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Wang R, Zhang S, Zhang J, Tong Q, Ye X, Wang K, Li J. Electromyographic biofeedback therapy for improving limb function after stroke: A systematic review and meta-analysis. PLoS One 2024; 19:e0289572. [PMID: 38206927 PMCID: PMC10783731 DOI: 10.1371/journal.pone.0289572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/21/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Upper and lower limb impairment is common after stroke. Electromyographic biofeedback therapy is a non-invasive treatment, and its effectiveness in functional rehabilitation of the limb after stroke still remains uncertain. OBJECTIVE The objective of this study was to evaluate whether electromyographic biofeedback can improve upper and lower limb dysfunction in stroke patients. METHODS PubMed, Embase, Cochrane Library, and Physiotherapy Evidence Database (PEDro) were searched from inception to 1st May 2022. Inclusion criteria were randomized controlled clinical trials of electromyographic biofeedback therapy interventions reporting changes in upper and lower limb function in post-stroke patients. Data were extracted by two independent reviewers and pooled in random-effects models using Review manager (RevMan) software. RESULTS Our analyses included 10 studies enrolling a total of 303 participants. Electromyographic biofeedback therapy can effectively improve limb function after stroke (standardized mean difference [SMD], 0.44; 95% confidence interval [CI], 0.12-0.77; P = 0.008) and in subgroup analyses, the effect sizes of short-term effect (SMD, 0.33; 95% CI, 0.02-0.64; P = 0.04) was significant, but the long-term was not (SMD, 0.61; 95% CI, -0.11-1.33; P = 0.10). In addition, Electromyographic biofeedback therapy can improve the active range of motion of shoulder (SMD, 1.49; 95% CI, 2.22; P<0.0001) and wrist joints (SMD, 0.77; 95% CI, 0.13-1.42; P = 0.02) after stroke. CONCLUSION In this meta-analysis, electromyographic biofeedback therapy intervention can improve upper and lower limb function in patients with stroke. Short-term (less than one month) improvement after electromyographic biofeedback therapy was supported, while evidence for long-term (more than one month) benefits was lacking. Range of motion in the glenohumeral and wrist joints were improved. Stronger evidence for individualized parameters, such as optimal treatment parameters and intervention period, is needed in the future. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_record.php?recordID=267596], identifier [CRD42022354363].
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Affiliation(s)
- Rui Wang
- Department of The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Shuangshuang Zhang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jie Zhang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qifeng Tong
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- College of Rehabilitation, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiangming Ye
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Kai Wang
- Department of Neurology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Juebao Li
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
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Li Y, Wang Q, Liu XL, Hui R, Zhang YP. Effect of the physical rehabilitation program based on self-care ability in patients with acute ischemic stroke: a quasi-experimental study. Front Neurol 2023; 14:1181651. [PMID: 37360351 PMCID: PMC10288520 DOI: 10.3389/fneur.2023.1181651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/10/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction It is the most practical goal of limb rehabilitation for stroke patients to make the upper limb, trunk, and lower limb joints link together as a whole and restore the ability to self-care. However, many previous studies focused on the single joint or single muscle group movement of stroke patients and did not integrate self-care ability training into the whole process of rehabilitation, which lacks accuracy, integrity, and systematization. Methods A quasi-experimental study was conducted in a tertiary hospital. Eligible patients were recruited according to the inclusion criteria and exclusion criteria and then divided into an experimental group (n = 80) and a control group (n = 80) by the medical district. The control group received the routine physical rehabilitation intervention. The experimental group adopted the physical rehabilitation program based on self-care ability led by the nurses specializing in stroke rehabilitation to carry out the multi-joint coordinated exercise based on the control group. The training time and frequency were the same in both groups (45 min per session, one session per day for three consecutive months). The primary outcome was myodynamia. Secondary outcomes were the modified Barthel Index (MBI) and Stroke Specific Quality of Life Scale (SS-QOL). The primary and secondary outcomes were assessed before the intervention and at 1 and 3 months of intervention. In this study, the TREND checklist was followed for non-randomized controlled trials. Results A total of 160 participants completed the study. The physical rehabilitation program based on self-care ability was better than the routine rehabilitation program. With the prolongation of intervention time, all outcomes improved gradually in the experimental group (P < 0.05), and the myodynamia of lower limbs recovered faster than that of upper limbs. In the control group, the myodynamia of the affected limb was not significantly improved (P > 0.05), with only a small increase in MBI and SS-QOL scores (P < 0.05). Conclusion The physical rehabilitation program based on self-care ability after stroke was beneficial for acute ischemic stroke patients and improved the patient's myodynamia, quality of life, and self-care ability within the third month.
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Affiliation(s)
- Ying Li
- Department of Nursing, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- School of Nursing, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Qian Wang
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Xiao-Ling Liu
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Rong Hui
- Department of Nursing, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Yin-Ping Zhang
- School of Nursing, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
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Pinheiro C, Figueiredo J, Cerqueira J, Santos CP. Robotic Biofeedback for Post-Stroke Gait Rehabilitation: A Scoping Review. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22197197. [PMID: 36236303 PMCID: PMC9573595 DOI: 10.3390/s22197197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 05/09/2023]
Abstract
This review aims to recommend directions for future research on robotic biofeedback towards prompt post-stroke gait rehabilitation by investigating the technical and clinical specifications of biofeedback systems (BSs), including the complementary use with assistive devices and/or physiotherapist-oriented cues. A literature search was conducted from January 2019 to September 2022 on Cochrane, Embase, PubMed, PEDro, Scopus, and Web of Science databases. Data regarding technical (sensors, biofeedback parameters, actuators, control strategies, assistive devices, physiotherapist-oriented cues) and clinical (participants' characteristics, protocols, outcome measures, BSs' effects) specifications of BSs were extracted from the relevant studies. A total of 31 studies were reviewed, which included 660 stroke survivors. Most studies reported visual biofeedback driven according to the comparison between real-time kinetic or spatiotemporal data from wearable sensors and a threshold. Most studies achieved statistically significant improvements on sensor-based and clinical outcomes between at least two evaluation time points. Future research should study the effectiveness of using multiple wearable sensors and actuators to provide personalized biofeedback to users with multiple sensorimotor deficits. There is space to explore BSs complementing different assistive devices and physiotherapist-oriented cues according to their needs. There is a lack of randomized-controlled studies to explore post-stroke stage, mental and sensory effects of BSs.
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Affiliation(s)
- Cristiana Pinheiro
- Center for MicroElectroMechanical Systems (CMEMS), University of Minho, 4800-058 Guimarães, Portugal
- LABBELS-Associate Laboratory, University of Minho, 4800-058 Guimarães, Portugal
| | - Joana Figueiredo
- Center for MicroElectroMechanical Systems (CMEMS), University of Minho, 4800-058 Guimarães, Portugal
- LABBELS-Associate Laboratory, University of Minho, 4800-058 Guimarães, Portugal
| | - João Cerqueira
- Life and Health Sciences Research Institute (ICVS), University of Minho, 4710-057 Braga, Portugal
- Clinical Academic Center (2CA-Braga), Hospital of Braga, 4710-243 Braga, Portugal
| | - Cristina P. Santos
- Center for MicroElectroMechanical Systems (CMEMS), University of Minho, 4800-058 Guimarães, Portugal
- LABBELS-Associate Laboratory, University of Minho, 4800-058 Guimarães, Portugal
- Clinical Academic Center (2CA-Braga), Hospital of Braga, 4710-243 Braga, Portugal
- Correspondence:
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Kim H, Kim H, Shin WS. Effects of Vibrotactile Biofeedback Providing Real-Time Pressure Information on Static Balance Ability and Weight Distribution Symmetry Index in Patients with Chronic Stroke. Brain Sci 2022; 12:brainsci12030358. [PMID: 35326314 PMCID: PMC8946531 DOI: 10.3390/brainsci12030358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/24/2022] [Accepted: 03/06/2022] [Indexed: 12/10/2022] Open
Abstract
Training with visual and auditory biofeedback, in patients with stroke, improved balance ability and asymmetric posture. We developed a new biofeedback training device to prevent falls and improve balance ability in patients with stroke. This device corrects motion errors by collecting the pressure information of patients in real-time. This randomized crossover study aimed to investigate the effect of this biofeedback training on the static balance ability and weight distribution symmetry index in 24 patients with chronic stroke. Pressure sensor-based vibrotactile biofeedback, visual biofeedback providing posture information, and standing without biofeedback were randomly applied for 1 d each with 24 h washout intervals to minimize adaptation. The static balance ability was measured for each biofeedback training type, and the weight distribution symmetry index was calculated using the collected weight-bearing rate data. The static balance ability and weight distribution symmetry index differed significantly according to the type of biofeedback training used. Post-hoc analysis revealed significant differences in the order of newly developed vibrotactile biofeedback, visual biofeedback, and standing without biofeedback. These findings provide evidence that pressure sensor-based vibrotactile biofeedback improves static balance ability and weight support rates by proposing better intervention for patients with chronic stroke in the clinical environment.
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Affiliation(s)
- Ho Kim
- Department of Physical Therapy, Graduate School of Health and Medicine, Daejeon University, Daejeon 34520, Korea;
| | - Hongjun Kim
- Department of Computer Engineering, Daejeon University, Daejeon 34520, Korea;
| | - Won-Seob Shin
- Department of Physical Therapy, College of Health and Medical Science, Daejeon University, Daejeon 34520, Korea
- Correspondence: ; Tel.: +82-42-280-2294
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Koiler R, Bakhshipour E, Glutting J, Lalime A, Kofa D, Getchell N. Repurposing an EMG Biofeedback Device for Gait Rehabilitation: Development, Validity and Reliability. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:6460. [PMID: 34203676 PMCID: PMC8296262 DOI: 10.3390/ijerph18126460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
Gait impairment often limits physical activity and negatively impacts quality of life. EMG-Biofeedback (EMG-BFB), one of the more effective interventions for improving gait impairment, has been limited to laboratory use due to system costs and technical requirements, and has therefore not been tested on a larger scale. In our research, we aimed to develop and validate a cost-effective, commercially available EMG-BFB device for home- and community-based use. We began by repurposing mTrigger® (mTrigger LLC, Newark, DE, USA), a cost-effective, portable EMG-BFB device, for gait application. This included developing features in the cellphone app such as step feedback, success rate, muscle activity calibration, and cloud integration. Next, we tested the validity and reliability of the mTrigger device in healthy adults by comparing it to a laboratory-grade EMG system. While wearing both devices, 32 adults walked overground and on a treadmill at four speeds (0.3, 0.6, 0.9, and 1.2 m/s). Statistical analysis revealed good to excellent test-retest reliability (r > 0.89) and good to excellent agreement in the detection of steps (ICC > 0.85) at all speeds between two systems for treadmill walking. Our results indicated that mTrigger compared favorably to a laboratory-grade EMG system in the ability to assess muscular activity and to provide biofeedback during walking in healthy adults.
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Affiliation(s)
- Reza Koiler
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, DE 19716, USA; (E.B.); (N.G.)
| | - Elham Bakhshipour
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, DE 19716, USA; (E.B.); (N.G.)
| | - Joseph Glutting
- School of Education, University of Delaware, Newark, DE 19716, USA;
| | - Amy Lalime
- Product & Marketing Manager, mTrigger, LLC, Newark, DE 19713, USA;
| | - Dexter Kofa
- Dexter Kofa, Mobile App Developer, Philadelphia, PA 19120, USA;
| | - Nancy Getchell
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, DE 19716, USA; (E.B.); (N.G.)
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE 19716, USA
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Mulloy F, Irwin G, Mullineaux DR. Effects of biofeedback on whole lower limb joint kinematics and external kinetics. J Sports Sci 2021; 39:2172-2179. [PMID: 34000964 DOI: 10.1080/02640414.2021.1923930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Biofeedback (BFb) is a useful tool to accelerate the skill development process. Limited research has applied BFb to the whole lower-limb in a complex skill therefore the aim of this research was to assess the effectiveness of a biofeedback intervention targeting whole lower limb kinematics. Thirty-two healthy participants were randomized to a BFb (n = 16) and a Control group (n = 16). Participants visited a motion capture laboratory on three occasions during one week, and returned for retention testing at 4-6 weeks. Following introduction to a novel lunge-touch task, visual BFb on lower limb joint kinematic extension angular velocities (ω) and timing were provided following each lunge. BFb was effective in increasing Hipω (F = 3.746, p = 0.03) and Kneeω (F = 10.241, p = 0.01). Peak Ankleω remained unchanged (F = 1.537, p = 0.23, η2 = 0.05), however Peak Ankleθ (F = 10.915, p < 0.001, η2 = 0.27) and AnkleROM (F = 9.543, p < 0.001, η2 = 0.24) significantly increased. Despite kinematic changes, there were no significant changes in any external kinetics. No significant correlations were found between Hipω, Kneeω or Ankleω and horizontal impulse (ImpulseY: r = 0.20, p = 0.26; r = -0.11, p = 0.24; and r = 0.22, p = 0.28, respectively). Findings demonstrate that BFb can be used to alter multiple kinematic variables in a complex skill, but do not necessarily alter associated kinetic variables not directly targeted by BFb.
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Affiliation(s)
- Franky Mulloy
- School of Sport and Exercise Science, University of Lincoln, Lincoln, UK
| | - Gareth Irwin
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - David R Mullineaux
- School of Sport and Exercise Science, University of Lincoln, Lincoln, UK
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Spencer J, Wolf SL, Kesar TM. Biofeedback for Post-stroke Gait Retraining: A Review of Current Evidence and Future Research Directions in the Context of Emerging Technologies. Front Neurol 2021; 12:637199. [PMID: 33859607 PMCID: PMC8042129 DOI: 10.3389/fneur.2021.637199] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/05/2021] [Indexed: 12/26/2022] Open
Abstract
Real-time gait biofeedback is a promising rehabilitation strategy for improving biomechanical deficits in walking patterns of post-stroke individuals. Because wearable sensor technologies are creating avenues for novel applications of gait biofeedback, including use in tele-health, there is a need to evaluate the state of the current evidence regarding the effectiveness of biofeedback for post-stroke gait training. The objectives of this review are to: (1) evaluate the current state of biofeedback literature pertaining to post-stroke gait training; and (2) determine future research directions related to gait biofeedback in context of evolving technologies. Our overall goal was to determine whether gait biofeedback is effective at improving stroke gait deficits while also probing why and for whom gait biofeedback may be an efficacious treatment modality. Our literature review showed that the effects of gait biofeedback on post-stroke walking dysfunction are promising but are inconsistent in methodology and therefore results. We summarize sources of methodological heterogeneity in previous literature, such as inconsistencies in feedback target, feedback mode, dosage, practice structure, feedback structure, and patient characteristics. There is a need for larger-sample studies that directly compare different feedback parameters, employ more uniform experimental designs, and evaluate characteristics of potential responders. However, as these uncertainties in existing literature are resolved, the application of gait biofeedback has potential to extend neurorehabilitation clinicians' cues to individuals with post-stroke gait deficits during ambulation in clinical, home, and community settings, thereby increasing the quantity and quality of skilled repetitions during task-oriented stepping training. In addition to identifying gaps in previous research, we posit that future research directions should comprise an amalgam of mechanism-focused and clinical research studies, to develop evidence-informed decision-making guidelines for gait biofeedback strategies that are tailored to individual-specific gait and sensorimotor impairments. Wearable sensor technologies have the potential to transform gait biofeedback and provide greater access and wider array of options for clinicians while lowering rehabilitation costs. Novel sensing technologies will be particularly valuable for telehealth and home-based stepping exercise programs. In summary, gait biofeedback is a promising intervention strategy that can enhance efficacy of post-stroke gait rehabilitation in both clinical and tele-rehabilitation settings and warrants more in-depth research.
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Affiliation(s)
- Jacob Spencer
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Steven L. Wolf
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
- Department of Cell Biology, Emory University School of Medicine, Atlanta, GA, United States
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, Decatur, GA, United States
| | - Trisha M. Kesar
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
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The Influence of EMG-Triggered Robotic Movement on Walking, Muscle Force and Spasticity after an Ischemic Stroke. ACTA ACUST UNITED AC 2021; 57:medicina57030227. [PMID: 33801295 PMCID: PMC8001928 DOI: 10.3390/medicina57030227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Application of the EMG-driven robotic training in everyday therapeutic processes is a modern and innovative form of neurorehabilitation among patients after stroke. Active participation of the patient contributes to significantly higher activation of the sensorimotor network during active motor control rather than during passive movement. The study objective was to determine the effect of electromyographic triggering (EMG-triggered) robotic rehabilitation device treatment on walking, muscle force, and spasticity after an ischemic stroke. Materials and Methods: A total of 60 participants with impaired motor function and gait after subacute stroke were included in the study. Each patient was randomly assigned to an intervention or control group (IG or CG). All patients, except standard therapy, underwent 1 additional session of therapy per day, 5 days a week for 6 weeks. IG had 30 min of training on the robot, while CG received exercises on the lower limb rotor. The subjects were assessed with Timed Up and Go Test (TUG), Ashworth scale, knee range of motion (ROM), Lovett Scale, and tight circumference at baseline and at weeks 2, 4, and 6. Results: For seven parameters, the values credibly increased between consecutive measurements, and for the Ashworth scale, they credibly decreased. The biggest changes were observed for the measurements made with Lovett scale. The average thigh circumference as measured 5 and 15 cm above the knee increased credibly more in the robot condition, as compared to control condition. Additionally, the decrease in Ashworth values over time, although statistically credible in both groups, was credibly higher in the robot condition. Conclusion: The inclusion of the EMG-triggered neurorehabilitation robot in the patient's daily rehabilitation plan has a positive effect on outcomes of the treatment. Both proposed rehabilitation protocols significantly improved patients' condition regarding all measured outcomes, but the spasticity and thigh circumference improved significantly better in the robotic group in comparison to controls.
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