the ipsilesional hemisphere and flipped the lesional right hemisphere in the Nirspark.

Result

Compared with the other two groups, stronger cerebral cortex activation was observed during ACT. One-way repeated measures ANOVA revealed significant differences in mean oxy-Hb changes among conditions in the four ROIs: contralesional PFC [F_{(2, 48)} = 6,798, p < 0.01], ipsilesional M1 [F_{(2, 48)} = 6.733, p < 0.01], ipsilesional S1 [F_{(2, 48)} = 4,392, p < 0.05], and ipsilesional PM [F_{(2, 48)} = 3.658, p < 0.05]. Oxy-Hb responses in the contralesional PFC region were stronger during ACT than during SUS (p < 0.01) and PAS (p < 0.05). Cortical activation in the ipsilesional M1 was significantly greater during ACT than during SUS (p < 0.01) and PAS (p < 0.05). Oxy-Hb responses in the ipsilesional S1 (p < 0.05) and ipsilesional PM (p < 0.05) were significantly higher during ACT than during PAS, and there is no significant difference in mean deoxy-Hb changes among conditions. Compared with SUS, the FC increased during ACT, which was characterized by the enhanced function of the ipsilesional cortex (p < 0.05), and there was no significant difference in FC between the ACT and PAS.

Conclusion

The study found that cortical activation during ACT was higher in the contralesional PFC, and ipsilesional M1 than during SUS, and showed tighter cortical FC between the cortices. The activation of the cerebral cortex of ACT was significantly higher than that of PAS, but there was no significant difference in FC. Our research helps to understand the difference in cerebral cortex activation between upper limb intelligent feedback robot rehabilitation and other rehabilitation training and provides an objective basis for the further application of upper limb intelligent feedback robots in the field of stroke rehabilitation.

Effectiveness of soft robotic glove versus repetitive transcranial magnetic stimulation in post-stroke patients with severe upper limb dysfunction: A randomised controlled trial

Purpose

To explore the difference in rehabilitation effect between soft robot gloves and repetitive transcranial magnetic stimulation (rTMS) in patients with severe upper limb motor dysfunction after a stroke.

Methods

A total of 69 post-stroke patients with severe upper limb dysfunction were randomly assigned to a repetitive transcranial magnetic group, a soft robotic glove group, and a conventional treatment group. The primary outcomes were the Fugl-Meyer Upper Extremity Assessment (FMA-UE) and the Modified Barthel Index (MBI). The secondary endpoints were the amplitude surface electromyogram of the extensor wrist muscle (sEMG) and the cerebral hemispheric resting motor threshold (RMT).

Results

The change of FMA-UE score in the soft robotic glove group was significantly better than that in the conventional treatment group (median difference: 2 points; 95% confidence interval [1, 3]; P < 0.05), but there was no significant difference compared with the repetitive transcranial magnetic stimulation group (median difference: 0 points; 95% confidence interval [-1, 2]; P [0.547] > 0.05). There was no significant difference in the change of MBI score between the soft robotic glove group and the conventional treatment and repetitive transcranial magnetic treatment groups [F = 2.458, P [0.093] > 0.05]. There was no significant difference in the change of sEMG score between the soft robotic glove group and the conventional treatment and repetitive transcranial magnetic treatment groups [H = 0.042, P [0.980] > 0.05]. Additionally, the change of RMT score in the soft robotic glove group was significantly inferior to that in the repetitive transcranial magnetic treatment group [difference: -1.09; 95% confidence interval [-2.048, 0.048]; P < 0.05], but there was no significant difference compared with the conventional treatment group [difference: 0.31 points; 95% confidence interval [-0.879, 0.358]; P [0.495] > 0.05].

Conclusion

For patients with severe dyskinesia after a stroke, soft robotic gloves are as effective as repetitive transcranial magnetic stimulation and may be a good choice for home rehabilitation. In addition, conventional treatment combined with repetitive transcranial magnetic stimulation (rTMS) or a soft robotic glove produced better rehabilitation outcomes than conventional treatment alone.

Artificial intelligence in elderly healthcare: A scoping review

The ageing population has led to a surge in the adoption of artificial intelligence (AI) technologies in elderly healthcare worldwide. However, in the advancement of AI technologies, there is currently a lack of clarity about the types and roles of AI technologies in elderly healthcare. This scoping review aimed to provide a comprehensive overview of AI technologies in elderly healthcare by exploring the types of AI technologies employed, and identifying their roles in elderly healthcare based on existing studies. A total of 10 databases were searched for this review, from January 1 2000 to July 31 2022. Based on the inclusion criteria, 105 studies were included. The AI devices utilized in elderly healthcare were summarised as robots, exoskeleton devices, intelligent homes, AI-enabled health smart applications and wearables, voice-activated devices, and virtual reality. Five roles of AI technologies were identified: rehabilitation therapists, emotional supporters, social facilitators, supervisors, and cognitive promoters. Results showed that the impact of AI technologies on elderly healthcare is promising and that AI technologies are capable of satisfying the unmet care needs of older adults and demonstrating great potential in its further development in this area. More well-designed randomised controlled trials are needed in the future to validate the roles of AI technologies in elderly healthcare.

Quo Vadis, Amadeo Hand Robot? A Randomized Study with a Hand Recovery Predictive Model in Subacute Stroke

BACKGROUND

Early identification of hand-prognosis-factors at patient's admission could help to select optimal synergistic rehabilitation programs based on conventional (COHT) or robot-assisted (RAT) therapies.

METHODS

In this bi-phase cross-over prospective study, 58 stroke patients were enrolled in two randomized groups. Both groups received same treatments A + B (A = 36 COHT sessions for 10 weeks; B = 36 RAT sessions for 10 weeks; 45 min/session; 3 to 5 times per week). Outcome repeated measures by blinded assessors included FMUL, BBT, NHPT, Amadeo Robot (AHR) and AMPS. Statistical comparisons by Pearson's rank correlations and one-way analyses of variance (ANOVA) with Bonferroni posthoc tests, with size effects and statistic power, were reported. Multiple backward linear regression models were used to predict the variability of sensorimotor and functional outcomes.

RESULTS

Isolated COHT or RAT treatments improved hand function at 3 months. While "higher hand paresis at admission" affected to sensorimotor and functional outcomes, "laterality of injury" did not seem to affect the recovery of the hand. Kinetic-kinematic parameters of robot allowed creating a predictive model of hand recovery at 3 and 6 months from 1st session.

CONCLUSIONS

Hand impairment is an important factor in define sensorimotor and functional outcomes, but not lesion laterality, to predict hand recovery.

Effects of robotic upper limb treatment after stroke on cognitive patterns: A systematic review

BACKGROUND

Robotic therapy (RT) has been internationally recognized for the motor rehabilitation of the upper limb. Although it seems that RT can stimulate and promote neuroplasticity, the effectiveness of robotics in restoring cognitive deficits has been considered only in a few recent studies.

OBJECTIVE

To verify whether, in the current state of the literature, cognitive measures are used as inclusion or exclusion criteria and/or outcomes measures in robotic upper limb rehabilitation in stroke patients.

METHODS

The systematic review was conducted according to PRISMA guidelines. Studies eligible were identified through PubMed/MEDLINE and Web of Science from inception to March 2021.

RESULTS

Eighty-one studies were considered in this systematic review. Seventy-three studies have at least a cognitive inclusion or exclusion criteria, while only seven studies assessed cognitive outcomes.

CONCLUSION

Despite the high presence of cognitive instruments used for inclusion/exclusion criteria their heterogeneity did not allow the identification of a guideline for the evaluation of patients in different stroke stages. Therefore, although the heterogeneity and the low percentage of studies that included cognitive outcomes, seemed that the latter were positively influenced by RT in post-stroke rehabilitation. Future larger RCTs are needed to outline which cognitive scales are most suitable and their cut-off, as well as what cognitive outcome measures to use in the various stages of post-stroke rehabilitation.

Immersive virtual reality for upper limb rehabilitation: comparing hand and controller interaction

Virtual reality shows great potential as an alternative to traditional therapies for motor rehabilitation given its ability to immerse the user in engaging scenarios that abstract them from medical facilities and tedious rehabilitation exercises. This paper presents a virtual reality application that includes three serious games and that was developed for motor rehabilitation. It uses a standalone headset and the user's hands without the need for any controller for interaction. Interacting with an immersive virtual reality environment using only natural hand gestures involves an interaction that is similar to that of real life, which would be especially desirable for patients with motor problems. A study involving 28 participants (4 with motor problems) was carried out to compare two types of interaction (hands vs. controllers). All of the participants completed the exercises. No significant differences were found in the number of attempts necessary to complete the games using the two types of interaction. The group that used controllers required less time to complete the exercise. The performance outcomes were independent of the gender and age of the participants. The subjective assessment of the participants with motor problems was not significantly different from the rest of the participants. With regard to the interaction type, the participants mostly preferred the interaction using their hands (78.5%). All four participants with motor problems preferred the hand interaction. These results suggest that the interaction with the user's hands together with standalone headsets could improve motivation, be well accepted by motor rehabilitation patients, and help to complete exercise therapy at home.

Upper-Limb Motor Intervention Elements That Drive Improvement in Biomarkers and Clinical Measures Post-Stroke: A Systematic Review in a Systems Paradigm

Objective

To use a systems paradigm to examine upper limb (UL) motor intervention elements driving biomarker and clinical measure improvement after stroke.

Methods

Databases were searched up to March 2022. Eligibility screening was completed by 2 authors. Studies using biomarkers and clinical measures pre- and post-upper limb intervention were included. Studies of adjunct interventions (eg, brain stimulation) were excluded. Cochrane Risk-of-Bias tools and Template for Intervention Description and Replication were used to rate studies. Studies were synthesized using a systems paradigm: intervention outcome was considered an emergent property of the systemic interactions of 4 intervention elements (demographics, type, quality, and dose) characterized by individual dimensions.

Results

Sixty-four studies (n = 1814 participants) containing 106 intervention groups (66 experimental; 40 control) were included. Combined biomarker and clinical outcomes defined 3 scenarios: restitution, mixed, and unchanged. The restitution scenario included more moderate-to-severely impaired participants in earlier recovery phases (<6 months). Interventions with graded difficulty were more frequently used in the restitution scenario compared with the unchanged scenario. No difference in quality or amount of therapy was identified when examining scenarios that demonstrated restitution compared to those that did not (mixed and unchanged).

Conclusions

A systems paradigm may be one of many approaches to understand UL motor restitution. This review found no single element consistently delivered improvements in biomarkers and clinical measures in the examined intervention groups. Complex patterns formed by multiple interacting intervention elements were observed in participants with and without restitution.

Tuning brain networks: The emerging role of transcranial direct current stimulation on structural plasticity

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique (NIBS) that has been proven to promote beneficial effects in a range of neurological and psychiatric disorders. Unfortunately, although has been widely investigated, the mechanism comprehension around tDCS effects presents still some gaps. Therefore, scientists are still trying to uncover the cellular and molecular mechanisms behind its positive effects to permit a more suitable application. Experimental models have provided converging evidence that tDCS elicits improvements in learning and memory by modulating both excitability and synaptic plasticity in neurons. Recently, among tDCS neurobiological effects, neural synchronization and dendritic structural changes have been reported in physiological and pathological conditions, suggesting possible effects at the neuronal circuit level. In this review, we bring in to focus the emerging effects of tDCS on the structural plasticity changes and neuronal rewiring, with the intent to match these two aspects with the underpinning molecular mechanisms identified so far, providing a new perspective to work on to unveil novel tDCS therapeutic use to treat brain dysfunctions.

Short and long-term effects of robot-assisted therapy on upper limb motor function and activity of daily living in patients post-stroke: a meta-analysis of randomized controlled trials

Objective

To investigate the effect of robot-assisted therapy (RAT) on upper limb motor control and activity function in poststroke patients compared with that of non-robotic therapy.

Methods

We searched PubMed, EMBASE, Cochrane Library, Google Scholar and Scopus. Randomized controlled trials published from 2010 to nowadays comparing the effect of RAT and control treatment on upper limb function of poststroke patients aged 18 or older were included. Researchers extracted all relevant data from the included studies, assessed the heterogeneity with inconsistency statistics (I² statistics), evaluated the risk of bias of individual studies and performed data analysis.

Result

Forty-six studies were included. Meta-analysis showed that the outcome of the Fugl-Meyer Upper Extremity assessment (FM-UE) (SMD = 0.20, P = 0.001) and activity function post intervention was significantly higher (SMD = 0.32, P < 0.001) in the RAT group than in the control group. Differences in outcomes of the FM-UE and activity function between the RAT group and control group were observed at the end of treatment and were not found at the follow-up. Additionally, the outcomes of the FM-UE (SMD = 0.15, P = 0.005) and activity function (SMD = 0.32, P = 0.002) were significantly different between the RAT and control groups only with a total training time of more than 15 h. Moreover, the differences in outcomes of FM-UE and activity post intervention were not significant when the arm robots were applied to patients with severe impairments (FM-UE: SMD = 0.14, P = 0.08; activity: SMD = 0.21, P = 0.06) or when patients were provided with patient-passive training (FM-UE: SMD = − 0.09, P = 0.85; activity: SMD = 0.70, P = 0.16).

Conclusion

RAT has the significant immediate benefits for motor control and activity function of hemiparetic upper limb in patients after stroke compared with controls, but there is no evidence to support its long-term additional benefits. The superiority of RAT in improving motor control and activity function is limited by the amount of training time and the patients' active participation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01058-8.

Effects of Intensive Vibratory Treatment with a Robotic System on the Recovery of Sensation and Function in Patients with Subacute and Chronic Stroke: A Non-Randomized Clinical Trial

Background: Sensory–motor deficits are frequent and affect the functionality after stroke. The use of robotic systems to improve functionality and motor performance is advisable; therefore, the aim of the present study was to evaluate the effects of intensive, high-frequency vibration treatment administered with a robotic system in subacute and chronic stroke patients in terms of upper limb sensitivity, motor function, quantity and quality of movement, and quality of life. Methods: A simple-blind, non-randomized controlled trial was conducted. The control group received conventional rehabilitation treatment and the experimental group received robotic treatment with an Amadeo^® robot in addition to their conventional rehabilitation sessions. Results: Intragroup analysis identified significant improvements in the experimental group in hand (p = 0.012), arm (p = 0.018), and shoulder (p = 0.027) sensitivity, as well as in motor function (FMA-UEmotor function, p = 0.028), integration of the affected limb (MAL-14amount scale, p = 0.011; MAL-14How well scale, p = 0.008), and perceived quality of life (SIS-16, p = 0.008). The measures between the control and experimental groups showed statistically significant differences in motor performance and spontaneous use of the affected limb (MAL-14amount scale, p = 0.021; MAL-14How well scale, p = 0.037). Conclusions: Intensive, high-frequency vibration with a robotic system, in combination with conventional intervention, improves the recovery of upper limb function in terms of quantity and quality of movement in patients with subacute and chronic stroke.

Moving toward Appropriate Motor Assessment Tools in People Affected by Severe Acquired Brain Injury: A Scoping Review with Clinical Advices

Severe acquired brain injury (SABI) is among the leading causes of death and disability worldwide. Patients following SABI may develop motor, sensory and cognitive disorders, alone or in combination. This review aims to point out the most used scales to assess motor function in SABI patients, also attempting to give some indications on their applicability in clinical practice. Studies were identified by searching on PubMed, Web of Science, PeDro and Cochrane databases between January and March 2022. We found that motor assessment tools are currently used by researchers/clinicians either in the acute/post-acute phase (for prognosis and rehabilitation purposes) or in the chronic phase (when functional items may also be considered). Moreover, specific scales exist only for patients with disorders of consciousness, whereas regarding motor function, SABI is mainly assessed by adapting the tools commonly used for stroke. Although some doubts remain about the validity of some of these assessment tools in SABI, to investigate motor outcomes is fundamental to establish a correct prognosis and plan a tailored rehabilitation training in these very frail and vulnerable patients.

Robot-assisted distal training improves upper limb dexterity and function after stroke: a systematic review and meta-regression

INTRODUCTION

Stroke is one of the top 10 causes of death worldwide, and more than half of stroke patients face distal upper extremity dysfunction. Considering that robot-assisted training may be effective in improving distal upper extremity function, the review evaluated the effect of robot-assisted distal training on motor function, hand dexterity, and spasticity after stroke.

METHODS

Eleven databases were systematically searched for randomised controlled trials (RCTs) from inception until Aug 28, 2021. Meta-analysis and meta-regression were performed to investigate the overall effect and source of heterogeneity, respectively.

RESULTS

Twenty-two trials involving 758 participants were included in this systematic review. The overall effect of robot-assisted distal training on the motor function of the wrists and hands was significant improvement (MD = 3.92; 95% CI, 3.04-4.80; P < 0.001). The robot-assisted training had a significantly beneficial effect on other motor functions (MD = 2.84; 95% CI, 1.54-4.14; P < 0.001); dexterity (MD = 9.01; 95% CI, -12.07--5.95; P < 0.001), spasticity, upper extremity strength (SMD = 0.42; 95% CI, 0.07-0.78; P = 0.02) and activities of daily living (SMD = 0.70; 95% CI, 0.29-1.23; P < 0.001). A series of subgroup analyses showed preferable design and effective regime of training. Meta-regression indicated the statistically significant effect of the year of trial, country, and duration on the effectiveness of training.

CONCLUSION

Robot-assisted distal training has a significant effect on motor function, dexterity and spasticity of the upper extremity, compared to conventional therapy.

Repetitive facilitative exercise under continuous electrical stimulation for recovery of pure motor isolated hand palsy after infarction of the "hand knob" area: A case report

PURPOSE

Pure motor isolated hand palsy (PMIHP) following infarction of the "hand knob" area is a rare entity in stroke. PMIHP usually recovers within the first few days, but there are rare cases where patients do not recover rapidly. Herein, we report a case of residual PMIHP in which repetitive facilitative exercise under concurrent low-amplitude continuous neuromuscular electrical stimulation ("RFE-under-cNMES") was introduced to improve hand function.

CASE DESCRIPTION

A 65-year-old man with PMIHP (30 days after onset) participated in a rehabilitation program involving RFE-under-cNMES. This protocol followed an A1-B1-A2-B2 schedule, where the "A"-period consisted of RFE-under-cNMES ("A1," 2 weeks; "A2," 1 week), and the "B"-period consisted of 1-week conventional rehabilitation.

OUTCOMES

The 5-week intervention promoted not only recovery from paralysis (8 points by the Fugl-Meyer Assessment), but also the ability to manipulate objects (13 points by the Action Research Arm test) and increased the subjective use of the affected upper limb during activities of daily living (2.88 points by the Motor Activity Log). Changes that exceeded the minimal clinically important difference occurred only in the RFE-under-cNMES period.

CONCLUSIONS

The patient had improved outcomes. Further studies are required to determine the possibility of RFE-under-cNMES relieving motor paralysis in patients with PMIHP who do not recover rapidly.

Home-Based Therapy After Stroke Using the Hand Spring Operated Movement Enhancer (HandSOME II)

We have developed a passive and lightweight wearable hand exoskeleton (HandSOME II) that improves range of motion and functional task practice in laboratory testing. For this longitudinal study, we recruited 15 individuals with chronic stroke and asked them to use the device at home for 1.5 h per weekday for 8 weeks. Subjects visited the clinic once per week to report progress and troubleshoot problems. Subjects were then given the HandSOME II for the next 3 months, and asked to continue to use it, but without any scheduled contact with the project team. Clinical evaluations and biomechanical testing was performed before and after the 8 week intervention and at the 3 month followup. EEG measures were taken before and after the 8 weeks of training to examine any recovery associated brain reorganization. Ten subjects completed the study. After 8 weeks of training, functional ability (Action Research Arm Test), flexor tone (Modified Ashworth Test), and real world use of the impaired limb (Motor Activity Log) improved significantly (p < 0.05). Gains in real world use were retained at the 3-month followup (p = 0.005). At both post-training and followup time points, biomechanical testing found significant gains in finger ROM and hand displacement in a reaching task (p < 0.05). Baseline functional connectivity correlated with gains in motor function, while changes in EEG functional connectivity paralleled changes in motor recovery. HandSOME II is a low-cost, home-based intervention that elicits brain plasticity and can improve functional motor outcomes in the chronic stroke population.

Pilot Test of Dosage Effects in HEXORR II for Robotic Hand Movement Therapy in Individuals With Chronic Stroke

Impaired use of the hand in functional tasks remains difficult to overcome in many individuals after a stroke. This often leads to compensation strategies using the less-affected limb, which allows for independence in some aspects of daily activities. However, recovery of hand function remains an important therapeutic goal of many individuals, and is often resistant to conventional therapies. In prior work, we developed HEXORR I, a robotic device that allows practice of finger and thumb movements with robotic assistance. In this study, we describe modifications to the device, now called HEXORR II, and a clinical trial in individuals with chronic stroke. Fifteen individuals with a diagnosis of chronic stroke were randomized to 12 or 24 sessions of robotic therapy. The sessions involved playing several video games using thumb and finger movement. The robot applied assistance to extension movement that was adapted based on task performance. Clinical and motion capture evaluations were performed before and after training and again at a 6-month followup. Fourteen individuals completed the protocol. Fugl-Meyer scores improved significantly at the 6 month time point compared to baseline, indicating reductions in upper extremity impairment. Flexor hypertonia (Modified Ashworth Scale) also decreased significantly due to the intervention. Motion capture found increased finger range of motion and extension ability after the intervention that continued to improve during the followup period. However, there was no change in a functional measure (Action Research Arm Test). At the followup, the high dose group had significant gains in hand displacement during a forward reach task. There were no other significant differences between groups. Future work with HEXORR II should focus on integrating it with functional task practice and incorporating grip and squeezing tasks.

Trial Registration:ClinicalTrials.gov, NCT04536987. Registered 3 September 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04536987.

Beyond motor recovery after stroke: The role of hand robotic rehabilitation plus virtual reality in improving cognitive function

Robot-assisted hand training adopting end-effector devices results in an additional reduction of motor impairment in comparison to usual care alone in different stages of stroke recovery. These devices often allow the patient to perform practical, attentive, and visual-spatial tasks in a semi-virtual reality (VR) setting. We aimed to investigate whether the hand end-effector robotic device Amadeo^TM could improve cognitive performance, beyond the motor deficit, as compared to the same amount of occupational treatment focused on the hand. Forty-eight patients (aged 54.3 ± 10.5 years, 62.5% female) affected by either ischemic or hemorrhagic stroke in the chronic phase were enrolled in the study. The experimental group (EG) underwent Amadeo^TM robotic training, while the control group (CG) performed occupational therapy involving the upper limb. Patients were assessed at the beginning and at the end of the rehabilitation protocol using a specific neuropsychological battery, as well as motor function tests. The EG showed greater improvements in different cognitive domains, including attentive abilities and executive functions, as well as in hand motor function, as compared to CG. Our study showed that task-oriented VR-based robotic rehabilitation enhanced not only motor function in the paretic arm but also global and specific cognitive abilities in post-stroke patients. We may argue that the hand robotic plus VR-based training may provide patients with an integration of cognitive and motor skill rehabilitation, thus amplifying the functional outcome achievement.

Exoskeleton versus end-effector robot-assisted therapy for finger-hand motor recovery in stroke survivors: systematic review and meta-analysis

INTRODUCTION

The growing number of stroke survivors with residual hand disabilities requires the development of efficient recovery therapy, and robotic rehabilitation can play an important role.

OBJECTIVE

The study aims to compare the relative effects of end-effector (EE) and exoskeleton (EXO) hand devices in motor recovery of patients with finger-hand motor impairment stroke.

METHODS

We identified randomized controlled trials (RCTs) through search in database on PubMed, Embase, MEDLINE, Cochrane library until October 2020. We included as outcomes: motricity index (MI), quick version of disabilities of the arm, shoulder, and hand (QuickDASH) questionnaire, and Fugl-Meyer assessment for upper extremity (FMAUE). We performed a systematic review, a meta-analysis, and a surface under the cumulative ranking analysis (SUCRA).

RESULTS

We included five RTCs and 149 subjects. MI showed a signifìcant improvement (p < .05) in robotic intervention group compared to control group (effect size, ES: 9.47; confidence interval, CI: 3.91, 15.03). QuickDASH reported a significant reduction (p < .05) in EXO group (ES: -6.71; CI: -9.17, -4.25). FMAUE showed a significant improvement (p < .05) in the EE group (ES:3; CI:1.97, 4.04). SUCRA analysis of MI demonstrated that robotic interventions are more likely to be the best option for motor recovery (97.3% of probability EXO; 48.3% EE; 4.4% control).

CONCLUSION

Despite the limited number of studies included, exoskeleton robotic devices might be a better option than end-effector devices in the treatment of fingers motor impairment in stroke patients. Further studies are still needed to confirm the findings and should focus on a direct comparison of the two devices.

The effect of Electromyography (EMG)-driven Robotic Treatment on the recovery of the hand Nine years after stroke

OBJECTIVE

To investigate the effect of electromyography (EMG)-driven robotic therapy on the recovery of the hand in a stroke case lasting 9 years.

CASE

An 18-year-old patient with hemiparesis due to the ischemic lesion was admitted to our clinic with hand impairment. Fifteen sessions (5 weeks x 3 times) of robotic rehabilitation were applied with the Hand of Hope. Average EMG (mV) of flexor digitorum superficialis (FDS) muscle, average force (N) and the rate of force development (RFD)(N/s) were also assessed before and after the treatment following the 5th and 10th sessions and at the end of treatment. Also, Fugl-Meyer Assessment of Upper Extremity Scale (FMU-UE), Motor Activity Log (MAL), Canadian Occupational Performance Score (COPM) and Visual Analog Scale (VAS) were used for assessment before and after the treatment.

RESULTS

The average EMG measured from FDS increased from 0.093-0.133 mV. The average force and average RFD increased from 45.6-97.7 and from 135.6-172.6 respectively. While affected and/or unaffected side force ratio increased dramatically from 54%-82%, the FMA-UE score increased from 56-59. The MAL quality of use score increased from 3.93-4.13. Performance and satisfaction scores of COPM changed from 5.25-7.25 and 4.5-8.25 respectively. VAS score for fatigue changed from 6 to 4.

DISCUSSION

The improvement achieved 9 years later with 15 sessions of rehabilitation suggests that improvement may be possible for chronic stroke patients.

Electroencephalogram-based neurofeedback training in persons with stroke: A scoping review in occupational therapy

BACKGROUND

Neurofeedback training targets the relevant brain response under minimal stress. It could be a promising approach for the treatment of patients with brain injury.

OBJECTIVE

This review aimed to examine the existing literature to confirm the effectiveness of applied electroencephalogram (EEG)-based neurofeedback training in the area of occupational therapy for upper limb stroke rehabilitation.

METHOD

All relevant literature published until July 1, 2020 in five prominent databases (PubMed, CINAHL, PsycINFO, MEDLINE Complete, and Web of Science) was reviewed, based on the five-step review framework proposed by Arksey and O'Malley.

RESULTS

After a thorough review, a total of 14 studies were included in this review. Almost studies reported significant improvements as a result of EEG-based neurofeedback training, but this had not always account for the differences in effectiveness between groups. However, the results of these studies suggested that neurofeedback training was effective as compared to the traditional treatment and more effective in combination with EEG than that with simple equipment application.

CONCLUSION

This review demonstrated the effectiveness of the combination of occupational therapy and EEG-based neurofeedback training. Most of these treatments are intended for inpatients, but they may be more effective for outpatients, especially if customized to their requirements. Also, such explorations to assess the suitability of the treatment for patient rehabilitation will help reduce barriers to effective interventions. An analysis of the opinions of participants and experts through satisfaction surveys will be helpful.

Robot-Assisted Therapy for Upper Extremity Motor Impairment After Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to review the effects of robot-assisted therapy (RT) for improving poststroke upper extremity motor impairment.

METHODS

The PubMed, Embase, Medline, and Web of Science databases were searched from inception to April 8, 2020. Randomized controlled trials that were conducted to evaluate the effects of RT on upper extremity motor impairment poststroke and that used Fugl-Meyer assessment for upper extremity scores as an outcome were included. Two authors independently screened articles, extracted data, and assessed the methodological quality of the included studies using the Physiotherapy Evidence Database (PEDro) scale. A random-effects meta-analysis was performed to pool the effect sizes across the studies.

RESULTS

Forty-one randomized controlled trials with 1916 stroke patients were included. Compared with dose-matched conventional rehabilitation, RT significantly improved the Fugl-Meyer assessment for upper extremity scores of the patients with stroke, with a small effect size (Hedges g = 0.25; 95% CI, 0.11-0.38; I2 = 45.9%). The subgroup analysis revealed that the effects of unilateral RT, but not that of bilateral RT, were superior to conventional rehabilitation (Hedges g = 0.32; 95% CI, 0.15-0.50; I2 = 55.9%). Regarding the type of robot devices, the effects of the end effector device (Hedges g = 0.22; 95% CI, 0.09-0.36; I2 = 35.4%), but not the exoskeleton device, were superior to conventional rehabilitation. Regarding the stroke stage, the between-group difference (ie, RT vs convention rehabilitation) was significant only for people with late subacute or chronic stroke (Hedges g = 0.33; 95% CI, 0.16-0.50; I2 = 34.2%).

CONCLUSION

RT might be superior to conventional rehabilitation in improving upper extremity motor impairment in people after stroke with notable upper extremity hemiplegia and limited potential for spontaneous recovery.

A randomized controlled trial on the effects induced by robot-assisted and usual-care rehabilitation on upper limb muscle synergies in post-stroke subjects

Muscle synergies are hypothesized to reflect connections among motoneurons in the spinal cord activated by central commands and sensory feedback. Robotic rehabilitation of upper limb in post-stroke subjects has shown promising results in terms of improvement of arm function and motor control achieved by reassembling muscle synergies into a set more similar to that of healthy people. However, in stroke survivors the potentially neurophysiological changes induced by robot-mediated learning versus usual care have not yet been investigated. We quantified upper limb motor deficits and the changes induced by rehabilitation in 32 post-stroke subjects through the movement analysis of two virtual untrained tasks of object placing and pronation. The sample analyzed in this study is part of a larger bi-center study and included all subjects who underwent kinematic analysis and were randomized into robot and usual care groups. Post-stroke subjects who followed robotic rehabilitation showed larger improvements in axial-to-proximal muscle synergies with respect to those who underwent usual care. This was associated to a significant improvement of the proximal kinematics. Both treatments had negative effects in muscle synergies controlling the distal district. This study supports the definition of new rehabilitative treatments for improving the neurophysiological recovery after stroke.

What the Tech? The Management of Neurological Dysfunction Through the Use of Digital Technology

Worldwide, it is estimated that millions of individuals suffer from a neurological disorder which can be the result of head injuries, ischaemic events such as a stroke, or neurodegenerative disorders such as Parkinson's disease (PD) and multiple sclerosis (MS). Problems with mobility and hemiparesis are common for these patients, making daily life, social factors and independence heavily affected. Current therapies aimed at improving such conditions are often tedious in nature, with patients often losing vital motivation and positive outlook towards their rehabilitation. The interest in the use of digital technology in neuro-rehabilitation has skyrocketed in the past decade. To gain insight, a systematic review of the literature in the field was conducting following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines for three categories: stroke, Parkinson's disease and multiple sclerosis. It was found that the majority of the literature (84%) was in favour of the use of digital technologies in the management of neurological dysfunction; with some papers taking a "neutral" or "against" standpoint. It was found that the use of technologies such as virtual reality (VR), robotics, wearable sensors and telehealth was highly accepted by patients, helped to improve function, reduced anxiety and make therapy more accessible to patients living in more remote areas. The most successful therapies were those that used a combination of conventional therapies and new digital technologies.

Lw-CNN-Based Myoelectric Signal Recognition and Real-Time Control of Robotic Arm for Upper-Limb Rehabilitation

Deep-learning models can realize the feature extraction and advanced abstraction of raw myoelectric signals without necessitating manual selection. Raw surface myoelectric signals are processed with a deep model in this study to investigate the feasibility of recognizing upper-limb motion intents and real-time control of auxiliary equipment for upper-limb rehabilitation training. Surface myoelectric signals are collected on six motions of eight subjects' upper limbs. A light-weight convolutional neural network (Lw-CNN) and support vector machine (SVM) model are designed for myoelectric signal pattern recognition. The offline and online performance of the two models are then compared. The average accuracy is (90 ± 5)% for the Lw-CNN and (82.5 ± 3.5)% for the SVM in offline testing of all subjects, which prevails over (84 ± 6)% for the online Lw-CNN and (79 ± 4)% for SVM. The robotic arm control accuracy is (88.5 ± 5.5)%. Significance analysis shows no significant correlation (p = 0.056) among real-time control, offline testing, and online testing. The Lw-CNN model performs well in the recognition of upper-limb motion intents and can realize real-time control of a commercial robotic arm.

Clinical Application of Virtual Reality for Upper Limb Motor Rehabilitation in Stroke: Review of Technologies and Clinical Evidence

Neurorehabilitation for stroke is important for upper limb motor recovery. Conventional rehabilitation such as occupational therapy has been used, but novel technologies are expected to open new opportunities for better recovery. Virtual reality (VR) is a technology with a set of informatics that provides interactive environments to patients. VR can enhance neuroplasticity and recovery after a stroke by providing more intensive, repetitive, and engaging training due to several advantages, including: (1) tasks with various difficulty levels for rehabilitation, (2) augmented real-time feedback, (3) more immersive and engaging experiences, (4) more standardized rehabilitation, and (5) safe simulation of real-world activities of daily living. In this comprehensive narrative review of the application of VR in motor rehabilitation after stroke, mainly for the upper limbs, we cover: (1) the technologies used in VR rehabilitation, including sensors; (2) the clinical application of and evidence for VR in stroke rehabilitation; and (3) considerations for VR application in stroke rehabilitation. Meta-analyses for upper limb VR rehabilitation after stroke were identified by an online search of Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Library, and KoreaMed. We expect that this review will provide insights into successful clinical applications or trials of VR for motor rehabilitation after stroke.

The Impact of Robotic Rehabilitation on the Motor System in Neurological Diseases. A Multimodal Neurophysiological Approach

Motor disability is a key feature of many neurological diseases, influencing the social roles of affected patients and their ability to perform daily life activities. Current rehabilitation capacities are overwhelmed by the age-related increase of motor dysfunctions seen, for example, in stroke, extrapyramidal or neuromuscular diseases. As the patient to rehabilitation personnel ration increases, robotic solutions might establish the possibility to rapidly satisfy the increasing demand for rehabilitation. This paper presents an inaugural exploratory study which investigates the interchangeability of a novel experimental robotic rehabilitation device system with classical physical therapy, using a multimodal neurophysiological assessment of the motor system-quantitative electroencephalogram (EEG), motor conduction times and turn/amplitude analysis. Preliminary results show no significant difference between the two methods; however, a significant effect of the therapy was found on different pathologies (beneficial for vascular and extrapyramidal, or limited, and only on preventing reduction of joint movements in neuromuscular).

Using Transcranial Direct Current Stimulation to Augment the Effect of Motor Imagery-Assisted Brain-Computer Interface Training in Chronic Stroke Patients-Cortical Reorganization Considerations

Introduction: Transcranial direct current stimulation (tDCS) has been shown to modulate cortical plasticity, enhance motor learning and post-stroke upper extremity motor recovery. It has also been demonstrated to facilitate activation of brain-computer interface (BCI) in stroke patients. We had previously demonstrated that BCI-assisted motor imagery (MI-BCI) can improve upper extremity impairment in chronic stroke participants. This study was carried out to investigate the effects of priming with tDCS prior to MI-BCI training in chronic stroke patients with moderate to severe upper extremity paresis and to investigate the cortical activity changes associated with training. Methods: This is a double-blinded randomized clinical trial. Participants were randomized to receive 10 sessions of 20-min 1 mA tDCS or sham-tDCS before MI-BCI, with the anode applied to the ipsilesional, and the cathode to the contralesional primary motor cortex (M1). Upper extremity sub-scale of the Fugl-Meyer Assessment (UE-FM) and corticospinal excitability measured by transcranial magnetic stimulation (TMS) were assessed before, after and 4 weeks after intervention. Results: Ten participants received real tDCS and nine received sham tDCS. UE-FM improved significantly in both groups after intervention. Of those with unrecordable motor evoked potential (MEP-) to the ipsilesional M1, significant improvement in UE-FM was found in the real-tDCS group, but not in the sham group. Resting motor threshold (RMT) of ipsilesional M1 decreased significantly after intervention in the real-tDCS group. Short intra-cortical inhibition (SICI) in the contralesional M1 was reduced significantly following intervention in the sham group. Correlation was found between baseline UE-FM score and changes in the contralesional SICI for all, as well as between changes in UE-FM and changes in contralesional RMT in the MEP- group. Conclusion: MI-BCI improved the motor function of the stroke-affected arm in chronic stroke patients with moderate to severe impairment. tDCS did not confer overall additional benefit although there was a trend toward greater benefit. Cortical activity changes in the contralesional M1 associated with functional improvement suggests a possible role for the contralesional M1 in stroke recovery in more severely affected patients. This has important implications in designing neuromodulatory interventions for future studies and tailoring treatment. Clinical Trial Registration: The study was registered at https://clinicaltrials.gov (NCT01897025).

Reliability, validity and discriminant ability of a robotic device for finger training in patients with subacute stroke

Background

The majority of stroke survivors experiences significant hand impairments, as weakness and spasticity, with a severe impact on the activity of daily living. To objectively evaluate hand deficits, quantitative measures are needed. The aim of this study is to assess the reliability, the validity and the discriminant ability of the instrumental measures provided by a robotic device for hand rehabilitation, in a sample of patients with subacute stroke.

Material and methods

In this study, 120 patients with stroke and 40 controls were enrolled. Clinical evaluation included finger flexion and extension strength (using the Medical Research Council, MRC), finger spasticity (using the Modified Ashworth Scale, MAS) and motor control and dexterity during ADL performance (by means of the Frenchay Arm Test, FAT). Robotic evaluations included finger flexion and extension strength, muscle tone at rest, and instrumented MAS and Modified Tardieu Scale. Subjects were evaluated twice, one day apart, to assess the test-retest reliability of the robotic measures, using the Intraclass Correlation Coefficient (ICC). To estimate the response stability, the standard errors of measurement and the minimum detectable change (MDC) were also calculated. Validity was assessed by analyzing the correlations between the robotic metrics and the clinical scales, using the Spearman’s Correlation Coefficient (r). Finally, we investigated the ability of the robotic measures to distinguish between patients with stroke and healthy subjects, by means of Mann-Whitney U tests.

Results

All the investigated measures were able to discriminate patients with stroke from healthy subjects (p < 0.001). Test-retest reliability was found to be excellent for finger strength (in both flexion and extension) and muscle tone, with ICCs higher than 0.9. MDCs were equal to 10.6 N for finger flexion, 3.4 N for finger extension, and 14.3 N for muscle tone. Conversely, test-retest reliability of the spasticity measures was poor. Finally, finger strength (in both flexion and extension) was correlated with the clinical scales (r of about 0.7 with MRC, and about 0.5 with FAT).

Discussion

Finger strength (in both flexion and extension) and muscle tone, as provided by a robotic device for hand rehabilitation, are reliable and sensitive measures. Moreover, finger strength is strongly correlated with clinical scales. Changes higher than the obtained MDC in these robotic measures could be considered as clinically relevant and used to assess the effect of a rehabilitation treatment in patients with subacute stroke.

A Paradigm Shift: Rehabilitation Robotics, Cognitive Skills Training, and Function After Stroke

Introduction: Robot-assisted therapy for upper extremity (UE) impairments post-stroke has yielded modest gains in motor capacity and little evidence of improved UE performance during activities of daily living. A paradigm shift that embodies principles of motor learning and exercise dependent neuroplasticity may improve robot therapy outcomes by incorporating active problem solving, salience of trained tasks, and strategies to facilitate the transfer of acquired motor skills to use of the paretic arm and hand during everyday activities.

Objective: To pilot and test the feasibility of a novel therapy protocol, the Active Learning Program for Stroke (ALPS), designed to complement repetitive, robot-assisted therapy for the paretic UE. Key ALPS ingredients included training in the use of cognitive strategies (e.g., STOP, THINK, DO, CHECK) and a goal-directed home action plan (HAP) to facilitate UE self-management and skill transfer.

Methods: Ten participants with moderate impairments in UE function >6 months after stroke received eighteen 1-h treatment sessions 2–3/x week over 6–8 weeks. In addition to ALPS training, individuals were randomly assigned to either robot-assisted therapy (RT) or robot therapy and task-oriented training (RT-TOT) to trial whether the inclusion of TOT reinforced participants' understanding and implementation of ALPS strategies.

Results: Statistically significant group differences were found for the upper limb subtest of the Fugl-Meyer Assessment (FMA-UE) at discharge and one-month follow-up favoring the RT group. Analyses to examine overall effects of the ALPS protocol in addition to RT and RT-TOT showed significant and moderate to large effects on the FMA-UE, Motor Activity Log, Wolf Motor Function Test, and hand portion of the Stroke Impact Scale.

Conclusion: The ALPS protocol was the first to extend cognitive strategy training to robot-assisted therapy. The intervention in this development of concept pilot trial was feasible and well-tolerated, with good potential to optimize paretic UE performance following robot-assisted therapy.