Robot-Assisted Arm Training versus Therapist-Mediated Training after Stroke: A Systematic Review and Meta-Analysis

Sensory Stimulation and Robot-Assisted Arm Training After Stroke: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Functional recovery after stroke is often limited, despite various treatment methods such as robot-assisted therapy. Repetitive sensory stimulation (RSS) might be a promising add-on therapy that is thought to directly drive plasticity processes. First positive effects on sensorimotor function have been shown. However, clinical studies are scarce, and the effect of RSS combined with robot-assisted training has not been evaluated yet. Therefore, our objective was to investigate the feasibility and sensorimotor effects of RSS (compared to a control group receiving sham stimulation) followed by robot-assisted arm therapy.

METHODS

Forty participants in the subacute phase (4.4-23.9 weeks) after stroke with a moderate to severe arm paresis were randomized to RSS or control group. Participants received 12 sessions of (sham-) stimulation within 3 weeks. Stimulation of the fingertips and the robot-assisted therapy were each applied in 45-min sessions. Motor and sensory outcome assessments (e.g. Fugl-Meyer-Assessment, grip strength) were measured at baseline, post intervention and at a 3-week follow-up.

RESULTS

Participants in both groups improved their sensorimotor function from baseline to post and follow-up measurements, as illustrated by most motor and sensory outcome assessments. However, no significant group effects were found for any measures at any time ( P > 0.058). Stimulations were well accepted, no safety issues arose.

DISCUSSION AND CONCLUSIONS

Feasibility of robot-assisted therapy with preceding RSS in persons with moderate to severe paresis was demonstrated. However, RSS preceding robot-assisted training failed to show a preliminary effect compared to the control intervention. Participants might have been too severely affected to identify changes driven by the RSS, or these might have been diluted or more difficult to identify because of the additional robotic training and neurorehabilitation.

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Robot-assisted therapy in stratified intervention: a randomized controlled trial on poststroke motor recovery

Objective

To compare the effects of robot-assisted therapy with conventional therapy for accelerating stratified intervention in poststroke patients with upper limb dysfunction.

Background

For stroke survivors, recovery of upper extremity function remains a major challenge in rehabilitation. Literature has suggested that the rate of recovery may improve if treatments can be individualized to their clinical profiles. However, there still lack clinical evidence on how to create treatment tailored to individual patients. Robot-assisted Therapy (RT) provides a straightforward approach to adjustment of the assistance-resistance continuum for individual patients. In early Brunnstrom stages of recovery, patients benefit from assistance training, whereas in later stages the training is favored with resistance. Therefore, RT may enhance Conventional Therapy (CT) but the use of RT in stratified intervention has not been investigated. This study evaluated the possible benefit of adopting RT following a protocol of upper-limb training, which was stratified with the Brunnstrom stage of each individual.

Methods

This study was a single-blinded randomized controlled trial. A total of 53 patients with stroke were recruited and randomized into 2 groups (CT, n = 27, 3 dropped out and RT, n = 26, 2 dropped out). Both groups were trained once per day, 5 days per week for 4 weeks. The CT group received 30 min of conventional therapy; the RT group received 30 min of upper limb robot-assisted training. Patients were assessed at the beginning, week-2, and week-4 of the treatment. The outcome measures included the Fugl-Meyer Assessment Upper-Extremity (FMA-UE) and the Modified Barthel Index (MBI).

Results

Across the 4-week intervention, participants in the RT group recovered 1.979 points of FMA-UE per week, compared to 1.198 points per week in the CT group (t94 = 3.333, p < 0.01); the recovery rate was 0.781 points/week higher in the RT group than in the CT group. Moreover, the recovery of FMA-UE was faster in proximal joints (t94 = 3.199, p < 0.01), and for patients in Brunnstrom Stage III (t34 = 2.526, p < 0.05). The improvements in MBI were not significantly different between RT and CT.

Conclusion

Robot-assisted therapy showed initial evidence for the acceleration of post-stroke recovery of motor function in the upper limb. Initial observations suggested that patients in Brunnstrom recovery stage III might benefit the most from the stratified intervention assisted by robotics.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=61834, Identifier [ChiCTR2000039010]. Registered 13 March 2020.

Efficacy of Daoyin combined with lower limb robot as a comprehensive rehabilitation intervention for stroke patients: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of a comprehensive rehabilitation approach combining Traditional Chinese Medicine Daoyin with lower limb robotics during the recovery phase of stroke patients.

METHODS

Stroke patients meeting the specified criteria were randomly assigned to one of four groups using a random number table: Control group, Daoyin group, lower limb robot group (LLR group), and Daoyin and lower limb robot group (DLLR group). Each group received distinct treatments based on conventional rehabilitation training. The treatment duration spanned two weeks with two days of rest per week. Pre- and post-intervention assessments included various scales: Fugl-Meyer Assessment (FMA), Berg balance scale (BBS), Barthel index (BI), Fatigue Scale-14 (FS-14), Pittsburgh sleep quality index (PSQI), Hamilton Anxiety Scale (HAMA), and Hamilton Depression Scale (HAMD).

RESULTS

Statistically significant differences were observed in the lower limb function measured by FAM between the Control group (15 ± 5) and the DLLR group (18 ± 5) (P = 0.049). In the Barthel index, a statistically significant difference was noted between the Control group (54 ± 18) and the DLLR group (64 ± 11) (P = 0.041). Additionally, significant differences were found in the Berg balance scale between the Control group (21 ± 10) and the DLLR group (27 ± 8) (P = 0.024), as well as between the Control group (21 ± 10) and the LLR group (26 ± 10) (P = 0.048).

CONCLUSION

The findings of this study suggest that the combined use of Daoyin and robotics not only enhances motor function in stroke patients but also has a positive impact on fatigue, sleep quality, and mood. This approach may offer a more effective rehabilitation strategy for stroke patients.

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

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

Exoskeleton-Assisted Anthropomorphic Movement Training for the Upper Limb After Stroke: The EAMT Randomized Trial

BACKGROUND

Robot-assisted arm training is generally delivered in the robot-like manner of planar or mechanical 3-dimensional movements. It remains unclear whether integrating upper extremity (UE) natural coordinated patterns into a robotic exoskeleton can improve outcomes. The study aimed to compare conventional therapist-mediated training to the practice of human-like gross movements derived from 5 typical UE functional activities managed with exoskeletal assistance as needed for patients after stroke.

METHODS

In this randomized, single-blind, noninferiority trial, patients with moderate-to-severe UE motor impairment due to subacute stroke were randomly assigned (1:1) to receive 20 sessions of 45-minute exoskeleton-assisted anthropomorphic movement training or conventional therapy. Treatment allocation was masked from independent assessors, but not from patients or investigators. The primary outcome was the change in the Fugl-Meyer Assessment for Upper Extremity from baseline to 4 weeks against a prespecified noninferiority margin of 4 points. Superiority would be tested if noninferiority was demonstrated. Post hoc subgroup analyses of baseline characteristics were performed for the primary outcome.

RESULTS

Between June 2020 and August 2021, totally 80 inpatients (67 [83.8%] males; age, 51.9±9.9 years; days since stroke onset, 54.6±38.0) were enrolled, randomly assigned to the intervention, and included in the intention-to-treat analysis. The mean Fugl-Meyer Assessment for Upper Extremity change in exoskeleton-assisted anthropomorphic movement training (14.73 points; [95% CI, 11.43-18.02]) was higher than that of conventional therapy (9.90 points; [95% CI, 8.15-11.65]) at 4 weeks (adjusted difference, 4.51 points [95% CI, 1.13-7.90]). Moreover, post hoc analysis favored the patient subgroup (Fugl-Meyer Assessment for Upper Extremity score, 23-38 points) with moderately severe motor impairment.

CONCLUSIONS

Exoskeleton-assisted anthropomorphic movement training appears to be effective for patients with subacute stroke through repetitive practice of human-like movements. Although the results indicate a positive sign for exoskeleton-assisted anthropomorphic movement training, further investigations into the long-term effects and paradigm optimization are warranted.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2100044078.

Effects of Upper Limb Robot-Assisted Rehabilitation Compared with Conventional Therapy in Patients with Stroke: Preliminary Results on a Daily Task Assessed Using Motion Analysis

Robotic rehabilitation of the upper limb has demonstrated promising results in terms of the improvement of arm function in post-stroke patients. The current literature suggests that robot-assisted therapy (RAT) is comparable to traditional approaches when clinical scales are used as outcome measures. Instead, the effects of RAT on the capacity to execute a daily life task with the affected upper limb are unknown, as measured using kinematic indices. Through kinematic analysis of a drinking task, we examined the improvement in upper limb performance between patients following a robotic or conventional 30-session rehabilitation intervention. In particular, we analyzed data from nineteen patients with subacute stroke (less than six months following stroke), nine of whom treated with a set of four robotic and sensor-based devices and ten with a traditional approach. According to our findings, the patients increased their movement efficiency and smoothness regardless of the rehabilitative approach. After the treatment (either robotic or conventional), no differences were found in terms of movement accuracy, planning, speed, or spatial posture. This research seems to demonstrate that the two investigated approaches have a comparable impact and may give insight into the design of rehabilitation therapy.

Effectiveness of robot-assisted arm exercise on arm and hand function in stroke survivors - A systematic review and meta-analysis

Objective: To examine the treatment effect of commercially available robotic-assisted devices, compared to traditional occupational- and physiotherapy on arm and hand function in persons with stroke. Methods: A systematic literature search was conducted in Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials up to January 2022. Randomized controlled trials (RCT's) involving persons with stroke of all ages and robot-assisted exercise as method for arm and hand function, compared to traditional therapy methods were included. Three authors performed the selection independently. The quality of evidence across studies was assessed using GRADE. Results: Eighteen RCT's were included in the study. A random effects meta-analysis showed a statistically significantly higher treatment effect in the robotic-assisted exercise group (p=<0.0001) compared to the traditional treatment group, with a total effect size of 0.44 (CI = 0.22-0.65). Heterogeneity was high, measured with I2 of 65%). Subgroup analyses showed no significant effects of the type of robotic device, treatment frequency or duration of intervention. Discussion and conclusion: Even though the analysis showed significant improvement in arm and hand function in favor of the robotic-assisted exercise group, the results in this systematic review should be interpreted with caution. This is due to high heterogeneity among the studies included and the presence of possible publication bias. Results of this study highlight the need for larger and more methodological robust RCT's, with a focus on reporting training intensity during robotic exercise.

Comparative Assessment of Robotic versus Classical Physical Therapy Using Muscle Strength and Ranges of Motion Testing in Neurological Diseases

The use of robotic systems in physical rehabilitation protocols has become increasingly attractive and has been given more focus in the last decade as a result of the high prevalence of motor deficits in the population, which is linked to an overburdened healthcare system. In accordance with current trends, three robotic devices have been designed, called ParReEx Elbow, ParReEx Wrist, and ASPIRE, which were designed to improve upper-limb medical recovery (shoulder, elbow, forearm, and wrist). The three automated systems were tested in a hospital setting with 23 patients (12 men and 11 women) suffering from motor deficits caused by various neurological diseases such as stroke, Parkinson’s disease, and amyotrophic lateral sclerosis (ALS). The patients were divided into three groups based on their pathology (vascular, extrapyramidal, and neuromuscular). Objective clinical measures, such as the Medical Research Council (MRC) scale, goniometry, and dynamometry, were used to compare pre- and post-rehabilitation assessments for both robotic-aided and manual physical rehabilitation therapy. The results of these tests showed that, with the exception of a few minor differences in muscular strength recovery, the robotic-assisted rehabilitation methods performed equally as well as the manual techniques, though only minor improvements were validated during short-term rehabilitation. The greatest achievements were obtained in the goniometric analysis where some rehabilitation amplitudes increased by over 40% in the vascular group, but the same analysis returned regressions in the neuromuscular group. The MRC scale analysis returned no significant differences, with most regressions occurring in the neuromuscular group. The dynamometric analysis mostly returned improvements, but the highest value evolution was 19.07%, which also in the vascular group. While the results were encouraging, more research is needed with a larger sample size and a longer study period in order to provide more information regarding the efficacy of both rehabilitation methods in neurological illnesses.

Design and Preliminary Evaluation of a Tongue-Operated Exoskeleton System for Upper Limb Rehabilitation

Stroke is a devastating condition that may cause upper limb paralysis. Robotic rehabilitation with self-initiated and assisted movements is a promising technology that could help restore upper limb function. Previous studies have established that the tongue motion can be used to communicate human intent and control a rehabilitation robot/assistive device. The goal of this study was to evaluate a tongue-operated exoskeleton system (TDS-KA), which we have developed for upper limb rehabilitation. We adopted a tongue-operated assistive technology, called the tongue drive system (TDS), and interfaced it with the exoskeleton KINARM. We also developed arm reaching and tracking tasks, controlled by different tongue operation modes, for training and evaluation of arm motor function. Arm reaching and tracking tasks were tested in 10 healthy participants (seven males and three females, 23-60 years) and two female stroke survivors with upper extremity impairment (32 and 58 years). All healthy and two stroke participants successfully performed the tasks. One stroke subject demonstrated a clinically significant improvement in Fugl-Meyer upper extremity score after practicing the tasks in six 3-h sessions. We conclude that the TDS-KA system can accurately translate tongue commands to exoskeleton arm movements, quantify the function of the arm, and perform rehabilitation training.

Robot-Assisted Arm Training in Stroke Individuals With Unilateral Spatial Neglect: A Pilot Study

Background: Robot-assisted arm training (RAT) is an innovative exercise-based therapy that provides highly intensive, adaptive, and task-specific training, yet its effects for stroke individuals with unilateral spatial neglect remain to be explored. The study was aimed to investigate the effects of RAT on unilateral spatial neglect, arm motor function, activities of daily living, and social participation after stroke.

Methods: In a pilot randomized controlled trial, individuals with unilateral spatial neglect after right hemisphere stroke were equally allocated to intervention group and control group, 45-min training daily, 5 days/week, for 4 weeks. Outcome measures included the Behavioral Inattention Test-conventional section (BIT-C), Catherine Bergego Scale (CBS), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Modified Barthel Index (MBI), and World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0).

Results: From November 2018 to February 2021, 20 stroke patients (mean age 47.40 ± 8.47) were enrolled in the study. Robot-assisted arm training was feasible and safe for individuals with unilateral spatial neglect. Both groups had significant improvements in all outcome measures. Participants assigned to RAT therapy had significantly greater improvements in BIT-C (difference, 7.70; 95% CI, 0.55–14.85, P = 0.04), FMA-UE (difference, 5.10; 95% CI, 1.52–8.68, P = 0.01), and WHODAS 2.0 (difference, −7.30; 95% CI, −12.50 to −2.10, P = 0.01). However, the change scores on CBS and MBI demonstrated no significance between the groups.

Conclusion: Our findings provide preliminary support for introducing robot-assisted arm training to remediate unilateral spatial neglect after stroke. The training program focusing on neglect of contralateral space and affected upper extremity may be effective in neglect symptoms, motor function recovery, and social participation, while not generalizing into improvements in activities of daily living.

Clinical Trial Registration: Chinese Clinical Trial Registry (http://www.chictr.org.cn/) on 17 October 2019, identifier: ChiCTR1900026656.

State of the art and challenges for the classification of studies on electromechanical and robotic devices in neurorehabilitation: a scoping review

INTRODUCTION

The rapid development of electromechanical and robotic devices has profoundly influenced neurorehabilitation. Growth in the scientific and technological aspects thereof is crucial for increasing the number of newly developed devices, and clinicians have welcomed such growth with enthusiasm. Nevertheless, improving the standard for the reporting clinical, technical, and normative aspects of such electromechanical and robotic devices remains an unmet need in neurorehabilitation. Accordingly, this study aimed to analyse the existing literature on electromechanical and robotic devices used in neurorehabilitation, considering the current clinical, technical, and regulatory classification systems.

EVIDENCE ACQUISITION

Within the CICERONE Consensus Conference framework, studies on electromechanical and robotic devices used for upper- and lower-limb rehabilitation in persons with neurological disabilities in adulthood and childhood were reviewed. We have conducted a literature search using the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, Science Direct, and Google Scholar. Clinical, technical, and regulatory classification systems were applied to collect information on the electromechanical and robotic devices. The study designs and populations were investigated.

EVIDENCE SYNTHESIS

Overall, 316 studies were included in the analysis. More than half (52%) of the studies were randomised controlled trials (RCTs). The population investigated the most suffered from strokes, followed by spinal cord injuries, multiple sclerosis, cerebral palsy, and traumatic brain injuries. In total, 100 devices were described; of these, 19% were certified with the CE mark. Overall, the main type of device was an exoskeleton. However, end-effector devices were primarily used for the upper limbs, whereas exoskeletons were used for the lower limbs (for both children and adults).

CONCLUSIONS

The current literature on robotic neurorehabilitation lacks detailed information regarding the technical characteristics of the devices used. This affects the understanding of the possible mechanisms underlying recovery. Unfortunately, many electromechanical and robotic devices are not provided with CE marks, strongly hindering the research on the clinical outcomes of rehabilitation treatments based on these devices. A more significant effort is needed to improve the description of the robotic devices used in neurorehabilitation in terms of the technical and functional details, along with high-quality RCT studies.