Assessing the motor status score: a scale for the evaluation of upper limb motor outcomes in patients after stroke

Multi-joint Assessment of Proprioception Impairments Poststroke

OBJECTIVES

To investigate shoulder, elbow and wrist proprioception impairment poststroke.

DESIGN

Proprioceptive acuity in terms of the threshold detection to passive motion at the shoulder, elbow and wrist joints was evaluated using an exoskeleton robot to the individual joints slowly in either inward or outward direction.

SETTING

A university research laboratory.

PARTICIPANTS

Seventeen stroke survivors and 17 healthy controls (N=34). Inclusion criteria of stroke survivors were (1) a single stroke; (2) stroke duration <1 year; and (3) cognitive ability to follow simple instructions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Threshold detection to passive motion and detection error at the shoulder, elbow and wrist.

RESULTS

There was significant impairment of proprioceptive acuity in stroke survivors as compared to healthy group at all 3 joints and in both the inward (shoulder horizontal adduction, elbow and wrist flexion, P<.01) and outward (P<.01) motion. Furthermore, the distal wrist joint showed more severe impairment in proprioception than the proximal shoulder and elbow joints poststroke (P<.01) in inward motion. Stroke survivors showed significantly larger detection error in identifying the individual joint in motion (P<.01) and the movement direction (P<.01) as compared to the healthy group. There were significant correlations among the proprioception acuity across the shoulder, elbow and wrist joints and 2 movement directions poststroke.

CONCLUSIONS

There were significant proprioceptive sensory impairments across the shoulder, elbow and wrist joints poststroke, especially at the distal wrist joint. Accurate evaluations of multi-joint proprioception deficit may help guide more focused rehabilitation.

Repetitive Transcranial Magnetic Stimulation of the Brain Region Activated by Motor Imagery Involving a Paretic Wrist and Hand for Upper-Extremity Motor Improvement in Severe Stroke: A Preliminary Study

Approximately two-thirds of stroke survivors experience chronic upper-limb paresis; however, treatment options are limited. Repetitive transcranial magnetic stimulation (rTMS) can enhance motor function recovery in stroke survivors, but its efficacy is controversial. We compared the efficacy of stimulating different targets in 10 chronic stroke patients with severe upper-limb motor impairment. Motor imagery-based brain-computer interface training augmented with virtual reality was used to induce neural activity in the brain region during an imagery task. Participants were then randomly assigned to two groups: an experimental group (received high-frequency rTMS delivered to the brain region activated earlier) and a comparison group (received low-frequency rTMS delivered to the contralesional primary motor cortex). Behavioural metrics and diffusion tensor imaging were compared pre- and post rTMS. After the intervention, participants in both groups improved somewhat. This preliminary study indicates that in chronic stroke patients with severe upper-limb motor impairment, inducing activation in specific brain regions during motor imagery tasks and selecting these regions as a target is feasible. Further studies are needed to explore the efficacy of this intervention.

Imitation encourages empathic capacity toward other individuals with physical disabilities

Many people have difficulty empathizing with others who have dissimilar characteristics, such as physical disabilities. We hypothesized that people with no disabilities imitating the movements of individuals with disabilities could improve the empathic capacity toward their difficulties. To evaluate this hypothesis, we used functional magnetic resonance imaging to measure the neural activity patterns of 26 healthy participants while they felt the difficulties of individuals with hemiplegia by adopting their perspective. The participants initially either imitated or observed hemiplegic hand movements shown in video clips. Subsequently, the videos were rewatched and their difficulties were rated. Analysis of the subjective rating scores indicated that after imitating the hemiplegic movements, the participants felt into the difficulties of hemiplegia better than if they simply observed them. The cross-validation approach of multivoxel pattern analyses demonstrated that the information regarding the effect of imitation on empathizing with the difficulties was represented in specific activation patterns of brain regions involved in the mirror neuron system and cognitive empathy by comparing to other conditions that did not contain the information. The cross-classification approach detected distinct activation patterns in the brain regions involved in affective and cognitive empathy, commonly while imitating the hemiplegic movements and subsequently feeling them. This indicated that the common representation related to these two types of empathy existed between imitating and feeling the hemiplegic movements. Furthermore, representational similarity analysis revealed that activity patterns in the anterior cingulate cortex linked to affective empathy tuned to the subjective assessment of hemiplegic movements. Our findings indicate that imitating the movements of individuals with hemiplegia triggered the affective empathic response and improved the cognitive empathic response toward them. The affective empathic response also linked the subjective assessment to the difficulties of hemiplegia, which was especially modulated by the experience of imitation. Imitating the movements of individuals with disabilities likely encourages empathic capacity from both affective and cognitive aspects, resulting in people with no disabilities precisely feeling what they are feeling.

Biomarkers for rhythmic and discrete dynamic primitives in locomotion

Rehabilitation can promote brain plasticity and improve motor control after central nervous system injuries. Our working model is that motor control is encoded using dynamic primitives: submovements, oscillations, and mechanical impedances. We hypothesize that therapies focusing on these primitives can achieve greater motor recovery. At the observational level, these primitives lead to discrete and rhythmic movements. Here, we propose two novel biomarkers to evaluate rhythmic and discrete movements in gait based on the feet forward position: the smoothness of their relative position, using the mean-squared jerk ratio (MSJR), to assess rhythmicity; and the angle between principal components of consecutive trajectories (dPCA), to detect discrete movements amidst rhythmic motion. We applied these methods to kinematic data collected with healthy individuals during experiments employing the MIT-Skywalker: level-ground walking at five speeds, with and without imposed ankle stiffness; walking at constant speed on ascending, descending, and laterally tilted slopes; and performing sidesteps. We found a decrease in MSJR as speed increases, related to increased rhythmicity, even with imposed stiffness. Rhythmicity seems unaffected by the terrain perturbations imposed. Finally, dPCA successfully detects sidesteps, discrete events amidst rhythmic movement. These biomarkers appear to accurately assess rhythmic and discrete movements during walking and can potentially improve clinical evaluation and rehabilitation of neurological patients.

Accurate prediction of clinical stroke scales and improved biomarkers of motor impairment from robotic measurements

Objective

One of the greatest challenges in clinical trial design is dealing with the subjectivity and variability introduced by human raters when measuring clinical end-points. We hypothesized that robotic measures that capture the kinematics of human movements collected longitudinally in patients after stroke would bear a significant relationship to the ordinal clinical scales and potentially lead to the development of more sensitive motor biomarkers that could improve the efficiency and cost of clinical trials.

Materials and methods

We used clinical scales and a robotic assay to measure arm movement in 208 patients 7, 14, 21, 30 and 90 days after acute ischemic stroke at two separate clinical sites. The robots are low impedance and low friction interactive devices that precisely measure speed, position and force, so that even a hemiparetic patient can generate a complete measurement profile. These profiles were used to develop predictive models of the clinical assessments employing a combination of artificial ant colonies and neural network ensembles.

Results

The resulting models replicated commonly used clinical scales to a cross-validated R² of 0.73, 0.75, 0.63 and 0.60 for the Fugl-Meyer, Motor Power, NIH stroke and modified Rankin scales, respectively. Moreover, when suitably scaled and combined, the robotic measures demonstrated a significant increase in effect size from day 7 to 90 over historical data (1.47 versus 0.67).

Discussion and conclusion

These results suggest that it is possible to derive surrogate biomarkers that can significantly reduce the sample size required to power future stroke clinical trials.

First-person perspective sharpens the understanding of distressful physical feelings associated with physical disability: A functional magnetic resonance study

We investigated whether observation of hand movements of people with hemiplegia by healthy individuals from the first-person perspective (FPP), compared to that from the third-person perspective (TPP), enables better understanding of disability-associated distress. We measured the neural activity of healthy individuals using functional magnetic resonance imaging while they observed hemiplegic movements from the FPP or TPP. Subjective assessment of the movements was determined with questionnaires. Compared to the TPP, the FPP elicited stronger activation in the inferior parietal lobule (IPL), right temporoparietal junction, and anterior cingulate cortex, which are associated with body representation, mentalization, and empathy, respectively. Enhanced IPL activity correlated positively with personal empathic traits. Observing movements of hemiplegic individuals from the FPP provided precise subjective understanding of the physically distressing aspects of their movements. These findings suggest that observing hemiplegic individuals from the FPP effectively improved observers' understanding of disability-associated distress via body representation, mentalization, and empathy systems.

Equal Opportunities for Stroke Survivors' Rehabilitation: A Study on the Validity of the Upper Extremity Fugl-Meyer Assessment Scale Translated and Adapted into Romanian

Background and objectives: The Upper Extremity Fugl-Meyer Assessment (UEFMA) is one of the most recommended and used methods of clinical evaluation not only for post-stroke motor function disability conditions but also for physiotherapy goal-setting. Up to the present, an official Romanian version has not been officially available. This study aims to carry out a translation, adaptation, and validation of UEFMA in Romanian, thus giving both patients and medical practitioners the equal opportunity of benefiting from its proficiency. Material and methods: The English version of the motor component of UEFMA was back and forth translated in the assent of best practice translation guidelines. The research was performed on a group of 64 post-stroke in-patients regarding psychometric properties for content validation and an exploratory and confirmatory factorial analysis was performed using the Bayesian model. To assess internal consistency and test–retest reliability, we used the Cronbach Alpha index and Intraclass Correlation Coefficient (ICC). We used Pearson correlation with the Functional Independence Measure (FIM) and Modified Rankin Scale (MRS) to determine concurrent validation. Standardized response mean (SRM) was applied to determine the responsiveness of the instrument used. Results: After performing the exploratory factor analysis, a single factor was extracted, with an Eigenvalue of 19.363, which explained 64.543% of the variation. The model was confirmed by Bayesian exploration, with Root Mean Square Residual (RMR) 0.051, Goodness-of-fit Index (GFI) 0.980, Normed-Fit Index (NFI) 0.978 and Relative Fit Index (RFI) 0.977. The Cronbach Alpha value was 0.981, the Intraclass Correlation Coefficient (ICC) index for average measures was 0.992, the Pearson correlation with FIM 0.789, and MRS −0.787, while the SRM was 1.117. Conclusions: The Romanian version of the UEFMA scale is a reliable, responsive and valid tool which can be used as a standardized assessment in post-stroke patients across Romania.

Video-guided exercise after stroke: a feasibility randomised controlled trial

BACKGROUND

Facilitating self-directed upper-limb exercise in people after a stroke whilst not in therapy sessions may increase therapy intensity and improve outcomes. Objectives: To investigate the feasibility and acceptability of video-guided exercise for facilitating upper-limb exercise after stroke.

METHODS

A single-blind feasibility randomized controlled trial with embedded qualitative study in stroke wards at a large teaching hospital in the United Kingdom. Fourteen participants with stroke were randomized to either video-guided exercise intervention or a "treatment-as-usual" control group. Intervention participants received a computer tablet containing filmed individualized exercises to guide out of therapy practice. The primary outcome measure was the Motor status scale (MSS) for the upper limb, which was used to guide possible sample sizes for a future main trial. Qualitative focus group and interview data on feasibility/acceptability were collected and analyzed.

RESULTS

The intervention was acceptable, but the need for motivation/support to exercise was highlighted. Based on similar assumptions to the feasibility study, circa ninety-two patients in each group would be needed to detect a difference of 5 in upper-limb motor status for a main trial.

CONCLUSION

A trial of video-guided exercise is feasible, although an optimal main trial would require some relatively minor changes to design, outcome measures, eligibility, and the intervention.

An interactive motion-tracking system for home-based assessing and training reach-to-target tasks in stroke survivors-a preliminary study

Quantitative evaluation and training of the reach-to-target ability in stroke patients are needed for postdischarge rehabilitation, which can be achieved using a motion-tracking system. However, most of these systems are either costly, involve sophisticated parameter interpretation, or are not designed for rehabilitation. We developed an interactive reach-to-target assessment and training system (IRTATS) based on a camera and three marker straps to detect tracking signals. IRTATS supports audiovisual feedback, personal goal setting, and use in a small clinic or home without the internet. This study aims to evaluate the reliability, validity of IRTATS, and its measurement accuracy of the range of motion (ROM). Ninety-nine stroke patients and 20 healthy adults were recruited for the study. Kinematic variables and active joint ROM (AROM) were assessed using IRTATS. The AROM was measured by a universal goniometer, and scores from multiple clinical scales concerning motor and activity capability were calculated. Although the AROMs measured by IRTATS and the goniometer did not agree, IRTATS has clinically acceptable reliability and validity. Three variables in IRTATS could discriminate the motor performance of patients and healthy subjects. IRTATS may provide a new supplement to conventional physiotherapy in the assessment of the reach-to-target ability in stroke patients. Graphical abstract System configuration • The system is based on an infrared camera and the adjustable marker straps as a sensor module. • It is portable and compact, and has clinically acceptable reliability and validity. • It supports audiovisual feedback, personal goal setting, and use in regions without the internet. • It can be used as an adjunct to conventional physiotherapy in the assessment of the reach-to-target ability.

Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment

End-effector (EE) and exoskeleton (Exo) robots have not been directly compared previously. The present study aimed to directly compare EE and Exo robots in chronic stroke patients with moderate-to-severe upper limb impairment. This single-blinded, randomised controlled trial included 38 patients with stroke who were admitted to the rehabilitation hospital. The patients were equally divided into EE and Exo groups. Baseline characteristics, including sex, age, stroke type, brain lesion side (left/right), stroke duration, Fugl–Meyer Assessment (FMA)–Upper Extremity score, and Wolf Motor Function Test (WMFT) score, were assessed. Additionally, impairment level (FMA, motor status score), activity (WMFT), and participation (stroke impact scale [SIS]) were evaluated. There were no significant differences in baseline characteristics between the groups. After the intervention, improvements were significantly better in the EE group with regard to activity and participation (WMFT–Functional ability rating scale, WMFT–Time, and SIS–Participation). There was no intervention-related adverse event. The EE robot intervention is better than the Exo robot intervention with regard to activity and participation among chronic stroke patients with moderate-to-severe upper limb impairment. Further research is needed to confirm this novel finding.

Outcome measurement of hand function following mirror therapy for stroke rehabilitation: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Mirror therapy is a treatment used to address hand function following a stroke. Measurement of outcomes using appropriate assessment tools is crucial; however, many assessment options exist.

PURPOSE OF THE STUDY

The purpose of this study is to systematically review outcome measures that are used to assess hand function following mirror therapy after stroke and, in addition, to identify the psychometric and descriptive properties of the included measures and through the linking process determine if the outcome measures are representative of the International Classification of Functioning, Disability and Health (ICF).

METHODS

Following a comprehensive literature search, outcome measures used in the included studies were linked to the ICF and analyzed based on descriptive information and psychometric properties.

RESULTS

Eleven studies met inclusion criteria and included 24 different assessment tools to measure hand or upper limb function. Most outcome measures used in the selected studies (63%) were rated by the evaluating therapist. Thirteen outcome measures (54%) linked to the ICF body function category and 10 measures (42%) linked to activities and participation. One outcome measure was linked to not defined, and all other ICF categories were not represented. A majority of outcome measures have been assessed for validity, reliability, and responsiveness, but responsiveness was the least investigated psychometric property.

DISCUSSION

Current studies on mirror therapy after stroke are not consistent in the assessment tools used to determine hand function. Understanding of study outcomes requires analysis of the assessment tools. The outcome measures used in the included studies are not representative of personal and environmental factors, but tools linking to body functions and activities and participations provide important information on functional outcome.

CONCLUSIONS

Integrating a combination of measures that are psychometrically sound and reflective of the ICF should be considered for assessment of hand function after mirror therapy after stroke.

Effectiveness of interventions to improve hand motor function in individuals with moderate to severe stroke: a systematic review protocol

INTRODUCTION

The human hand is extremely involved in our daily lives. However, the rehabilitation of hand function after stroke can be rather difficult due to the complexity of hand structure and function, as well as neural basis that supports hand function. Specifically, in individuals with moderate to severe impairment following a stroke, previous evidence for effective treatments that recover hand function in this population is limited, and thus has never been reviewed. With the progress of rehabilitation science and tool development, results from more and more clinical trials are now available, thereby justifying conducting a systematic review.

METHODS AND ANALYSIS

This systematic review protocol is consistent with the methodology recommended by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane handbook for systematic reviews of interventions. Electronic searches will be carried out in the PubMed, CINAHL, Physiotherapy Evidence Database and Cochrane Library databases, along with manual searches in the reference lists from included studies and published systematic reviews. The date range parameters used in searching all databases is between January 1999 and January 2019. Randomised controlled trials (RCTs) published in English, with the primary outcome focusing on hand motor function, will be included. Two reviewers will screen all retrieved titles, abstracts and full texts, perform the evaluation of the risk bias and extract all data independently. The risk of bias of the included RCTs will be evaluated by the Cochrane Collaboration's tool. A qualitative synthesis will be provided in text and table, to summarise the main results of the selected publications. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. The quality of the included publications will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation system from the Cochrane Handbook for Systematic Reviews of Interventions.

ETHICS AND DISSEMINATION

No ethical approval is needed, and the results of this review will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

CRD42019128285.

Effects of pseudoexperience on the understanding of hemiplegic movements in physical therapists: An fMRI study

Physical therapists (PTs) are required to obtain an accurate understanding of the physical and mental states of their patients through observational assessment. To perform comprehensive observational assessments of patients' movements, PTs likely need to engage their own neural systems involved in action understanding and theory of mind, such as the action observation network (AON) and the right temporoparietal junction (rTPJ). Both systems are modulated by the observer's actual experience with the observed movements. Although, most PTs do not have physical experience with neurological disabilities, they routinely examine hemiplegic movements in stroke patients, and are thus considered to have acquired pseudoexperience with hemiplegia. We hypothesized that the PTs' pseudoexperience with hemiplegia would modulate the neural system associated with the understanding of others to elaborately comprehend the physical and mental states associated with hemiplegia. To investigate our hypothesis, we recruited 19 PTs and 19 naïve participants (NPs) to undergo functional MRI (fMRI) for cortical activity measurement while viewing videos of hemiplegic (HHM) and non-hemiplegic (non-HHM) hand movements. The participants subsequently viewed the same videos again outside the MRI scanner, and evaluated the observed hand movements via a questionnaire. Compared to the NPs, the PTs showed greater activation in the AON and rTPJ while observing HHMs. Psychophysiological interaction analyses revealed increased connectivity between the rTPJ and AON when the PTs viewed the HHMs. Behavioral analyses further indicated that the PTs more accurately assessed feeling states associated with HHMs than did NPs. These findings suggest that the PTs' pseudoexperience modulates the AON and rTPJ, enabling them to better understand hemiplegia-associated feeling states.

Evaluation of Performance-Based Outcome Measures for the Upper Limb: A Comprehensive Narrative Review

Objective performance-based outcome measures (OMs) have the potential to provide unbiased and reproducible assessments of limb function. However, very few of these performance-based OMs have been validated for upper limb (UL) prosthesis users. OMs validated in other clinical populations (eg, neurologic or musculoskeletal conditions) could be used to fill gaps in existing performance-based OMs for UL amputees. Additionally, a joint review might reveal consistent gaps across multiple clinical populations. Therefore, the objective of this review was to systematically characterize prominent measures used in both sets of clinical populations with regard to (1) location of task performance around the body, (2) possible grips employed, (3) bilateral versus unilateral task participation, and (4) details of scoring mechanisms. A systematic literature search was conducted in EMBASE, Medline, and Cumulative Index to Nursing and Allied Health electronic databases for variations of the following terms: stroke, musculoskeletal dysfunction, amputation, prosthesis, upper limb, outcome, assessments. Articles were included if they described performance-based OMs developed for disabilities of the UL. Results show most tasks were performed with 1 hand in the space directly in front of the participant. The tip, tripod, and cylindrical grips were most commonly used for the specific tasks. Few measures assessed sensation and movement quality. Overall, several limitations in OMs were identified. The solution to these limitations may be to modify and validate existing measures originally developed for other clinical populations as first steps to more aptly measure prosthesis use while more complete assessments for UL prosthesis users are being developed.

LEVEL OF EVIDENCE

Level III.

Robot-assisted post-stroke motion rehabilitation in upper extremities: a survey

Recent neurological research indicates that the impaired motor skills of post-stroke patients can be enhanced and possibly restored through task-oriented repetitive training. This is due to neuroplasticity – the ability of the brain to change through adulthood. Various rehabilitation processes have been developed to take advantage of neuroplasticity to retrain neural pathways and restore or improve motor skills lost as a result of stroke or spinal cord injuries (SCI). Research in this area over the last few decades has resulted in a better understanding of the dynamics of rehabilitation in post-stroke patients and development of auxiliary devices and tools to induce repeated targeted body movements. With the growing number of stroke rehabilitation therapies, the application of robotics within the rehabilitation process has received much attention. As such, numerous mechanical and robot-assisted upper limb and hand function training devices have been proposed. A systematic review of robotic-assisted upper extremity (UE) motion rehabilitation therapies was carried out in this study. The strengths and limitations of each method and its effectiveness in arm and hand function recovery were evaluated. The study provides a comparative analysis of the latest developments and trends in this field, and assists in identifying research gaps and potential future work.

Continuous passive motion improves shoulder joint integrity following stroke

Objective: In a pilot study of patients with a first stroke and hemiparesis, we sought to determine whether treatment of the upper limb with continuous passive motion (CPM) that was device delivered would alter impairment, disability or the associated adverse symptoms of shoulder joint instability, pain and tone.

Design: Patients were randomly assigned to receive daily CPM treatments or participate in self-range of motion groups under the supervision of an occupational therapist. All patients received standard daily poststroke therapy for 3.5 h per day. A blinded evaluator at admission and discharge assessed patients using standardized scales of impairment, disability and adverse symptoms.

Setting: Specialized stroke unit of an acute rehabilitation hospital.

Subjects: Two hundred and eighty consecutive patients were screened and 35 of these with a first unilateral stroke, 139-6 days following the acute event, provided informed consent and were randomly assigned to CPM treatment or supervised group self-range exercise.

Main measures: Thirty-two completed the study and were evaluated using standardized measures for motor impairment (Fugl-Meyer, Motor Status Scale and Medical Research Council Motor Power), adverse symptoms (gleno-humeral stability, pain and tone), and disability (Functional Independence Measure).

Results: CPM-treated patients demonstrated positive trends towards improved shoulder joint stability (p =0.06, confidence interval -0.03, 2.3) when compared with patients performing therapist-supervised self-range of motion. There were no significant differences in motor impairment, disability, pain or tone.

Conclusions: Device-delivered continuous passive range of motion may offer an enhanced benefit for some adverse symptom reduction in the hemiplegic arm after stroke over traditional self-range of motion exercise.

Does Shorter Rehabilitation Limit Potential Recovery Poststroke?

Objective. To examine retrospectively the recovery of patients engaged in robotic research during a 6- to 7-week course of inpatient rehabilitation. Because timing of the Interim evaluation at 31/2 weeks was comparable to the present length of inpatient stroke rehabilitation, the authors assessed whether significant gains in motor abilities occurred after the time when most stroke patients today are discharged home. Methods. Fifty-six inpatients with a single, unilateral stroke were randomly assigned to a robot therapy or robot exposure group. Therapists blinded to group assignment administered the Fugl-Meyer, Motor Status Score, and MRC motor power test. Results. Significant improvements in upper-limb motor abilities occurred throughout a period approximately twice the present length of stay in inpatient rehabilitation. However, in the latter half of this period, patients who received conventional therapy showed little improvement, whereas patients who received robot training plus conventional therapy continued to improve. Conclusion. Further opportunities for recovery after stroke are possible by extending intensive therapy beyond present inpatient rehabilitation stays.

Longitudinal Assessment of Motor Recovery of Contralateral Hand after Basal Ganglia Infarction Using Functional Magnetic Resonance Imaging

We used functional fMRI to study the brain activation during active finger movements at different time points during the recovery phase following basal ganglia infarction. Four hemiplegic patients with basal ganglia infarction were serially evaluated at different time points spanning the acute and chronic phase using fMRI. To evaluate motor recovery, the patients were asked to perform functional tasks arranged in a block design manner with their hand. On follow-up (chronic phase), three patients achieved significant recovery of motor function of affected limbs. Activation of bilateral sensorimotor cortex (SMC) was observed in two of these patients, while activation of cerebellum was observed in all patients. No remarkable recovery of motor function was noted in one patient with left basal ganglia infarction. In this patient, the activation domain was located in SMC of both sides in acute phase and in ipsilateral SMC in chronic phase. Contralateral SMC appears to be involved in the functional rehabilitation following basal ganglia infarction. The cerebellum may act as an intermediary during functional recovery following basal ganglia infarction. The activation domain associated with active finger movement may be bilateral in acute phase; one patient was ipsilateral in the chronic stage.

Robotic Technology and Stroke Rehabilitation: Translating Research into Practice

Research on the effectiveness of robotic therapy for the paretic upper limb after stroke has shown statistically significant reductions in motor impairment during both acute and chronic phases of recovery. Despite growing empirical support for this technology and a stronger focus on optimizing rehabilitation outcomes and productivity, there continues to be a disconnect between research and clinical practice. We review studies on the use of robot-aided neurorehabilitation for the paretic arm after stroke and discuss ways in which this technology may provide opportunities for intensive training that complement more conventional therapy methods.

Advances in the Understanding and Treatment of Stroke Impairment Using Robotic Devices

The presence of robotic devices in rehabilitation centers is now becoming commonplace across the world, challenging heath care professionals to rethink treatment strategies for motor impairment in hemiparetic stroke patients. In this article, we will discuss some of the motivations for using these devices, review clinical outcomes following robotic-assisted training in both the upper and lower extremities, and detail how these devices can provide quantitative evaluations of function. We will also address the clinical issues that need to be considered when using robotic devices to treat stroke patients, and finally a vision of where this field is heading will be discussed.

Interventions for improving upper limb function after stroke

BACKGROUND

Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

OBJECTIVES

To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

METHODS

SEARCH METHODS

We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

SELECTION CRITERIA

We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

DATA COLLECTION AND ANALYSIS

Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

MAIN RESULTS

Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

AUTHORS' CONCLUSIONS

Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

Assessment of movement quality in robot- assisted upper limb rehabilitation after stroke: a review

Studies of stroke patients undergoing robot-assisted rehabilitation have revealed various kinematic parameters describing movement quality of the upper limb. However, due to the different level of stroke impairment and different assessment criteria and interventions, the evaluation of the effectiveness of rehabilitation program is undermined. This paper presents a systematic review of kinematic assessments of movement quality of the upper limb and identifies the suitable parameters describing impairments in stroke patients. A total of 41 different clinical and pilot studies on different phases of stroke recovery utilizing kinematic parameters are evaluated. Kinematic parameters describing movement accuracy are mostly reported for chronic patients with statistically significant outcomes and correlate strongly with clinical assessments. Meanwhile, parameters describing feed-forward sensorimotor control are the most frequently reported in studies on sub-acute patients with significant outcomes albeit without correlation to any clinical assessments. However, lack of measures in coordinated movement and proximal component of upper limb enunciate the difficulties to distinguish the exploitation of joint redundancies exhibited by stroke patients in completing the movement. A further study on overall measures of coordinated movement is recommended.

Acceptability of robotic technology in neuro-rehabilitation: preliminary results on chronic stroke patients

During the last decade, different robotic devices have been developed for motor rehabilitation of stroke survivors. These devices have been shown to improve motor impairment and contribute to the understanding of mechanisms underlying motor recovery after a stroke. The assessment of the robotic technology for rehabilitation assumes great importance. The aim of this study is to present preliminary results on the assessment of the acceptability of the robotic technology for rehabilitation on a group of thirty-four chronic stroke patients. The results from questionnaires on the patients' acceptability of two different robot-assisted rehabilitation scenarios show that the robotic approach was well accepted and tolerated by the patients.

Effects of the Alternate Combination of "Error-Enhancing" and "Active Assistive" Robot-Mediated Treatments on Stroke Patients

This paper aimed at investigating the effects of a novel robotic-aided rehabilitation treatment for the recovery of the upper limb related capabilities in chronic post stroke patients. Eighteen post-stroke patients were enrolled in a six-week therapy program and divided into two groups. They were all required to perform horizontal pointing movements both in the presence of a robot-generated divergent force field (DF) that pushed their hands proportional to the trajectory error and perpendicular to the direction of motion, and according to the typical active assistive (AA) approach used in robotic therapy. We used a crossover experimental paradigm where the two groups switched from one therapy treatment to the other. The hypothesis underlying this paper was that the use of the destabilizing scenario forced the patient to keep the end-point position as close as possible to the ideal path, hence requiring a more active control of the arm with respect to the AA approach. Our findings confirmed this hypothesis. In addition, when the DF treatment was provided in the first therapy cycle, patients also showed straighter and smoother paths during the subsequent AA therapy cycle, while this was not true in the opposite case. In conclusion, the results herein reported provide evidence that the use of an unstable DF field can lead to better recovery outcomes, and therefore it potentially more effective than solely active assistance therapy alone.

Neural correlates of motor impairment during motor imagery and motor execution in sub-cortical stroke

OBJECTIVE

This study aims at identifying the neural substrates for motor execution (ME) and motor imagery (MI) in patients after stroke and their correlations with functional outcomes.

METHODS

10 chronic stroke patients with left sub-cortical lesions and 10 unimpaired subjects were recruited. Their cortical processes were studied when they were asked to perform ME and MI unimanually using their unaffected and affected wrists during fMRI.

RESULTS

From correlation results, the supplementary motor area (SMA), its activation volume and congruence in functional neuroanatomy associated with ME and MI using affected wrist positively correlated with motor performance. During ME of the affected wrist, the precuneus, its activation volume and congruence in functional neuroanatomy between patient and unimpaired groups showed a negative correlation, while, in non-primary motor areas, the hemispheric balance of premotor cortex and the congruence in functional neuroanatomy of contralesional inferior parietal lobule between patient and unimpaired groups showed a positive correlation with motor performance.

CONCLUSIONS

The non-primary motor-related areas were revealed to play a critical role in determining motor outcomes after left sub-cortical stroke, which was demonstrated in the stroke patients. In particular, SMA might be the key neural substrate associated with motor recovery.

Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review

OBJECTIVE

To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro, and AMED.

STUDY SELECTION

Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions.

DATA EXTRACTION

Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended.

DATA SYNTHESIS

The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test.

CONCLUSIONS

The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

Robot-aided therapy on the upper limb of subacute and chronic stroke patients: a biomechanical approach

The goal of this study is to propose a methodology for evaluating recovery mechanisms in subacute and chronic post-stroke patients after a robot-aided upper-limb therapy, using a set of biomechanical parameters. Fifty-six post-stroke subjects, thirteen subacute and forty-three chronic patients participated in the study. A 2 dof robotic system, implementing an "assist-as-needed" control strategy, was used. Biomechanical parameters related (i) to the speed measured at the robot's end-effector and (ii) to the movement's smoothness were computed. Outcome clinical measures show a decrease in motor impairment after the treatment both in chronic and subacute patients. All the biomechanical parameters show an improvement between admission and discharge. Our results show that the robot-aided training can contribute to reduce the motor impairment in both subacute and chronic patients and identify neurophysiological mechanisms underlying the different stages of motor recovery.

Modeling upper limb clinical scales by robot-measured performance parameters

The status of motor function in stroke survivors and the effect of any therapeutic intervention are generally measured by physiotherapists using clinical assessment scales that probe specific aspects of a subject's motor behavior. Although they are widely accepted, these measurement tools are limited by interrater and intrarater reliability and are time-consuming to apply. This paper analyzes the changes in movement kinematics and kinetics during robot-aided neurorehabilitation of subjects after stroke and verifies the possibility of estimating outcome measures by means of a set of robot measured parameters.

A simple bedside test for upper extremity impairment after stroke: validation of the Utrecht Arm/Hand Test

PURPOSE

To examine the intra- and inter-rater reliability, criterion validity and responsiveness of the Utrecht Arm/hand Test (UAT), a quick and easy assessment method for upper extremity impairment after stroke.

METHOD

Study 1 (N= 29): Repeated administration of the UAT at admission and discharge; comparison with scores on the Fugl-Meyer test (FM), Action Research Arm test (ARA) and Self-Care scale of the Functional Independence Measure (FIM). Study 2 (N = 192): Admission of the UAT and Frenchay Arm Test at admission (FAT) and discharge. Computation of Spearman correlations between UAT and FAT and comparison of the Effect Size and the Standardised Response Mean of both measures.

RESULTS

Study 1: Spearman correlations between UAT and FM were 0.93 at admission and 0.94 at discharge. Correlations with ARA and FIM were also high: 0.90 and 0.76 at admission, and 0.89 and 0.73 at discharge. Inter-rater and intra-rater reliability were excellent (weighted kappa 0.98-0.99). Study 2: Correlations between UAT and FAT were 0.93 at admission and 0.90 at discharge. The mean UAT score improved from 3.7 at admission up to 4.6 at discharge (p < 0.001). The Effect Size and Standardised Response Mean of the UAT were better than those of the FAT.

CONCLUSION

The UAT is a simple, valid and reliable bedside test for the evaluation of upper extremity impairment after stroke.

Kinematic robot-based evaluation scales and clinical counterparts to measure upper limb motor performance in patients with chronic stroke

BACKGROUND

Human-administered clinical scales are the accepted standard for quantifying motor performance of stroke subjects. Although they are widely accepted, these measurement tools are limited by interrater and intrarater reliability and are time-consuming to apply. In contrast, robot-based measures are highly repeatable, have high resolution, and could potentially reduce assessment time. Although robotic and other objective metrics have proliferated in the literature, they are not as well established as clinical scales and their relationship to clinical scales is mostly unknown.

OBJECTIVE

To test the performance of linear regression models to estimate clinical scores for the upper extremity from systematic robot-based metrics.

METHODS

Twenty kinematic and kinetic metrics were derived from movement data recorded with the shoulder-and-elbow InMotion2 robot (Interactive Motion Technologies, Inc), a commercial version of the MIT-Manus. Kinematic metrics were aggregated into macro-metrics and micro-metrics and collected from 111 chronic stroke subjects. Multiple linear regression models were developed to calculate Fugl-Meyer Assessment, Motor Status Score, Motor Power, and Modified Ashworth Scale from these robot-based metrics.

RESULTS

Best performance-complexity trade-off was achieved by the Motor Status Score model with 8 kinematic macro-metrics (R = .71 for training; R = .72 for validation). Models including kinematic micro-metrics did not achieve significantly higher performance. Performances of the Modified Ashworth Scale models were consistently low (R = .35-.42 for training; R = .08-.17 for validation).

CONCLUSIONS

The authors identified a set of kinetic and kinematic macro-metrics that may be used for fast outcome evaluations. These metrics represent a first step toward the development of unified, automated measures of therapy outcome.

Comparison of bilateral and unilateral training for upper extremity hemiparesis in stroke

BACKGROUND

Upper extremity hemiparesis is the most common poststroke disability. Longitudinal studies have indicated that 30% to 66% of stroke survivors do not have full arm function 6 months poststroke. One promising treatment approach is bilateral training. To date, no randomized, blinded study of efficacy comparing 2 groups (bilateral training vs unilateral training) using analogous tasks has been performed in chronic stroke survivors with moderate upper extremity impairment.

OBJECTIVE

To compare the effectiveness of bilateral training with unilateral training for individuals with moderate upper limb hemiparesis. The authors hypothesized that bilateral training would be superior to unilateral training in the proximal extremity but not the distal one.

METHODS

Twenty-four subjects participated in a randomized, single-blind training study. Subjects in the bilateral group (n = 12) practiced bilateral symmetrical activities, whereas the unilateral group (n = 12) performed the same activity with the affected arm only. The activities consisted of reaching-based tasks that were both rhythmic and discrete. The Motor Assessment Scale (MAS), Motor Status Scale (MSS), and muscle strength were used as outcome measures. Assessments were administered at baseline and posttraining by a rater blinded to group assignment.

RESULTS

Both groups had significant improvements on the MSS and measures of strength. The bilateral group had significantly greater improvement on the Upper Arm Function scale (a subscale of the MAS-Upper Limb Items).

CONCLUSION

Both bilateral and unilateral training are efficacious for moderately impaired chronic stroke survivors. Bilateral training may be more advantageous for proximal arm function.

Robotic neurorehabilitation: a computational motor learning perspective

Conventional neurorehabilitation appears to have little impact on impairment over and above that of spontaneous biological recovery. Robotic neurorehabilitation has the potential for a greater impact on impairment due to easy deployment, its applicability across of a wide range of motor impairment, its high measurement reliability, and the capacity to deliver high dosage and high intensity training protocols. We first describe current knowledge of the natural history of arm recovery after stroke and of outcome prediction in individual patients. Rehabilitation strategies and outcome measures for impairment versus function are compared. The topics of dosage, intensity, and time of rehabilitation are then discussed. Robots are particularly suitable for both rigorous testing and application of motor learning principles to neurorehabilitation. Computational motor control and learning principles derived from studies in healthy subjects are introduced in the context of robotic neurorehabilitation. Particular attention is paid to the idea of context, task generalization and training schedule. The assumptions that underlie the choice of both movement trajectory programmed into the robot and the degree of active participation required by subjects are examined. We consider rehabilitation as a general learning problem, and examine it from the perspective of theoretical learning frameworks such as supervised and unsupervised learning. We discuss the limitations of current robotic neurorehabilitation paradigms and suggest new research directions from the perspective of computational motor learning.

Development and feasibility study of a sensory-enhanced robot-aided motor training in stroke rehabilitation

Functional impairment of the upper limb is a major challenge faced by many stroke survivors. The present study aimed at developing a novel sensory-enhanced robot-aided motor training program and testing its feasibility in stroke rehabilitation. A specially designed robot handle was developed as an attachment to the Inmotion2 robotic system. This handle provided sensory stimulation through pins connected to small servo motors inside the handle. Vibration of the pins was activated during motor training once pressure on the handle reached a certain threshold indicating an active motion of the study subject. Nine chronic stroke survivors were randomly assigned to either a sensory-enhanced robot-aided motor training group (SERMT) or robot-aided motor training only group (RMT). All participants underwent a 6-week motor training program, performing target reaching movements with the specialized handle with or without vibration stimulation during training. Motor Status (MS) scores were measured for functional outcome prior to and after training. The results showed significant improvement in the total MS scores after training in both experimental groups. However, MS sub-scores for the shoulder/elbow and the wrist/hand increased significantly only in the SERMT group (p<0.05). Future studies are required to confirm these preliminary findings.

A pilot study of activity-based therapy in the arm motor recovery post stroke: a randomized controlled trial

Objective: To determine the efficacy of activity-based therapies using arm ergometer or robotic or group occupational therapy for motor recovery of the paretic arm in patients with an acute stroke (≤4 weeks) admitted to an inpatient rehabilitation facility, and to obtain information to plan a large randomized controlled trial.

Design: Prospective, randomized controlled study.

Setting: Stroke unit in a rehabilitation hospital.

Subjects: Thirty patients with an acute stroke (≤4 weeks) who had arm weakness (Medical Research Council grade 2 or less at the shoulder joint).

Intervention: Occupational therapy (OT) group (control) (n = 10), arm ergometer (n = 10) or robotic (n = 10) therapy group. All patients received standard, inpatient, post-stroke rehabilitation training for 3 hours a day, plus 12 additional 40-minute sessions of the activity-based therapy.

Main measures: The primary outcome measures were discharge scores in the Fugl-Meyer Assessment Scale for upper limb impairment, Motor Status Scale, total Functional Independence Measure (FIM) and FIM-motor and FIM-cognition subscores.

Results: The three groups (OT group versus arm ergometer versus robotic) were comparable on clinical demographic measures except the robotic group was significantly older and there were more haemorrhagic stroke patients in the arm ergometer group. After adjusting for age, stroke type and outcome measures at baseline, a similar degree of improvement in the discharge scores was found in all of the primary outcome measures.

Conclusion: This study suggests that activity-based therapies using an arm ergometer or robot when used over shortened training periods have the same effect as OT group therapy in decreasing impairment and improving disability in the paretic arm of severely affected stroke patients in the subacute phase.

Assistive control system using continuous myoelectric signal in robot-aided arm training for patients after stroke

In some stroke rehabilitation programs, robotic systems have been used to aid the patient to train. In this study, a myoelectrically controlled robotic system with 1 degree-of-freedom was developed to assist elbow training in a horizontal plane with intention involvement for people after stroke. The system could provide continuous assistance in extension torque, which was proportional to the amplitude of the subject's electromyographic (EMG) signal from the triceps, and could provide resistive torques during movement. This study investigated the system's effect on restoring the upper limb functions of eight subjects after chronic stroke in a twenty-session rehabilitation training program. In each session, there were 18 trials comprising different combinations of assistive and resistive torques and an evaluation trial. Each trial consisted of five cycles of repetitive elbow flexion and extension between 90 degrees and 0 degrees at a constant velocity of 10 degrees/s. With the assistive extension torque, subjects could reach a more extended position in the first session. After 20 sessions of training, there were statistically significant improvements in the modified Ashworth scale, Fugl-Meyer scale for shoulder and elbow, motor status scale, elbow extension range, muscle strength, and root mean square error between actual elbow angle and target angle. The results showed that the twenty-session training program improved upper limb functions.

Quantitative evaluation of motor functional recovery process in chronic stroke patients during robot-assisted wrist training

This study was to investigate the motor functional recovery process in chronic stroke during robot-assisted wrist training. Fifteen subjects with chronic upper extremity paresis after stroke attended a 20-session wrist tracking training using an interactive rehabilitation robot. Electromyographic (EMG) parameters, i.e., EMG activation levels of four muscles: biceps brachii (BIC), triceps brachii (TRI, lateral head), flexor carpiradialis (FCR), and extensor carpiradialis (ECR) and their co-contraction indexes (CI) were used to monitor the neuromuscular changes during the training course. The EMG activation levels of the FCR (11.1% of decrease from the initial), BIC (17.1% of decrease from the initial), and ECR (29.4% of decrease from the initial) muscles decreased significantly during the training (P<0.05). Such decrease was associated with decreased Modified Ashworth Scores for both the wrist and elbow joints (P<0.05). Significant decrease (P<0.05) was also found in CIs of muscle pairs, BIC&TRI (21% of decrease from the initial), FCR&BIC (11.3% of decrease from the initial), ECR&BIC (49.3% of decrease from the initial). The decreased CIs related to the BIC muscle were mainly caused by the reduction in the BIC EMG activation level, suggesting a better isolation of the wrist movements from the elbow motions. The decreased CI of ECR& FCR in the later training sessions (P<0.05) was due to the reduced co-contraction phase of the antagonist muscle pair in the tracking tasks. Significant improvements (P<0.05) were also found in motor outcomes related to the shoulder/elbow and wrist/hand scores assessed by the Fugl-Meyer assessment before and after the training. According to the evolution of the EMG parameters along the training course, further motor improvements could be obtained by providing more training sessions, since the decreases of the EMG parameters did not reach a steady state before the end of the training. The results in this study provided an objective and quantitative EMG measure to describe the motor recovery process during poststroke robot-assisted wrist for the further understanding on the neuromuscular mechanism associated with the recovery.

Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke

Investigators have demonstrated that a variety of intensive movement training protocols for persistent upper limb paralysis in patients with chronic stroke (6 months or more after stroke) improve motor outcome. This randomized controlled study determined in patients with upper limb motor impairment after chronic stroke whether movement therapy delivered by a robot or by a therapist using an intensive training protocol was superior. Robotic training (n = 11) and an intensive movement protocol (n = 10) improved the impairment measures of motor outcome significantly and comparably; there were no significant changes in disability measures. Motor gains were maintained at the 3-month evaluation after training. These data contribute to the growing awareness that persistent impairments in those with chronic stroke may not reflect exhausted capacity for improvement. These new protocols, rendered by either therapist or robot, can be standardized, tested, and replicated, and potentially will contribute to rational activity-based programs.

Variation of Muscle Coactivation Patterns in Chronic Stroke During Robot-Assisted Elbow Training

OBJECTIVE

To investigate the variation of muscle coactivation patterns during the course of robot-assisted rehabilitation on elbow flexion and extension for chronic stroke.

DESIGN

A detailed electromyographic analysis was conducted on muscle activation levels and muscle coactivation patterns, represented by a cocontraction index of a muscle pair, for the muscles of biceps brachii, triceps brachii, anterior deltoid, and posterior deltoid, during training of elbow extension and flexion, actively assisted by a robot, from 0 degrees to 90 degrees by tracking a target moving at a speed of 10 degrees /s on the screen.

SETTING

Rehabilitation center research laboratory.

PARTICIPANTS

Seven hemiplegic chronic stroke patients received elbow training.

INTERVENTIONS

Each subject received 20 sessions (1.5 hours/session) of the elbow training on his/her paretic side at an intensity of 3 to 5 times a week for a training period of 7 consecutive weeks.

MAIN OUTCOME MEASURES

Muscle cocontraction index, muscle activation level, and Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and Motor Status Scale (MSS) scores.

RESULTS

The electromyographic activation levels of the biceps brachii, triceps brachii, and anterior deltoid of each subject decreased during the training. The overall electromyographic activation levels of the biceps and triceps, which, summarizing the performance of all subjects, decreased significantly in the middle sessions (from the 8th to 12th sessions) of the training (P<.05), associated with the significant decrease (P<.05) in the MAS score. The overall electromyographic activation level of the anterior deltoid also decreased significantly from the 8th to 20th sessions (P<.05). Significant decreases in the cocontractions of all muscle pairs were observed in all subjects and also in the overall cocontraction index (P<.05). The cocontraction between the biceps and triceps significantly decreased when the overall electromyographic levels of the 2 muscles were stable from the 10th to 20th sessions (P<.05). Significant improvements (P<.05) on the FMA and MSS score were also found by the pre- and postassessments.

CONCLUSIONS

In the 20-session robot-assisted training, the excessive muscle activations reduced mainly in the first half of the training course, which could be related to the learning process of the tracking skill and also to the reduction in muscle spasticity. The muscle coordination for achieving elbow tracking improved significantly in the latter sessions of the training, represented as decreased cocontraction indexes between the muscle pairs.

Assessing mechanisms of recovery during robot-aided neurorehabilitation of the upper limb

OBJECTIVE

The present study aimed to qualify and quantify the different components of motor recovery in a group of stroke patients treated by robot-aided techniques. In addition, the learning model of each motor recovery component was analyzed.

METHODS

Two groups of poststroke patients were treated with the use of an elbow-shoulder manipulator, respectively, within (recent) and after (chronic) the first 6 months of their cerebrovascular accident. Both groups were evaluated by means of standard clinical assessment scales and a robot-measured evaluation method.

RESULTS

These findings confirm that motor training consisting of voluntary movements assisted by the robot device led to significant improvements in motor performance in terms of the kinematic and dynamic components of the arm movements. This corresponded to improvement of impairment as confirmed by the clinical scale results.

CONCLUSIONS

Knowledge of the recovery components and of the associated performance acquisition model may be useful in assessing and training stroke patients and should make it possible to precisely plan and, if necessary, modify the rehabilitation strategies.

Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study

Objective. To test if functional electrical stimulation (FES) can enhance the recovery of upper extremity function during early stroke rehabilitation. Methods. Open-label block-randomized trial, begun during inpatient rehabilitation and continued at the patients' home. Patients were assigned to either FES combined with task-specific upper extremity rehabilitation (n = 7) or a control group that received task-specific therapy alone (n = 8) over 12 weeks. Outcome measures . Hand function (Box & Blocks, B&B; Jebsen-Taylor light object lift, J-T) and motor control (modified Fugl-Meyer, mF-M) were video-recorded for both upper extremities at baseline, 4, 8, and 12 weeks. Results. B&B mean score at 12 weeks favored ( P = .049) the FES group (42.3 ± 16.6 blocks) over the control group (26.3 ± 11.0 blocks). The FES group J-T task was 6.7 ± 2.9 seconds and faster ( P = .049) than the 11.8 ± 5.4 seconds of the control group. Mean mF-M score of the FES group at 12 weeks was 49.3 ± 5.1 points out of 54, compared to the control group that scored 40.6 ± 8.2 points ( P = .042). All patients regained hand function. Conclusion. Upper extremity task-oriented training that begins soon after stroke that incorporates FES may improve upper extremity functional use in patients with mild/moderate paresis more than task-oriented training without FES.

Therapeutic Robotics: A Technology Push: Stroke rehabilitation is being aided by robots that guide movement of shoulders and elbows, wrists, hands, arms and ankles to significantly improve recovery of patients

In this paper, we present a retrospective and chronological review of our efforts to revolutionize the way physical medicine is practiced by developing and deploying therapeutic robots. We present a sample of our clinical results with well over 300 stroke patients, both inpatients and outpatients, proving that movement therapy has a measurable and significant impact on recovery following brain injury. Bolstered by this result, we embarked on a two-pronged approach: 1) to determine what constitutes best therapy practice and 2) to develop additional therapeutic robots. We review our robots developed over the past 15 years and their unique characteristics. All are configured both to deliver reproducible therapy but also to measure outcomes with minimal encumbrance, thus providing critical measurement tools to help unravel the key question posed under the first prong: what constitutes "best practice"? We believe that a "gym" of robots like these will become a central feature of physical medicine and the rehabilitation clinic within the next ten years.

Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as Measures of Upper-Extremity Motor Weakness After Stroke

OBJECTIVE

To assess the relative responsiveness of 2 commonly used upper-extremity motor scales, the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA), in evaluating recovery of upper-extremity function after an acute stroke in patients undergoing inpatient rehabilitation.

DESIGN

Prospective.

SETTING

An acute stroke rehabilitation unit.

PARTICIPANTS

One hundred four consecutive admissions (43 men, 61 women; mean age +/- standard deviation, 72+/-13y) to a rehabilitation unit 16+/-9 days after acute stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The following assessments were completed within 72 hours of admission and 24 hours before discharge: ARAT, upper-extremity motor domain of the FMA, National Institutes of Health Stroke Scale, FIM instrument total score, and FIM activities of daily living (FIM-ADL) subscore.

RESULTS

The Spearman rank correlation statistic indicated that the 2 upper-limb motor scales (ARAT, FMA) correlated highly with one another, both on admission (rho = .77, P < .001) and on discharge (rho = .87, P < .001). The mean change in score from admission to discharge was 10+/-15 for the ARAT and 10+/-13 for the FMA motor score. The responsiveness to change as measured by the standard response mean was .68 for the ARAT and .74 for the FMA motor score. The Spearman rank correlation of each upper-limb motor scale with the FIM-ADL at the time of admission was as follows: ARAT, rho equal to .32 (P < .001) and FMA motor score, rho equal to .54 (P < .001).

CONCLUSIONS

Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function.

Joint-Angle–Dependent Neuromuscular Dysfunctions at the Wrist in Persons After Stroke

OBJECTIVE

To evaluate the joint-angle-dependent neuromuscular functions at the affected wrist in hemiplegic subjects after stroke while doing isometric maximal voluntary wrist flexion and extension across different wrist angles.

DESIGN

We investigated torques during isometric maximal voluntary wrist flexions and extensions at 8 different wrist angles, ranging from -45 degrees to 60 degrees. We used the associated electromyographic activities of 2 agonist and antagonist muscle pairs related to wrist and elbow joints for the analysis of muscular coactivations. We compared the data obtained from poststroke subjects' affected and unaffected sides.

SETTING

A research laboratory in a rehabilitation center.

PARTICIPANTS

Eleven subjects with hemiplegia after stroke with passive range of motion (ROM) in the wrist from -45 degrees to 60 degrees.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Directly measured torques, torques after normalization during maximal isometric wrist contractions, and normalized moving average electromyographic signals of each muscle at the tested positions.

RESULTS

The measured torques of the affected wrists were significantly lower than those of the unaffected wrists at all tested angles during wrist flexion and extension (P<.05). The angle-dependent patterns of the normalized torque across the tested wrist angles varied from those of the unaffected wrists (2-way analysis of variance, P<.05). There were decreases in normalized torques during both flexion and extension at the extended positions in the affected group (P<.05). Abnormal cocontractions were found in agonist and antagonist muscle pairs related to wrist and elbow joints, and between the elbow flexor and wrist extensor when subjects did the wrist contractions on the paretic side, especially at the wrist extended positions.

CONCLUSIONS

Wrist muscle weakness was distributed unevenly across the selected wrist ROM on the affected side, as represented by the varied patterns of the normalized torque-angle relationship, compared with the unaffected wrists. There were reductions in the selective control of muscle coactivating synergies both single-jointly and cross-jointly in the impaired nervous system during wrist contractions; the extent of these reductions was also related to the wrist angle configuration.

Robotics and other devices in the treatment of patients recovering from stroke

Stroke is the leading cause of permanent disability in the United States despite advances in prevention and novel interventional treatments. Randomized controlled studies have demonstrated the effectiveness of specialized post-stroke rehabilitation units, but administrative orders have severely limited the length of stay, so novel approaches to the treatment of recovery need to be tested in outpatients. Although the mechanisms of stroke recovery depend on multiple factors, a number of techniques that concentrate on enhanced exercise of the paralyzed limb have demonstrated effectiveness in reducing the motor impairment. For example, interactive robotic devices are new tools for therapists to deliver enhanced sensorimotor training for the paralyzed upper limb, which can potentially improve patient outcome and increase patient productivity. New data support the idea that for some post-stroke patients and for some aspects of training-induced recovery, timing of the training may be less important than the quality and intensity of the training. The positive outcome that resulted in the interactive robotic trials contrasts with the failure to find a beneficial result in trials that used a noninteractive device that delivered continuous passive motion only. New pilot data from novel devices to move the wrist demonstrate benefit and suggest that successive improvement of the function of the arm progressing to the distal muscles may eventually lead to significant disability reduction. These data from robotic trials continue to contribute to the emerging scientific basis of neuro-rehabilitation.