The effects of robot-assisted left-hand training on hemispatial neglect in older patients with chronic stroke: A pilot and randomized controlled trial

Assistive technology on upper extremity function for stroke patients: A systematic review with meta-analysis

BACKGROUND

In stroke rehabilitation, the selection of appropriate assistive devices is of paramount importance for patients. Specifically, the choice of device can significantly influence the functional recovery of the upper limb, impacting their overall activities or functional tasks.

OBJECTIVES

This review aimed to comprehensively analyze and summarize the clinical evidence from randomized controlled trials (RCTs) regarding the therapeutic effects of commonly used assistive devices on upper extremity function in patients with stroke.

METHODS

To evaluate assistive devices for patients with stroke, we summarized qualitatively throughout synthesis of results, such as therapeutic intervention, intensity, outcome, and summary of results, and examined risk of bias, heterogeneity, mean difference, 95% confidence interval, and I-squared value. To analyze, we used RoB 2 and RevMan 5.4.

RESULTS

The qualitative synthesis included 31 RCTs. The randomization process and the reporting of results showed minimal bias, but there were issues with bias from intended interventions, and missing outcome data presented some concerns. The quantitative synthesis included 16 RCTs. There was a significant difference in the Fugl-Meyer assessment-upper extremity functioning (FMA-UE) scores between the groups, with a total mean difference (95% confidence interval) of 2.40 (0.21, 4.60), heterogeneity values were Tau2 = 0.32, chi-square = 8.22, degrees of freedom = 8 (p = 0.41), and I2 = 3% for FMA-UE and the test for the overall effect produced Z = 2.14 (p = 0.03) in patients with chronic stroke. However, there was no significant difference in all other outcome measures.

CONCLUSIONS

Upper-limb robots did not demonstrate significant superiority over conventional treatments in improving function of upper limbs, with the exception of FMA-UE scores for patients with chronic stroke. The mean difference of FMA-UE was also lower than minimally important difference. Nonetheless, the usage of upper-limb robots may contribute to enhanced function for patients with stroke, as those devices support clinicians and enable a greater number of movement repetitions within specific time frames.

The leading global health challenges in the artificial intelligence era

Millions of people's health is at risk because of several factors and multiple overlapping crises, all of which hit the vulnerable the most. These challenges are dynamic and evolve in response to emerging health challenges and concerns, which need effective collaboration among countries working toward achieving Sustainable Development Goals (SDGs) and securing global health. Mental Health, the Impact of climate change, cardiovascular diseases (CVDs), diabetes, Infectious diseases, health system, and population aging are examples of challenges known to pose a vast burden worldwide. We are at a point known as the "digital revolution," characterized by the expansion of artificial intelligence (AI) and a fusion of technology types. AI has emerged as a powerful tool for addressing various health challenges, and the last ten years have been influential due to the rapid expansion in the production and accessibility of health-related data. The computational models and algorithms can understand complicated health and medical data to perform various functions and deep-learning strategies. This narrative mini-review summarizes the most current AI applications to address the leading global health challenges. Harnessing its capabilities can ultimately mitigate the Impact of these challenges and revolutionize the field. It has the ability to strengthen global health through personalized health care and improved preparedness and response to future challenges. However, ethical and legal concerns about individual or community privacy and autonomy must be addressed for effective implementation.

Short- and Long-Term Effects of Repetitive Transcranial Magnetic Stimulation on Poststroke Visuospatial Neglect: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This systematic review and meta-analysis aimed to assess the effects of repetitive transcranial magnetic stimulation and select a suitable protocol for poststroke visuospatial neglect.

DESIGN

PubMed, Cochrane Library, and Embase databases were searched for relevant studies from the inception date to October 31, 2021. The inclusion criteria were (1) randomized controlled trials, (2) people with visuospatial neglect, (3) treatment with different repetitive transcranial magnetic stimulation protocols, (4) comparison with sham or blank control, and (5) reports of performance measurements.

RESULTS

Data were obtained from 11 randomized controlled trials. The effects of immediate and 1-mo postintervention were measured using line bisection test, cancellation test, and Catherine Bergego Scale. Results showed statistically significant improvement when applying low-frequency (0.5-1 Hz) repetitive transcranial magnetic stimulation or continuous theta burst stimulation to the left hemisphere on short- and long-term line bisection test (standardized mean difference = -1.10, 95% confidence interval = -1.84 to -0.37; standardized mean difference = -1.25, 95% confidence interval = -2.11 to -0.39) and cancellation test (standardized mean difference = 1.08, 95% confidence interval = 0.45 to 1.71; standardized mean difference = 1.45, 95% confidence interval = 0.42, 2.47).

CONCLUSIONS

Repetitive transcranial magnetic stimulation may be considered a treatment option for poststroke visuospatial neglect. This review proves that a decrease in neuronal excitation in the left hemisphere, which restores the interhemispheric balance, benefits poststroke visuospatial neglect.

Advances in the Rehabilitation of Hemispatial Inattention

PURPOSE OF REVIEW

There continue to be a plethora of approaches to the rehabilitation of hemispatial inattention, from different forms of sensory stimulation (visual, auditory and somatosensory feedback), through all major modes of non-invasive brain stimulation to drug therapies. Here we summarise trials published in the years 2017-2022 and tabulate their effect sizes, with the aim of drawing on common themes that may serve to inform future rehabilitative studies.

RECENT FINDINGS

Immersive virtual reality approaches to visual stimulation seem well tolerated, although they have yet to yield any clinically relevant improvements. Dynamic auditory stimulation looks very promising and has high potential for implementation. Robotic interventions are limited by their cost and are perhaps best suited to patients with a co-occurring hemiparesis. Regarding brain stimulation, rTMS continues to demonstrate moderate effects but tDCS studies have yielded disappointing results so far. Drugs, primarily aimed at the dopaminergic system, often demonstrate beneficial effects of a medium size, but as with many of the approaches, it seems difficult to predict responders and non-responders. Our main recommendation is that researchers consider incorporating single-case experimental designs into their studies as rehabilitation trials are likely to remain small in terms of patient numbers, and this is the best way to deal with all the factors that cause large between-subject heterogeneity.

Unilateral Spatial Neglect Recovery Poststroke

Unilateral spatial neglect (USN) is a common and disabling cognitive consequence of stroke wherein individuals demonstrate decreased response to contralesional information. Here, we provide an updated narrative review of studies that shed light on the neural mechanisms and predictors of recovery of USN. Additionally, we report a rapid review of randomized controlled trials focusing on USN intervention, both nonpharmacological and pharmacological, published in the last 5 years. Randomized controlled trials are reviewed within the context of systematic reviews and meta-analyses of USN interventions published within the same time frame. The quality of randomized controlled trials of treatment is higher compared to quality reported in previous reviews and meta-analyses. However, remaining weaknesses in participant demographic reporting, as well as small, heterogenous samples, render generalizability and cross-study interpretation a challenge. Nevertheless, evidence regarding neural mechanisms underlying USN recovery and regarding the effectiveness of targeted USN interventions is accumulating and strengthening, setting the foundation for future investigations into patient-specific factors that may influence treatment response. We identify gaps and provide suggestions for future USN intervention research.

[Hand robotic devices in neurorehabilitation: A systematic review on the feasibility and effectiveness of stroke rehabilitation]

Robot-assisted therapy is a relatively new intervention, increasingly used in the rehabilitation treatment of stroke patients. It allows to increase the number of repetitions in the performance of specific tasks movements. For this review, a search was carried out between August and October 2021 in the PubMed, Web of Science, Scopus, Cochrane, PEDro and OTseeker databases, selecting a total of six randomized controlled trials where robot-assisted hand therapy was used in stroke rehabilitation. Studies agree that robot-assisted hand therapy has benefits in all phases of stroke rehabilitation that translate into motor and functional improvements of the upper limb and improvements in hemispatial neglect.

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.

Effect of Robot-Assisted Training on Unilateral Spatial Neglect After Stroke: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Several studies have shown that robotic devices can effectively improve motor function in stroke patients through limb activation. However, the effects of robot-assisted therapy on perceptual deficits after stroke is unclear.

OBJECTIVE

This review aimed to evaluate the effectiveness of robotic limb activation in patients with unilateral spatial neglect (USN) after stroke.

METHODS

In this systematic review, a literature search was performed using MEDLINE, EMBASE, CENTRAL, CINAHL, and LILACS databases without language restrictions. Randomized controlled trials (RCTs) and quasi-RCTs of robot-assisted therapy for USN after stroke were selected. Two reviewers independently assessed the risk of bias and certainty of the evidence of the included studies.

RESULTS

A total of 630 studies were identified, including five studies for qualitative synthesis and four meta-analyses. The results of RCTs comparing robotic limb activation with a control group suggested an improvement in the degree of USN measured by the line bisection test (standardized mean difference [SMD], -0.64; 95% confidence interval [CI], -1.13 to -0.15; P = .01). There were no differences between the groups in the motor-free visual perception test 3rd edition (SMD, 0.27; 95% CI, -0.25-0.79; P = .31), star cancellation test (SMD, 0.26; 95% CI, -0.42-0.94; P = .54), Albert's test (SMD, -0.67; 95% CI, -2.01-0.66; P = .32), and Catherine Bergego Scale (SMD, -0.81; 95% CI, -2.07-0.45; P = .21).

CONCLUSION

The study demonstrated that limb activation through robotic therapy can improve midline perception. However, there was no impact on tasks assessing visual scanning, functionality, or activities of daily living.

Non-pharmacological interventions for spatial neglect or inattention following stroke and other non-progressive brain injury

BACKGROUND

People with spatial neglect after stroke or other brain injury have difficulty attending to one side of space. Various rehabilitation interventions have been used, but evidence of their benefit is unclear.

OBJECTIVES

The main objective was to determine the effects of non-pharmacological interventions for people with spatial neglect after stroke and other adult-acquired non-progressive brain injury.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched October 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; last searched October 2020), MEDLINE (1966 to October 2020), Embase (1980 to October 2020), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1983 to October 2020), and PsycINFO (1974 to October 2020). We also searched ongoing trials registers and screened reference lists.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of any non-pharmacological intervention specifically aimed at spatial neglect. We excluded studies of general rehabilitation and studies with mixed participant groups, unless separate neglect data were available.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Review authors categorised the interventions into eight broad types deemed to be applicable to clinical practice through iterative discussion: visual interventions, prism adaptation, body awareness interventions, mental function interventions, movement interventions, non-invasive brain stimulation, electrical stimulation, and acupuncture. We assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included 65 RCTs with 1951 participants, all of which included people with spatial neglect following stroke. Most studies measured outcomes using standardised neglect assessments. Fifty-one studies measured effects on ADL immediately after completion of the intervention period; only 16 reported persisting effects on ADL (our primary outcome). One study (30 participants) reported discharge destination, and one (24 participants) reported depression. No studies reported falls, balance, or quality of life. Only two studies were judged to be entirely at low risk of bias, and all were small, with fewer than 50 participants per group. We found no definitive (phase 3) clinical trials. None of the studies reported any patient or public involvement. Visual interventions versus any control: evidence is very uncertain about the effects of visual interventions for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 55 participants) (standardised mean difference (SMD) -0.04, 95% confidence interval (CI) -0.57 to 0.49); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Prism adaptation versus any control: evidence is very uncertain about the effects of prism adaptation for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 39 participants) (SMD -0.29, 95% CI -0.93 to 0.35); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Body awareness interventions versus any control: evidence is very uncertain about the effects of body awareness interventions for spatial neglect based on measures of persisting functional ability in ADL (5 studies, 125 participants) (SMD 0.61, 95% CI 0.24 to 0.97); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Mental function interventions versus any control: we found no trials of mental function interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of mental function interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Movement interventions versus any control: we found no trials of movement interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of body awareness interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Non-invasive brain stimulation (NIBS) versus any control: evidence is very uncertain about the effects of NIBS on spatial neglect based on measures of persisting functional ability in ADL (3 studies, 92 participants) (SMD 0.35, 95% CI -0.08 to 0.77); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Electrical stimulation versus any control: we found no trials of electrical stimulation for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of electrical stimulation on spatial neglect based on immediate neglect assessments. Acupuncture versus any control: we found no trials of acupuncture for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of acupuncture on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments.

AUTHORS' CONCLUSIONS

The effectiveness of non-pharmacological interventions for spatial neglect in improving functional ability in ADL and increasing independence remains unproven. Many strategies have been proposed to aid rehabilitation of spatial neglect, but none has yet been sufficiently researched through high-quality fully powered randomised trials to establish potential or adverse effects. As a consequence, no rehabilitation approach can be supported or refuted based on current evidence from RCTs. As recommended by a number of national clinical guidelines, clinicians should continue to provide rehabilitation for neglect that enables people to meet their rehabilitation goals. Clinicians and stroke survivors should have the opportunity, and are strongly encouraged, to participate in research. Future studies need to have appropriate high-quality methodological design, delivery, and reporting to enable appraisal and interpretation of results. Future studies also must evaluate outcomes of importance to patients, such as persisting functional ability in ADL. One way to improve the quality of research is to involve people with experience with the condition in designing and running trials.