Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review

Effect of robotic exoskeleton training on lower limb function, activity and participation in stroke patients: a systematic review and meta-analysis of randomized controlled trials

Background

The current lower limb robotic exoskeleton training (LRET) for treating and managing stroke patients remains a huge challenge. Comprehensive ICF analysis and informative treatment options are needed. This review aims to analyze LRET' s efficacy for stroke patients, based on ICF, and explore the impact of intervention intensities, devices, and stroke phases.

Methods

We searched Web of Science, PubMed, and The Cochrane Library for RCTs on LRET for stroke patients. Two authors reviewed studies, extracted data, and assessed quality and bias. Standardized protocols were used. PEDro and ROB2 were employed for quality assessment. All analyses were done with RevMan 5.4.

Results

Thirty-four randomized controlled trials (1,166 participants) were included. For function, LRET significantly improved motor control (MD = 1.15, 95%CI = 0.29-2.01, p = 0.009, FMA-LE), and gait parameters (MD = 0.09, 95%CI = 0.03-0.16, p = 0.004, Instrumented Gait Velocity; MD = 0.06, 95%CI = 0.02-0.09, p = 0.002, Step length; MD = 4.48, 95%CI = 0.32-8.65, p = 0.04, Cadence) compared with conventional rehabilitation. For activity, LRET significantly improved walking independence (MD = 0.25, 95%CI = 0.02-0.48, p = 0.03, FAC), Gait Velocity (MD = 0.07, 95%CI = 0.03-0.11, p = 0.001) and balance (MD = 2.34, 95%CI = 0.21-4.47, p = 0.03, BBS). For participation, social participation (MD = 0.12, 95%CI = 0.03-0.21, p = 0.01, EQ-5D) was superior to conventional rehabilitation. Based on subgroup analyses, LRET improved motor control (MD = 1.37, 95%CI = 0.47-2.27, p = 0.003, FMA-LE), gait parameters (MD = 0.08, 95%CI = 0.02-0.14, p = 0.006, Step length), Gait Velocity (MD = 0.11, 95%CI = 0.03-0.19, p = 0.005) and activities of daily living (MD = 2.77, 95%CI = 1.37-4.16, p = 0.0001, BI) for the subacute patients, while no significant improvement for the chronic patients. For exoskeleton devices, treadmill-based exoskeletons showed significant superiority for balance (MD = 4.81, 95%CI = 3.10-6.52, p < 0.00001, BBS) and activities of daily living (MD = 2.67, 95%CI = 1.25-4.09, p = 0.00002, BI), while Over-ground exoskeletons was more effective for gait parameters (MD = 0.05, 95%CI = 0.02-0.08, p = 0.0009, Step length; MD = 6.60, 95%CI = 2.06-11.15, p = 0.004, Cadence) and walking independence (MD = 0.29, 95%CI = 0.14-0.44, p = 0.0002, FAC). Depending on the training regimen, better results may be achieved with daily training intensities of 45-60 min and weekly training intensities of 3 h or more.

Conclusion

These findings offer insights for healthcare professionals to make effective LRET choices based on stroke patient needs though uncertainties remain. Particularly, the assessment of ICF participation levels and the design of time-intensive training deserve further study.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, Unique Identifier: CRD42024501750.

Clinicians' perspectives and usage of rehabilitation technology: a survey

PURPOSE

The aim of this study was to investigate clinicians' perspectives regarding their usage of rehabilitation technology in their day-to-day practice and uncover the factors that impact clinicians' use of rehabilitation technology in their daily practice.

MATERIALS AND METHODS

An online survey was used to gather cross-sectional data from American occupational therapists, occupational therapy assistants, physical therapists, physical therapy assistants, and speech language pathologists. This survey used Likert-scale, multiple choice, and free-response questions.

RESULTS

Approximately half (n = 56/105, 53.3%) of our clinicians reported using rehabilitation in their daily practice. Less than 20% (n = 18/105, 17.1%) of the respondents strongly agreed that they felt comfortable implementing new rehabilitation technology, and few reported that their workplace encouraged (n = 16/85, 18.8%) or strongly encouraged (n = 14/85, 16.5%) the use of rehabilitation technology in practice. Additionally, excluding the 2011-2020 graduate clinicians that reported that they had not learned about rehabilitation technology in school or fieldwork, few reported feeling prepared (n = 14/97, 14.4%) or very prepared (n = 4/97, 4.1%) to use rehabilitation technology after graduation.

CONCLUSIONS

Our findings have revealed a sizable knowledge-to-practice gap in regard to clinicians' preparedness to engage with and advocate for rehabilitation technology in their day-to-day practice.

Application of Novel Wearable Self-Balancing Exoskeleton Robot Capable for Complete Self-Support in Post-stroke Rehabilitation: A Case Study

Early weight-bearing and trunk control training are essential components for promoting lower limb motor recovery in individuals with stroke. In this case study, we presented the successful implementation of a three-week wearable self-balancing exoskeleton robot training program for a 57-year-old male patient who had suffered from a stroke. After carefully reviewing the patient's previous medical records, conducting a thorough assessment, and excluding other potential contraindications, we introduced wearable self-balancing exoskeleton robot training to complement conventional rehabilitation in managing balance and lower limb function. The training program included early initiation of weight bearing and trunk control training following an ischemic stroke, aimed at promoting motor recovery and improving functional independence. The findings indicated that training with a wearable self-balancing exoskeleton robot enhanced the balance and motor function of the hemiplegic patient, with commendable adherence. Furthermore, the participants consistently reported increased satisfaction and confidence during the training sessions. This case report not only provided preliminary evidence of the effectiveness of the wearable self-balancing exoskeleton robot in promoting functional recovery following a stroke but also outlined a comprehensive training program that may hold value for future clinical application.

Fostering the discussion of planetary health in occupational therapy and physiotherapy

INTRODUCTION

Occupational therapists and physiotherapists aim to promote health, prevent various diseases and help people in their rehabilitation processes. So far, there is a paucity of understanding of the big picture of how the new paradigm of planetary health (PH) is connected to the education and practice of these professionals.

METHODS

This research aimed to address this gap by investigating and deploying a bibliometric analysis to elucidate the pivotal role of occupational therapists and physiotherapists in addressing PH challenges. The ultimate goal is to construct a comprehensive framework crosschecking the bibliometric analysis and the collection of 10 case studies selected by experts to outline how best practices in occupational therapy and physiotherapy, related to the three pillars of sustainability and the UN's Sustainable Development Goals (SDGs), can contribute to increasing PH.

RESULTS

The bibliometric analysis revealed four major research strands: 1) enhancing patient care and quality of life; 2) integrating sustainability in health care and rehabilitation; 3) professional development and clinical competence; and 4) evidence-based practice and quality improvement. Moreover, further temporal analysis revealed how the topic evolved, from advancing evidence-based practice and clinical effectiveness, exploring the strengthening of health care and person-centred practices, to connecting the topic to aspects also predicted by the SDGs, such as integrating environmental and climate concerns in therapy and addressing psychological and self-care impacts on health. The case studies confirmed this trend, and a framework of PH in occupational therapy and physiotherapy through the lens of the SDGs was developed to support future research and practitioners in advancing this research field.

CONCLUSIONS

Occupational therapists and physiotherapists are essential players in public health and can integrate sustainability at every level of practice, from using resources during therapy sessions to advocating for more sustainable lifestyles.

Safety and practicality study of using an exoskeleton in acute neurosurgery patients

INTRODUCTION

Early mobilization is key in neurologically impaired persons, limiting complications and improving long-term recovery. Self-balanced exoskeletons are used in rehabilitation departments to help patients stand and walk. We report the first case series of exoskeleton use in acute neurosurgery and intensive care patients, evaluating safety, clinical feasibility and patients' satisfaction.

METHODS

We report a retrospective observational study including individuals hospitalized in the neurosurgical intensive care and neurosurgery departments. We included patients with a medical prescription for an exoskeleton session, and who met no contraindication. Patients benefited from standing sessions using a self-balanced exoskeleton (Atalante, Wandercraft, France). Patients and sessions data were collected. Safety, feasibility and adherence were evaluated.

RESULTS

Seventeen patients were scheduled for 70 standing sessions, of which 27 (39%) were completed. They were typically hospitalized for intracranial hemorrhage (74%) and presented with unilateral motor impairments, able to stand but with very insufficient weight shifting to the hemiplegic limb, requiring support (MRC 36.2 ± 3.70, SPB 2.0 ± 1.3, SPD 0.7 ± 0.5). The average duration of standing sessions was 16 ± 9 min. The only side effect was orthostatic hypotension (18.5%), which resolved with returning to seating position. The most frequent reason for not completing a session was understaffing (75%). All patients were satisfied and expressed a desire to repeat it.

CONCLUSIONS

Physiotherapy using the exoskeleton is safe and feasible in the acute neurosurgery setting, although it requires adaptation from the staff to organize the sessions. An efficacy study is ongoing to evaluate the benefits for the patients.

Effects of high-intensity interval robot-assisted gait training on cardiopulmonary function and walking ability in chronic stroke survivors: A multicenter single-blind randomized controlled trial

BACKGROUND

Chronic stroke can impair cardiopulmonary function, mobility, and daily activities. This study assessed the impact of robot-assisted gait training (RAGT) on such impairments.

OBJECTIVE

To investigate the effects of robot-assisted gait training on cardiopulmonary function, walking ability, lower extremity function and strength, activities of daily living (ADLs), and blood test results among individuals with chronic stroke.

METHODS

A multicenter, prospective, single-blinded, randomized controlled trial with 22 chronic stroke participants compared RAGT against a control exercise regimen. RAGT involved three days weekly sessions of high-intensity interval training for 8 weeks (24 sessions) with a Morning Walk® device. The control group also performed home exercises. (24 sessions) Measures included VO2max, Functional Ambulatory Category, 2-minute walk test, 10-meter walk test, Motricity Index-Lower, Korean version of the Fugl-Meyer Assessment Scale, Modified Barthel Index, Berg Balance Scale, muscle strength, InBody body composition, and blood tests (cholesterol, lipid, glucose).

RESULTS

RAGT significantly improved VO2max, gait, balance, and lower limb strength compared with controls, with significant improvements in 2-minute walk test, 10-meter walk test, Motricity Index-Lower, and Fugl-Meyer Assessment outcomes. No changes were seen in muscle mass or blood markers.

CONCLUSION

RAGT enhances cardiopulmonary function and ambulatory capacity in chronic stroke patients, underscoring its potential in stroke rehabilitation.

The effect of the Lokomat® robotic-orthosis system on lower extremity rehabilitation in patients with stroke: a systematic review and meta-analysis

Background

The Lokomat® is a device utilized for gait training in post-stroke patients. Through a systematic review, the objective was to determine whether robot-assisted gait training with the Lokomat® is more effective in enhancing lower extremity rehabilitation in patients with stroke in comparison to conventional physical therapy (CPT).

Methods

In this study, a systematic search was conducted in various databases, including CINAHL, MEDLINE, PubMed, Embase, Cochrane Library, Scopus, Web of Science, and Physiotherapy Evidence Database (PEDro), as well as bibliographies of previous meta-analyses, to identify all randomized controlled trials that investigated the use of Lokomat® devices in adult stroke patients. The study aimed to derive pooled estimates of standardized mean differences for six outcomes, namely, Fugl-Meyer Assessment lower-extremity subscale (FMA-LE), Berg Balance Scale (BBS), gait speed, functional ambulation category scale (FAC), timed up and go (TUG), and functional independence measure (FIM), through random effects meta-analyses.

Results

The review analyzed 21 studies with a total of 709 participants and found that the use of Lokomat® in stroke patients resulted in favorable outcomes for the recovery of balance as measured by the BBS (mean difference = 2.71, 95% CI 1.39 to 4.03; p < 0.0001). However, the FAC showed that Lokomat® was less effective than the CPT group (mean difference = -0.28, 95% CI -0.45 to 0.11, P = 0.001). There were no significant differences in FMA-LE (mean difference = 1.27, 95% CI -0.88 to 3.42, P = 0.25), gait speed (mean difference = 0.02, 95% CI -0.03 to 0.07, P = 0.44), TUG (mean difference = -0.12, 95% CI -0.71 to 0.46, P = 0.68), or FIM (mean difference = 2.12, 95% CI -2.92 to 7.16, P = 0.41) between the Lokomat® and CPT groups for stroke patients.

Conclusion

Our results indicate that, with the exception of more notable improvements in balance, robot-assisted gait training utilizing the Lokomat® was not superior to CPT based on the current literature. Considering its ability to reduce therapists' work intensity and burden, the way in which Lokomat® is applied should be strengthened, or future randomized controlled trial studies should use more sensitive assessment criteria.

Robotic-Assisted Rehabilitation for Post-Stroke Shoulder Pain: A Systematic Review

Post-stroke shoulder pain (PSSP) is a debilitating consequence of hemiplegia, often hindering rehabilitation efforts and further limiting motor recovery. With the advent of robotic-assisted therapies in neurorehabilitation, there is potential for innovative interventions for PSSP. This study systematically reviewed the current literature to determine the effectiveness of robotic-assisted rehabilitation in addressing PSSP in stroke patients. A comprehensive search of databases was conducted, targeting articles published up to August 2023. Studies were included if they investigated the impact of robotic-assisted rehabilitation on PSSP. The outcome of interest was pain reduction. The risk of bias was assessed using the Cochrane database. Of the 187 initially identified articles, 3 studies met the inclusion criteria, encompassing 174 patients. The reviewed studies indicated a potential benefit of robotic-assisted rehabilitation in reducing PSSP, with some studies also noting improvements in the range of motion and overall motor function. However, the results varied across studies, with some showing more significant benefits than others, because these use different protocols and robotic equipment.

Effectiveness of a family-based program for post-stroke patients and families: A cluster randomized controlled trial

Objective

To examine the effectiveness of a family-based program for post-stroke patients and their families.

Methods

A cluster randomized controlled trial design was used. Participants were randomly selected in the experimental group (3 districts) and the comparison group (3 districts), with 62 families recruited. Sixty-two persons with new stroke and families (family caregivers and family members) who met the inclusion criteria were assigned to two groups, 31 in each group. Using the Neuman System Model as a framework, we implemented the stressors assessment and family-based intervention into the program. Participants in the comparison group received usual care, and those in the experimental group underwent a stressors assessment and received the family-based program. Measurement of functional status, depression, and complications in post-stroke patients and family function in family caregivers and family members, as well as caregiver burden and caregiver stress in family caregivers, were assessed at baseline, 4 weeks, and 12 weeks after enrollment. Data analysis included descriptive statistics, the chi-square test, Bonferroni test, and repeated measures analysis of variance.

Results

After participating in a 12-week family-based program, post-stroke patients in the experimental group showed statistically significant improvements in their functional status and decreased depression compared to the comparison group (P < 0.05). The family function of the experimental group was significantly improved, and caregivers' burden and stress were decreased compared to the comparison group (P < 0.05). Three patients in the experimental group and seven in the comparison group experienced complications.

Conclusions

The study findings suggest that the present family-based program improved family function in family caregivers and family members and decreased caregiver burden and stress in family caregivers. The program also improved functional status and reduced depression in post-stroke patients. It is suggested the duration of the program be extended to assess its sustainable effectiveness.

Defining, quantifying, and reporting intensity, dose, and dosage of neurorehabilitative interventions focusing on motor outcomes

Introduction

Determining the minimal amount of therapy needed for positive neurorehabilitative outcomes is important for optimizing active treatment interventions to improve motor outcomes. However, there are various challenges when quantifying these relationships: first, several consensuses on the definition and usage of the terms intensity, dose, and dosage of motor interventions have been proposed, but there seems to be no agreement, and the terms are still used inconsistently. Second, randomized controlled trials frequently underreport items relevant to determining the intensity, dose, and dosage of the interventions. Third, there is no universal measure to quantify therapy intensity accurately. This "perspectives" paper aims to increase awareness of these topics among neurorehabilitation specialists.

Defining quantifying and reporting

We searched the literature for definitions of intensity, dose, and dosage and adapted the ones we considered the most appropriate to fit the needs of neurorehabilitative interventions. Furthermore, we suggest refining the template for intervention description and replication (TIDieR) to enhance the reporting of randomized controlled trials. Finally, we performed a systematic literature search to provide a list of intensity measures and complemented these with some novel candidate measures.

Discussion

The proposed definitions of intensity, dose, and dosage could improve the communication between neurorehabilitation specialists and the reporting of dose and dosage in interventional studies. Quantifying intensity is necessary to improve our understanding of the minimal intensity, dose, and dosage of therapy needed to improve motor outcomes in neurorehabilitation. We consider the lack of appropriate intensity measures a significant gap in knowledge requiring future research.

Feasibility of an Intelligent Algorithm Based on an Assist-as-Needed Controller for a Robot-Aided Gait Trainer (Lokomat) in Neurological Disorders: A Longitudinal Pilot Study

Most robotic gait assisted devices are designed to provide constant assistance during the training without taking into account each patient’s functional ability. The Lokomat offers an assist-as-needed control via the integrated exercise “Adaptive Gait Support” (AGS), which adapts the robotic support based on the patient’s abilities. The aims of this study were to examine the feasibility and characteristics of the AGS during long-term application. Ten patients suffering from neurological diseases underwent an 8-week Lokomat training with the AGS. They additionally performed conventional walking tests and a robotic force measurement. The difference between robotic support during adaptive and conventional training and the relationship between the robotic assessment and the conventional walking and force tests were examined. The results show that AGS is feasible during long-term application in a heterogeneous population. The support during AGS training in most of the gait phases was significantly lower than during conventional Lokomat training. A relationship between the robotic support level determined by the AGS and conventional walking tests was revealed. Moreover, combining the isometric force data and AGS data could divide patients into clusters, based on their ability to generate high forces and their level of motor control. AGS shows a high potential in assessing patients’ walking ability, as well as in providing challenging training, e.g., by automatically adjusting the robotic support throughout the whole gait cycle and enabling training at lower robotic support.

Stroke Rehabilitation and Motor Recovery

OBJECTIVE

Up to 50% of the nearly 800,000 patients who experience a new or recurrent stroke each year in the United States fail to achieve full independence afterward. More effective approaches to enhance motor recovery following stroke are needed. This article reviews the rehabilitative principles and strategies that can be used to maximize post-stroke recovery.

LATEST DEVELOPMENTS

Evidence dictates that mobilization should not begin prior to 24 hours following stroke, but detailed guidelines beyond this are lacking. Specific classes of potentially detrimental medications should be avoided in the early days poststroke. Patients with stroke who are unable to return home should be referred for evaluation to an inpatient rehabilitation facility. Research suggests that a substantial increase in both the dose and intensity of upper and lower extremity exercise is beneficial. A clinical trial supports vagus nerve stimulation as an adjunct to occupational therapy for motor recovery in the upper extremity. The data remain somewhat mixed as to whether robotics, transcranial magnetic stimulation, functional electrical stimulation, and transcranial direct current stimulation are better than dose-matched traditional exercise. No current drug therapy has been proven to augment exercise poststroke to enhance motor recovery.

ESSENTIAL POINTS

Neurologists will collaborate with rehabilitation professionals for several months following a patient's stroke. Many questions still remain about the ideal exercise regimen to maximize motor recovery in patients poststroke. The next several years will likely bring a host of new research studies exploring the latest strategies to enhance motor recovery using poststroke exercise.

Factors Influencing Utilization of Assistive Devices by Tibetan Seniors on the Qinghai-Tibet Plateau: Based on Research Strategy of Triangulation

PURPOSE

To investigate the current situation of assistive device (AD) usage among seniors in Tibet, China, and explore its influencing factors.

METHODS

A mixed-methods design was used. Cognition, attitude, behavior, and preference toward ADs were assessed by a self-designed questionnaire. Additionally, participants responded to the open-ended questions. Anderson's behavior model analyzed the impacts of the prerequisite factors, enabling factors, and demand factors influencing the utilization of ADs by Tibetan seniors.

RESULTS

Of the 211 Tibetan seniors, 149 (70.6%) Tibetan seniors expressed the willingness to utilize ADs. Binary Logistic regression analysis showed that one prerequisite factor: age; one enabling factor: care situation, and one demand factor: dysfunctional condition were factors influencing the utilization of ADs. Qualitative comments described: psychological, physical environment, and social support factors were the main influencing factors.

CONCLUSION

This study presents the current situation to utilize ADs by Tibetan seniors on the Qinghai-Tibet Plateau, incorporates Anderson's behavioral model for quantitative analysis, and combines qualitative research to explore the facilitating and hindering factors, to provide reference and basis for the development of ADs for seniors and policy formulation. The sample size of this study is relatively small and limited to ethnic groups, and we plan to increase the sample size and include more ethnic groups in the future study.

Effectiveness of robot-assisted arm therapy in stroke rehabilitation: An overview of systematic reviews

BACKGROUND

Robot-assisted arm therapy (RAT) has been used mainly in stroke rehabilitation in the last 20 years with rising expectations and growing evidence summarized in systematic reviews (SRs).

OBJECTIVE

The aim of this study is to provide an overview of SRs about the effectiveness, within the ICF domains, and safety of RAT in the rehabilitation of adult with stroke compared to other treatments.

METHODS

The search strategy was conducted using search strings adapted explicitly for each database. A screening base on title and abstract was realized to find all the potentially relevant studies. The methodological quality of the included SRs was assessed using AMSTAR-2. A pre-determined standardized form was used to realize the data extraction.

RESULTS

18 SRs were included in this overview. Generally, positive effects from the RAT were found for motor function and muscle strength, whereas there is no agreement for muscle tone effects. No effect was found for pain, and only a SR reported the positive impact of RAT in daily living activity.

CONCLUSION

RAT can be considered a valuable option to increase motor function and muscle strength after stroke. However, the poor quality of most of the included SRs could limit the certainty around the results.

Robot-assisted therapy for upper limb paresis after stroke: Use of robotic algorithms in advanced practice

BACKGROUND

Rehabilitation of stroke-related upper limb paresis is a major public health issue.

OBJECTIVE

Robotic systems have been developed to facilitate neurorehabilitation by providing key elements required to stimulate brain plasticity and motor recovery, namely repetitive, intensive, adaptative training with feedback. Although the positive effect of robot-assisted therapy on motor impairments has been well demonstrated, the effect on functional capacity is less certain.

METHOD

This narrative review outlines the principles of robot-assisted therapy for the rehabilitation of post-stroke upper limb paresis.

RESULTS

A paradigm is proposed to promote not only recovery of impairment but also function.

CONCLUSION

Further studies that would integrate some principles of the paradigm described in this paper are needed.

New technologies promoting active upper limb rehabilitation after stroke: an overview and network meta-analysis

INTRODUCTION

The primary aim of this work was to summarize and compare the effects of active rehabilitation assisted by new technologies (virtual reality [VR], robot-assisted therapy [RAT] and telerehabilitation [TR)) on upper limb motor function and everyday living activity during the subacute and chronic phases of stroke. The secondary aims were to compare the effects of these technologies according to the intervention design (in addition to or in substitution of conventional therapy), the duration of active rehabilitation and the severity of patients' motor impairments.

EVIDENCE ACQUISITION

Several databases, namely PubMed, Scopus, Embase and Cochrane Library, were searched. Studies were included if they were meta-analyses with a moderate to high level of confidence (assessed with AMSTAR-2) that compared the effects of a new technology promoting active rehabilitation to that of a conventional therapy program among patients with stroke. Network meta-analyses were conducted to compare the effects of the new technologies.

EVIDENCE SYNTHESIS

Eighteen different meta-analyses were selected and fifteen included in the quantitative analysis. In total these 15 meta-analyses were based on 189 different randomized controlled trials. VR (SMD≥0.25; P<0.05), RAT (SMD≥0.29; P≤0.29) and TR (SMD≥-0.08; P≤0.64) were found to be at least as effective as conventional therapy. During the subacute phase, RAT's greatest effect was observed for patients with severe-moderate impairments whereas VR and TR's greatest effects were observed for patients with mild impairments. During the chronic phase, the highest effects were observed for patients with mild impairments, for all studies technologies. Network meta-analyses showed that VR and RAT were both significantly superior to TR in improving motor function during the chronic phase but revealed no significant difference between VR, RAT and TR effectiveness on both motor function (during the subacute phase) and activity (during both chronic and subacute phase).

CONCLUSIONS

This overview provides low-to-moderate evidence that rehabilitation assisted with technologies are at least as effective as conventional therapy for patients with stroke. While VR and RAT seem to be more efficient during the subacute phase, all technologies seem to be as efficient as one another in the chronic phase.

Rehabilitation robotics after stroke: a bibliometric literature review

INTRODUCTION

Stroke is the leading cause of long-term disability in developed countries. Due to population aging, the number of people requiring rehabilitation after stroke is going to rise in the coming decades. Robot-mediated neurorehabilitation has the potential to improve clinical outcomes of rehabilitation treatments. A statistical analysis of the literature aims to focus on the main trend of this topic.

AREAS COVERED

A bibliometric survey on post-stroke robotic rehabilitation was performed through a database collection of scientific publications in the field of rehabilitation robotics. By covering the last 20 years, 17429 sources were collected. Relevant patterns and statistics concerning the main research areas were analyzed. Leading journals and conferences which publish and disseminate knowledge in the field were identified. A detailed nomenclature study was carried out. The time trends of the research field were captured. Opinions and predictions of future trends that are expected to shape the near future of the field were discussed.

EXPERT OPINION

Data analysis reveals the continuous expansion of the research field over the last two decades, which is expected to rise considerably in near future. More attention will be paid to the lower limbs rehabilitation and disease/design specific applications in early-stage patients.

Motor Rehabilitation of Upper Limbs Using a Gesture-Based Serious Game: Evaluation of Usability and User Experience

Objective: Gesture-based serious games can be based on playful and interactive scenarios to enhance user engagement and experience during exercises, thereby increasing efficiency in the motor rehabilitation process. This study aimed to develop the Rehabilite Game (RG) as a complementary therapy tool for upper limb rehabilitation in clinics and home environments and to evaluate aspects of usability and user experience of it. Materials and Methods: The evaluation consisted of the use of a gesture-based serious game with motor rehabilitation sessions managed in a web platform. Thirty-three participants were recruited (21 physiotherapists and 12 patients). The protocol allowed each participant to have the experience of playing sessions with different combinations of settings. The User Experience Questionnaire (UEQ) was used to evaluate aspects of usability and user experience. The study was approved by the Research Ethics Board of the Federal University of Piaui (number 3,429,494). Results: The level of satisfaction with the RG was positive, with an excellent Net Promoter Score for 85.7% of physiotherapists and 100% of patients. All six UEQ scales (attractiveness, perspicuity, efficiency, dependability, stimulation, and novelty) reflected acceptance. Conclusion: The study demonstrated that, according to the results obtained in the experiments, the RG had positive feedback from physiotherapists and patients, indicating that the game can be used in a clinical trial to be compared with other rehabilitation techniques.

Effects of Health Qigong Exercise on Lower Limb Motor Function in Parkinson's Disease

Purpose

This study explored the effects of Health Qigong exercise on lower limb motor function in patients with Parkinson's disease (PD).

Patients and Methods

A total of 40 patients with PD were recruited and randomly allocated into the experimental group and the control group. The experimental group completed an intervention of Health Qigong exercise over 12 weeks, while the control group did not perform any regular physical activity. Data relating to gait, lower-limb joint range of motion, Timed Up and Go, as well as scores for motor function scale from the Unified Parkinson's Comprehensive Rating Scale III (UPCRS III) before and after the intervention were collected for Repeated Measure ANOVA.

Results

Compared to the control group, Health Qigong exercise improved the constant- and high-speed stride length and gait velocity of patients, but not constant- and high-speed stride frequency. Left and right hip flexion and extension range were improved as well as left and right knee flexion range. Finally, Timed Up and Go time became significantly slower and UPCRS III score significantly decreased.

Conclusion

Health Qigong exercise can improve walking ability and lower limb joint range of motion in patients with PD, lessen motor difficulties, and improve the quality of life. This non-pharmacological exercise intervention may be a useful adjustment treatment for PD.

A model-free deep reinforcement learning approach for control of exoskeleton gait patterns

Lower-body exoskeleton control that adapts to users and provides assistance-as-needed can increase user participation and motor learning and allow for more effective gait rehabilitation. Adaptive model-based control methods have previously been developed to consider a user’s interaction with an exoskeleton; however, the predefined dynamics models required are challenging to define accurately, due to the complex dynamics and nonlinearities of the human-exoskeleton interaction. Model-free deep reinforcement learning (DRL) approaches can provide accurate and robust control in robotics applications and have shown potential for lower-body exoskeletons. In this paper, we present a new model-free DRL method for end-to-end learning of desired gait patterns for over-ground gait rehabilitation with an exoskeleton. This control technique is the first to accurately track any gait pattern desired in physiotherapy without requiring a predefined dynamics model and is robust to varying post-stroke individuals’ baseline gait patterns and their interactions and perturbations. Simulated experiments of an exoskeleton paired to a musculoskeletal model show that the DRL method is robust to different post-stroke users and is able to accurately track desired gait pattern trajectories both seen and unseen in training.

Changes in kinesiostabilogram parameters and movement speed of stroke patients while increasing their physical activity due to the use of biofeedback method

Balance disorders are complications of stroke survivors. Aim of this study was the establish effectiveness of the biofeedback approach. In this intervention study 245 patients with early diagnosis of acute disturbance of cerebral circulation (ADCC) were examined. Patients able to move independently were treated by standard conservative ADCC therapy on an outpatient approach, but they continued to have problems with coordination of movement in upright position. Then they were submitted to an increasing physical activity based on five sessions of biofeedback, i.e., a complex rehabilitation of patients with motor pathology "Trust-M" according to TU 9442-001-63704475-2010. Mobility rates were assessed using a web camera. Patients' quality of life was evaluated by SF-36 questionnaire and the Hospital Anxiety and Depression Scale (HADS). All parameters were recorded before and after 5 sessions of biofeedback. After treatment, the stability indicators improved and all patients showed a significant increase in motion rate and quality of life. At the same time, the severity of pain and of depression and anxiety decreased. Negative correlations of average strength between the quadrant and patient HADS scaling rates were obtained. In conclusion, our work shows effectiveness of the biofeedback technique for correcting coordination in stroke survivors.

The effect of robot-assisted gait training on cortical activation in stroke patients: A functional near-infrared spectroscopy study

OBJECTIVE

To investigate the effects of the robot-assisted gait training on cortical activation and functional outcomes in stroke patients.

METHODS

The patients were randomly assigned: training with Morning Walk® (Morning Walk group; n = 30); conventional physiotherapy (control group; n = 30). Rehabilitation was performed five times a week for 3 weeks. The primary outcome was the cortical activation in the Morning Walk group. The secondary outcomes included gait speed, 10-Meter Walk Test (10MWT), FAC, Motricity Index-Lower (MI-Lower), Modified Barthel Index (MBI), Rivermead Mobility Index (RMI), and Berg Balance Scale (BBS).

RESULTS

Thirty-six subjects were analyzed, 18 in the Morning Walk group and 18 in the control group. The cortical activation was lower in affected hemisphere than unaffected hemisphere at the beginning of robot rehabilitation. After training, the affected hemisphere achieved a higher increase in cortical activation than the unaffected hemisphere. Consequently, the cortical activation in affected hemisphere was significantly higher than that in unaffected hemisphere (P = 0.036). FAC, MBI, BBS, and RMI scores significantly improved in both groups. The Morning Walk group had significantly greater improvements than the control group in 10MWT (P = 0.017), gait speed (P = 0.043), BBS (P = 0.010), and MI-Lower (P = 0.047) scores.

CONCLUSION

Robot-assisted gait training not only improved functional outcomes but also increased cortical activation in stroke patients.

Effect of robotic-assisted gait training on functional status, walking and quality of life in complete spinal cord injury

The purpose of this study was to investigate the effect of robotic-assisted gait training (RAGT) on functional status and the quality of life in patients with subacute complete spinal cord injury (SCI). Thirty-seven patients with complete SCI were included in this study. All patients underwent conventional rehabilitation 5 days a week for 8 weeks. The patients were divided into two groups: those who received RAGT (group I, n = 17) and those who received only conventional rehabilitation (group II, n = 20) for 30 min twice a week for a total of 8 weeks. Evaluations were performed using the Walking Index SCI II (WISCI II) for ambulation, Functional Independence Measure (FIM) for functional status and Short Form 36 (SF-36) for the quality of life at the beginning and end of rehabilitation. The mean duration of injury was 3.5 ± 2.1 months in group I and 3.8 ± 2.6 months in group II (P > 0.05). Significant improvement was observed in both groups as per WISCI II and FIM scores (P < 0.05). However, no significant inter-group difference was noted in pre- and post-treatment FIM and WISCI II change scores (P > 0.05). In groups I and II, there was significant improvement only in physical activity scores of SF-36 compared with baseline scores (P < 0.05); however, other SF-36 subparameter scores did not differ significantly between pre- and post-treatment (P > 0.05). Treatment with RAGT has positive effects on functional independence, ambulation and the quality of life in patients with subacute complete SCI. RAGT combined with conventional therapy in patients with complete SCI may facilitate the improvement of patient condition more than conventional therapy alone.

An innovative training based on robotics for older people with subacute stroke: study protocol for a randomized controlled trial

BACKGROUND

Stroke is a leading cause of disability, injury, and death in elderly people and represents a major public health problem with substantial medical and economic consequences. The incidence of stroke rapidly increases with age, doubling for each decade after age 55 years. Gait impairment is one of the most important problems after stroke, and improving walking function is often a key component of any rehabilitation program. To achieve this goal, a robotic gait trainer seems to be promising. In fact, some studies underline the efficacy of robotic gait training based on end-effector technology, for different diseases, in particular in stroke patients. In this randomized controlled trial, we verify the efficacy of the robotic treatment in terms of improving the gait and reducing the risk of falling and its long-term effects.

METHODS

In this single-blind randomized controlled trial, we will include 152 elderly subacute stroke patients divided in two groups to receive a traditional rehabilitation program or a robotic rehabilitation using G-EO system, an end-effector device for the gait rehabilitation, in addition to the traditional therapy. Twenty treatment sessions will be conducted, divided into 3 training sessions per week, for 7 weeks. The control group will perform traditional therapy sessions lasting 50 min. The technological intervention group, using the G-EO system, will carry out 30 min of traditional therapy and 20 min of treatment with a robotic system. The primary outcome of the study is the evaluation of the falling risk. Secondary outcomes are the assessment of the gait improvements and the fear of falling. Further evaluations, such as length and asymmetry of the step, walking and functional status, and acceptance of the technology, will be carried.

DISCUSSION

The final goal of the present study is to propose a new approach and an innovative therapeutic plan in the post-stroke rehabilitation, focused on the use of a robotic device, in order to obtain the beneficial effects of this treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04087083 . Registered on September 12, 2019.

Caregiver burden in stroke inpatients: a randomized study comparing robot-assisted gait training and conventional therapy

The effects of caregiver burden during the inpatient rehabilitation period have not yet been investigated. The purpose of this study was to evaluate the burden on stroke survivors' caregivers during the inpatient rehabilitation period, and to compare the associations of robot-assisted gait training and conventional therapy with caregiver burden. Our randomized, crossover, prospective study included 63 stroke survivors and their caregivers, who were randomly assigned to one of two groups. The patients in group I received robot-assisted gait training for 2 weeks, followed by conventional therapy for a further 2 weeks. The patients in group II received conventional therapy for 2 weeks followed by robot-assisted gait training for a further 2 weeks. The caregiver burden inventory, beck depression index, and beck hopelessness scale were administered to the caregivers at day 0, on the "switch day" (day 15), and day 30. Before inpatient rehabilitation, 18 (35%) of the caregivers had somewhat elevated scores on the caregiver burden inventory; however, at the end of rehabilitation, 42 (66.6%) of the caregivers were in a high-burden state. The caregiver burden inventory scores differed significantly between baseline and the end of rehabilitation in both groups. Caregiver depression scores also increased significantly in both groups (p < 0.0001), while hopelessness scores increased only in group II (p = 0.027). Caregiver burden increased during the inpatient stroke rehabilitation period. During inpatient rehabilitation, both robot-assisted gait training and conventional therapy increased caregiver burden.ClinicalTrials.gov Number NCT03535467, First Posted: 24 May 2018.

Effect of robotic-assisted gait training on objective biomechanical measures of gait in persons post-stroke: a systematic review and meta-analysis

BACKGROUND

Robotic-Assisted Gait Training (RAGT) may enable high-intensive and task-specific gait training post-stroke. The effect of RAGT on gait movement patterns has however not been comprehensively reviewed. The purpose of this review was to summarize the evidence for potentially superior effects of RAGT on biomechanical measures of gait post-stroke when compared with non-robotic gait training alone.

METHODS

Nine databases were searched using database-specific search terms from their inception until January 2021. We included randomized controlled trials investigating the effects of RAGT (e.g., using exoskeletons or end-effectors) on spatiotemporal, kinematic and kinetic parameters among adults suffering from any stage of stroke. Screening, data extraction and judgement of risk of bias (using the Cochrane Risk of bias 2 tool) were performed by 2-3 independent reviewers. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria were used to evaluate the certainty of evidence for the biomechanical gait measures of interest.

RESULTS

Thirteen studies including a total of 412 individuals (mean age: 52-69 years; 264 males) met eligibility criteria and were included. RAGT was employed either as monotherapy or in combination with other therapies in a subacute or chronic phase post-stroke. The included studies showed a high risk of bias (n = 6), some concerns (n = 6) or a low risk of bias (n = 1). Meta-analyses using a random-effects model for gait speed, cadence, step length (non-affected side) and spatial asymmetry revealed no significant differences between the RAGT and comparator groups, while stride length (mean difference [MD] 2.86 cm), step length (affected side; MD 2.67 cm) and temporal asymmetry calculated in ratio-values (MD 0.09) improved slightly more in the RAGT groups. There were serious weaknesses with almost all GRADE domains (risk of bias, consistency, directness, or precision of the findings) for the included outcome measures (spatiotemporal and kinematic gait parameters). Kinetic parameters were not reported at all.

CONCLUSION

There were few relevant studies and the review synthesis revealed a very low certainty in current evidence for employing RAGT to improve gait biomechanics post-stroke. Further high-quality, robust clinical trials on RAGT that complement clinical data with biomechanical data are thus warranted to disentangle the potential effects of such interventions on gait biomechanics post-stroke.

Stability Analysis and User Perception of Haptic Rendering Combining Virtual Elastic, Viscous and Inertial Effects

Virtual Reality environments are being used on a mass scale in fields, such as Industry and Medicine. These virtual scenarios serve very different purposes such as prototyping, gaming and exercising. Interaction with the virtual environment is mainly achieved by senses of sight and hearing through devices, such as a mouse or VR glasses. To this end, haptic research started a few decades ago with the aim of improving this interaction through a sense of touch. A key element, hitherto not researched, is the effective combination of virtual elastic, viscous, and inertial effects in haptic feedback restored to the user and the safety implications of these feedback effects. It is of particular importance in neurological rehabilitation exercising, as interaction realism and safety are of great importance in therapy and for the patient. Therefore, this work addresses the stability analysis of the combination of three haptic effects—elastic, viscous, and inertial—and the subjective feeling on the part of users regarding different combinations of these effects. A theoretical analysis is presented with a view to establishing stable control principles, and a user-study was carried out in order to help understand the perception of users to different combinations of haptic effects.

Long-term changes in technology acceptance of a robotic system in stroke treatment: a pilot study

Objectives

This pilot field study aimed to detect long-term changes in technology acceptance (TAM), user experience (UX) during use of an experimental demonstrator Bi-Manu-Interact (BMI) in stroke rehabilitation.

Methods

In 10 therapy sessions, patients performed a 20 min workout per session with the BMI. Patients with stroke were interviewed after the first (T0) and the 10th training session (T1) with a structured questionnaire about UX, TAM and potential to use the BMI at home. Nine patients (n=4 females) aged 33–78 years (M=60.22; SD=13.17) participated in the study.

Results

After using the BMI no statistically significant differences have been found in UX and TAM (T0 vs. T1). But small to large effect sizes have been found which imply a practical relevance of the differences. The potential to use the BMI at home showed an increase in readiness for at T1 compared to T0.

Conclusion

Descriptive data suggest that familiarity gained through repetitive training sessions. The findings are coherent with previous studies.

Preliminary development and technical evaluation of a belt-actuated robotic rehabilitation platform

BACKGROUND:

To provide effective rehabilitation in the early post-injury stage, a novel robotic rehabilitation platform is proposed, which provides full-body arm-leg rehabilitation via belt actuation to severely disabled patients who are restricted to bed rest.

OBJECTIVE:

To design and technically evaluate the preliminary development of the rehabilitation platform, with focus on the generation of various leg movements.

METHODS:

Two computer models were developed by importing the components from SolidWorks into Simscape Multibody in MATLAB. This allowed simulation of various stepping movements in supine-lying and side-lying positions. Two belt-actuated test rigs were manufactured and automatic control programs were developed in TIA Portal. Finally, the functionality of the test rigs was technically evaluated.

RESULTS:

Computer simulation yielded target positions for the generation of various stepping movements in the experimental platforms. The control system enabled the two-drive test rig to provide three modes of stepping in a supine position. In addition, the four-drive test rig produced walking-like stepping in a side-lying position.

CONCLUSIONS:

This work confirmed the feasibility of the mechanical development and control system of the test rigs, which are deemed applicable for further development of the overall novel robotic rehabilitation platform.

Stroke Affected Lower Limbs Rehabilitation Combining Virtual Reality With Tactile Feedback

In our study, we tested a combination of virtual reality (VR) and robotics in the original adjuvant method of post-stroke lower limb walk restoration in acute phase using a simulation with visual and tactile biofeedback based on VR immersion and physical impact to the soles of patients. The duration of adjuvant therapy was 10 daily sessions of 15 min each. The study showed the following significant rehabilitation progress in Control (N = 27) vs. Experimental (N = 35) groups, respectively: 1.56 ± 0.29 (mean ± SD) and 2.51 ± 0.31 points by Rivermead Mobility Index (p = 0.0286); 2.15 ± 0.84 and 6.29 ± 1.20 points by Fugl-Meyer Assessment Lower Extremities scale (p = 0.0127); and 6.19 ± 1.36 and 13.49 ± 2.26 points by Berg Balance scale (p = 0.0163). P-values were obtained by the Mann-Whitney U test. The simple and intuitive mechanism of rehabilitation, including through the use of sensory and semantic components, allows the therapy of a patient with diaschisis and afferent and motor aphasia. Safety of use allows one to apply the proposed method of therapy at the earliest stage of a stroke. We consider the main finding of this study that the application of rehabilitation with implicit interaction with VR environment produced by the robotics action has measurable significant influence on the restoration of the affected motor function of the lower limbs compared with standard rehabilitation therapy.

Robotic rehabilitation of the paralyzed upper limb for a stroke patient using the single-joint hybrid assistive limb: a case study assessed by accelerometer on the wrist

[Purpose] Recent studies have reported the effectiveness of robotic rehabilitation of paralyzed upper limbs in stroke patients. For example, the Single-Joint Hybrid Assistive Limb has been shown to improve upper limb impairments. However, limited data are available on the effectiveness of robotic rehabilitation of the upper limb with regards to daily living. In this case study, an accelerometer was adopted to examine whether rehabilitation using the Single-Joint Hybrid Assistive Limb improved upper limb activity during daily living in a stroke patient. [Participant and Methods] The participant was a 69-year-old male diagnosed with stroke and left hemiparesis. The Single-Joint Hybrid Assistive Limb was applied to the participant’s elbow on the paralyzed side. The participant wore an accelerometer on each wrist to measure the activities of the upper limbs. Clinical tests of the paralyzed upper limb were also performed. [Results] The activity of the paralytic limb was significantly higher after Single-Joint Hybrid Assistive Limb intervention than before the intervention. On the other hand, none of the results of the clinical tests changed beyond a clinically important difference. [Conclusion] The Single-Joint Hybrid Assistive Limb could be useful for promoting active use of a paralyzed upper limb in daily living. In addition, an accelerometer could be especially useful for evaluating the effects of robotic rehabilitation.

The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis

Background. High-intensity repetitive training is challenging to provide poststroke. Robotic approaches can facilitate such training by unweighting the limb and/or by improving trajectory control, but the extent to which these types of assistance are necessary is not known. Objective. The purpose of this study was to examine the extent to which robotic path assistance and/or weight support facilitate repetitive 3D movements in high functioning and low functioning subjects with poststroke arm motor impairment relative to healthy controls. Methods. Seven healthy controls and 18 subjects with chronic poststroke right-sided hemiparesis performed 300 repetitions of a 3D circle-drawing task using a 3D Cable-driven Arm Exoskeleton (CAREX) robot. Subjects performed 100 repetitions each with path assistance alone, weight support alone, and path assistance plus weight support in a random order over a single session. Kinematic data from the task were used to compute the normalized error and speed as well as the speed-error relationship. Results. Low functioning stroke subjects (Fugl-Meyer Scale score = 16.6 ± 6.5) showed the lowest error with path assistance plus weight support, whereas high functioning stroke subjects (Fugl-Meyer Scale score = 59.6 ± 6.8) moved faster with path assistance alone. When both speed and error were considered together, low functioning subjects significantly reduced their error and increased their speed but showed no difference across the robotic conditions. Conclusions. Robotic assistance can facilitate repetitive task performance in individuals with severe arm motor impairment, but path assistance provides little advantage over weight support alone. Future studies focusing on antigravity arm movement control are warranted poststroke.

Acupuncture of fascia points to relieve hand spasm after stroke: a study protocol for a multicenter randomized controlled trial

Background

The loss of functional ability of patients after stroke is mostly caused by dysfunction of the upper limbs, especially the hands. Hand functional exercise is the premise of alleviating hand dysfunction, and the relief of hand spasm is the basis of timely and effective hand functional exercise. Previous clinical observation have shown that fascial-point needling can effectively alleviate hand spasm immediately after stroke, but further evidence from large-sample studies is needed. The overall objective of this trial is to further evaluate the clinical efficacy of fascial-point acupuncture on hand spasm after stroke.

Methods/design

This multicenter randomized controlled trial will compare the efficacy of fascial-point acupuncture versus sham acupuncture and routine rehabilitation therapy in stroke patients with hand spasm. Patients will be randomized to undergo either the fascial-point acupuncture, the sham acupuncture or the control (routine rehabilitation therapy). We will recruit 210 stroke inpatients who meet the trial criteria and observe the remission of hand spasm and improvement of limb function after 4 weeks of intervention. The first evaluation indices are the remission of hand spasm and the duration of spasm remission. The second evaluation indices are the hand function of the affected limbs and the activities of daily living. When the accumulative total number of cases included reaches 120, a mid-term analysis will be conducted to determine any evidence that experimental intervention does have an advantage.

Discussion

Our aim is to evaluate the efficacy of fascial-point acupuncture in relieving hand spasm after stroke. The results should provide more evidence for the clinical application of this therapy in the future.

Trial registration

Chinese Clinical Trial Registry (ChiCTR), ID: ChiCTR1900022379. Registered on 9 April 2019

Portable Motion-Analysis Device for Upper-Limb Research, Assessment, and Rehabilitation in Non-Laboratory Settings

This study presents the design and feasibility testing of an interactive portable motion-analysis device for the assessment of upper-limb motor functions in clinical and home settings. The device engages subjects to perform tasks that imitate activities of daily living, e.g. drinking from a cup and moving other complex objects. Sitting at a magnetic table subjects hold a 3D printed cup with an adjustable magnet and move this cup on the table to targets that can be drawn on the table surface. A ball rolling inside the cup can enhance the task challenge by introducing additional dynamics. A single video camera with a portable computer tracks real-time kinematics of the cup and the rolling ball using a custom-developed, color-based computer-vision algorithm. Preliminary verification with marker-based 3D-motion capture demonstrated that the device produces accurate kinematic measurements. Based on the real-time 2D cup coordinates, audio-visual feedback about performance can be delivered to increase motivation. The feasibility of using this device in clinical diagnostics is demonstrated on 2 neurotypical children and also 3 children with upper-extremity impairments in the hospital, where conventional motion-analysis systems are difficult to use. The device meets key needs for clinical practice: 1) a portable solution for quantitative motor assessment for upper-limb movement disorders at non-laboratory clinical settings, 2) a low-cost rehabilitation device that can increase the volume of in-home physical therapy, and 3) the device affords testing and training a variety of motor tasks inspired by daily challenges to enhance self-confidence to participate in day-to-day activities.

Robot-Assisted Stair Climbing Training on Postural Control and Sensory Integration Processes in Chronic Post-stroke Patients: A Randomized Controlled Clinical Trial

BACKGROUND

Postural control disturbances are one of the important causes of disability in stroke patients affecting balance and mobility. The impairment of sensory input integration from visual, somatosensory and vestibular systems contributes to postural control disorders in post-stroke patients. Robot-assisted gait training may be considered a valuable tool in improving gait and postural control abnormalities.

OBJECTIVE

The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility.

METHODS

This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with postural instability. The experimental group (EG, n = 16) received robot-assisted stair climbing training. The control group (n = 16) received sensory integration balance training. Training protocols lasted for 5 weeks (50 min/session, two sessions/week). Before, after, and at 1-month follow-up, a blinded rater evaluated patients using a comprehensive test battery. Primary outcome: Berg Balance Scale (BBS). Secondary outcomes:10-meter walking test, 6-min walking test, Dynamic gait index (DGI), stair climbing test (SCT) up and down, the Time Up and Go, and length of sway and sway area of the Center of Pressure (CoP) assessed using the stabilometric assessment.

RESULTS

There was a non-significant main effect of group on primary and secondary outcomes. A significant Time × Group interaction was measured on 6-min walking test (p = 0.013) and on posturographic outcomes (p = 0.005). Post hoc within-group analysis showed only in the EG a significant reduction of sway area and the CoP length on compliant surface in the eyes-closed and dome conditions.

CONCLUSION

Postural control disorders in patients with chronic stroke may be ameliorated by robot-assisted stair climbing training and sensory integration balance training. The robot-assisted stair climbing training contributed to improving sensorimotor integration processes on compliant surfaces. Clinical trial registration (NCT03566901).

Exoskeleton and End-Effector Robots for Upper and Lower Limbs Rehabilitation: Narrative Review

Recovery of upper and lower limbs function is essential to reach independence in daily activities in patients with upper motor neuron syndrome (UMNS). Rehabilitation can provide a guide for motor recovery influencing the neurobiology of neuronal plasticity providing controlled, repetitive, and variable patterns. Increasing therapy dosage, intensity, number of repetition, execution of task-oriented exercises, and combining top-down and bottom-up approaches can promote plasticity and functional recovery. Robotic exoskeletons for upper and lower limbs, based on the principle of motor learning, have been introduced in neurorehabilitation. In this narrative review, we provide an overview of literature published on exoskeleton devices for upper and lower limb rehabilitation in patients with UMNS; we summarized the available current research evidence and outlined the new challenges that neurorehabilitation and bioengineering will have to face in the upcoming years. Robotic treatment should be considered a rehabilitation tool useful to generate a more complex, controlled multisensory stimulation of the patient and useful to modify the plasticity of neural connections through the experience of movement. Efficacy and efficiency of robotic treatment should be defined starting from intensity, complexity, and specificity of the robotic exercise, that are related to human-robot interaction in terms of motion, emotion, motivation, meaning of the task, feedback from the exoskeleton, and fine motion assistance. Duration of a single session, global period of the treatment, and the timing for beginning of robotic treatment are still open questions. There is the need to evaluate and individualize the treatment according to patient's characteristics. Robotic devices for upper and lower limbs open a window to define therapeutic modalities as possible beneficial drug, able to boost biological, neurobiological, and epigenetic changes in central nervous system. We need to implement large and innovative research programs to answer these issues in the near future.

Analysis of heterogeneity in a systematic review using meta-regression technique

AIM

Heterogeneity is an important consideration in systematic reviews, as high heterogeneity may imply that it is not suitable to perform meta-analysis. The degree of variation could be caused by clinical or methodological differences among the studies, or it could be due to the randomness of chance. Methods of assessing heterogeneity are calculating a statistical test for heterogeneity (the I value), visual evaluations of forest plots, conducting subgroup analysis or meta-regression. We conducted meta-regression on data of our previous systematic review on the effectiveness of robotic rehabilitation, and in this article, we present the findings and discuss its implications.

METHOD

In our meta-regression plots, plotted on the x-axis was the trial covariate (duration of intervention group therapy), and plotted on the y-axis was the effect size measure (standardized mean differences), with positive effect sizes favouring robotic intervention. Analysis using random effects was applied, and each study symbol was sized in proportion to its precision (inverse-variance weighting).

RESULTS

Differences were observed in the meta-regression plots between the subgroups of therapy ratio = 0 and therapy ratio more than 0 for upper limb movement, lower limb walking and activities of daily living. For upper limb movement, positive linear relationships were found for both subgroups. However, in terms of the strength of the relationship, a stronger relationship was found for therapy ratio = 0. For lower limb walking, opposing linear relationships were found in both subgroups: therapy ratio = 0 had a negative linear relationship, whereas therapy ratio more than 0 had a positive linear relationship. For activities of daily living, positive linear relationships were found for both subgroups, but a stronger linear relationship was found for therapy ratio = 0.

CONCLUSION

From the meta-regression analysis, we found that differing levels of linear relationships and the varying spread of effect sizes across positive and negative ranges were the likely sources of heterogeneity. This was especially so in the meta-regression of lower limb walking, which showed opposing directions of linear relationships. The wider spread of effect sizes for therapy ratio = 0 could indicate that some robotic devices were more effective than others. In addition, for therapy ratio more than 0, the effect sizes were mainly found in the positive region, which implied that adding conventional training to robotic training was generally positive for robotic devices.

Modular Design and Decentralized Control of the Recupera Exoskeleton for Stroke Rehabilitation

Robot-assisted therapy has become increasingly popular and useful in post-stroke neurorehabilitation. This paper presents an overview of the design and control of the dual-arm Recupera exoskeleton to provide intense therapist-guided as well as self training for sensorimotor rehabilitation of the upper body. The exoskeleton features a lightweight design, high level of modularity, decentralized computing, and various levels of safety implementation. Due to its modularity, the system can be used as a wheel-chair mounted system or as a full-body system. Both systems enable a wide range of therapies while efficiently grounding the weight of the system and without compromising the patient’s mobility. Furthermore, two rehabilitation therapies implemented on the exoskeleton system, namely teach & replay therapy and mirror therapy, are presented along with experimental results.

The effectiveness of using modern technologies in early recovery period treatment of post-stroke patients

This study presents the results of investigation «Amadeo», «Armeo» effectiveness in treatment of 61 post-stroke patients during early recovery period with upper limbs motor dysfunction. Comparative characteristics of treatment effectiveness in patients with ischemic and hemorrhage stroke are given. The results of investigation represent positive effect of using robotic technologies in post stroke patients rehabilitation therapy.