Robotic therapy provides a stimulus for upper limb motor recovery after stroke that is complementary to and distinct from conventional therapy

Assistance level quantification-based human-robot interaction space reshaping for rehabilitation training

Stroke has become a major disease that seriously threatens human health due to its high incidence and disability rates. Most patients undergo upper limb motor dysfunction after stroke, which significantly impairs the ability of stroke survivors in their activities of daily living (ADL). Robots provide an optional solution for stroke rehabilitation by attending therapy in the hospital and the community, however, the rehabilitation robot still has difficulty in providing needed assistance interactively like human clinicians in conventional therapy. For safe and rehabilitation training, a human-robot interaction space reshaping method was proposed based on the recovery states of patients. According to different recovery states, we designed seven experimental protocols suitable for distinguishing rehabilitation training sessions. To achieve assist-as-needed (AAN) control, a PSO-SVM classification model and an LSTM-KF regression model were introduced to recognize the motor ability of patients with electromyography (EMG) and kinematic data, and a region controller for interaction space shaping was studied. Ten groups of offline and online experiments and corresponding data processing were conducted, and the machine learning and AAN control results were presented, which ensured the effective and the safe upper limb rehabilitation training. To discuss the human-robot interaction in different training stages and sessions, we defined a quantified assistance level index that characterizes the rehabilitation needs by considering the engagement of the patients and had the potential to apply in clinical upper limb rehabilitation training.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Effects of robotic upper limb treatment after stroke on cognitive patterns: A systematic review

BACKGROUND

Robotic therapy (RT) has been internationally recognized for the motor rehabilitation of the upper limb. Although it seems that RT can stimulate and promote neuroplasticity, the effectiveness of robotics in restoring cognitive deficits has been considered only in a few recent studies.

OBJECTIVE

To verify whether, in the current state of the literature, cognitive measures are used as inclusion or exclusion criteria and/or outcomes measures in robotic upper limb rehabilitation in stroke patients.

METHODS

The systematic review was conducted according to PRISMA guidelines. Studies eligible were identified through PubMed/MEDLINE and Web of Science from inception to March 2021.

RESULTS

Eighty-one studies were considered in this systematic review. Seventy-three studies have at least a cognitive inclusion or exclusion criteria, while only seven studies assessed cognitive outcomes.

CONCLUSION

Despite the high presence of cognitive instruments used for inclusion/exclusion criteria their heterogeneity did not allow the identification of a guideline for the evaluation of patients in different stroke stages. Therefore, although the heterogeneity and the low percentage of studies that included cognitive outcomes, seemed that the latter were positively influenced by RT in post-stroke rehabilitation. Future larger RCTs are needed to outline which cognitive scales are most suitable and their cut-off, as well as what cognitive outcome measures to use in the various stages of post-stroke rehabilitation.

Assisted Movement With Proprioceptive Stimulation Augments Recovery From Moderate-To-Severe Upper Limb Impairment During Subacute Stroke Period: A Randomized Clinical Trial

BACKGROUND

Robotic assisted movement has become an accepted method of treating the moderately-to-mildly impaired upper limb after stroke.

OBJECTIVE

To determine whether, during the subacute phase of recovery, a novel type of robotic assisted training reduces moderate-to-severe impairment in the upper limb beyond that resulting from spontaneous recovery and prescribed outpatient therapy.

METHODS

A prospective, randomized, double-blinded, placebo-controlled, semi-crossover study of 83 participants. Over 6- to 9-weeks, participants received 18, 30-min training sessions of the hand and wrist. The test intervention consisted of assisted motion, biofeedback, and antagonist muscle vibration delivered by a robotic device. Test Group participants received the test intervention, and Control Group participants received a placebo intervention designed to have no effect. Subsequently, Control Group participants crossed over to receive the test intervention.

RESULTS

At enrollment, the average age (±SD) of participants was 57.0 ± 12.8 year and weeks since stroke was 11.6 ± 5.4. The average Fugl-Meyer baseline score of Test Group participants was 20.9, increasing by 10.8 with training, and in Control Group participants was 23.7 increasing by 6.4 with training, representing a significant difference (4.4) in change scores (P = .01). During the crossover phase, Control Group participants showed a significant increase in FMA-UL score (i.e., 4.7 ± 6.7 points, P = .003) as well as in other, more specific measures of impairment.

CONCLUSIONS

Robotic impairment-oriented training, as used in this study, can significantly enhance recovery during the subacute phase of recovery. Spontaneous recovery and prescribed outpatient therapy during this phase do not fully exploit the potential for remediating moderate-to-severe upper limb impairment.ClinicalTrials.gov Registry: NCT00609115-Subacute stroke rehabilitation with AMES.

Path Planning and Impedance Control of a Soft Modular Exoskeleton for Coordinated Upper Limb Rehabilitation

The coordinated rehabilitation of the upper limb is important for the recovery of the daily living abilities of stroke patients. However, the guidance of the joint coordination model is generally lacking in the current robot-assisted rehabilitation. Modular robots with soft joints can assist patients to perform coordinated training with safety and compliance. In this study, a novel coordinated path planning and impedance control method is proposed for the modular exoskeleton elbow-wrist rehabilitation robot driven by pneumatic artificial muscles (PAMs). A convolutional neural network-long short-term memory (CNN-LSTM) model is established to describe the coordination relationship of the upper limb joints, so as to generate adaptive trajectories conformed to the coordination laws. Guided by the planned trajectory, an impedance adjustment strategy is proposed to realize active training within a virtual coordinated tunnel to achieve the robot-assisted upper limb coordinated training. The experimental results showed that the CNN-LSTM hybrid neural network can effectively quantify the coordinated relationship between the upper limb joints, and the impedance control method ensures that the robotic assistance path is always in the virtual coordination tunnel, which can improve the movement coordination of the patient and enhance the rehabilitation effectiveness.

Pilot Test of Dosage Effects in HEXORR II for Robotic Hand Movement Therapy in Individuals With Chronic Stroke

Impaired use of the hand in functional tasks remains difficult to overcome in many individuals after a stroke. This often leads to compensation strategies using the less-affected limb, which allows for independence in some aspects of daily activities. However, recovery of hand function remains an important therapeutic goal of many individuals, and is often resistant to conventional therapies. In prior work, we developed HEXORR I, a robotic device that allows practice of finger and thumb movements with robotic assistance. In this study, we describe modifications to the device, now called HEXORR II, and a clinical trial in individuals with chronic stroke. Fifteen individuals with a diagnosis of chronic stroke were randomized to 12 or 24 sessions of robotic therapy. The sessions involved playing several video games using thumb and finger movement. The robot applied assistance to extension movement that was adapted based on task performance. Clinical and motion capture evaluations were performed before and after training and again at a 6-month followup. Fourteen individuals completed the protocol. Fugl-Meyer scores improved significantly at the 6 month time point compared to baseline, indicating reductions in upper extremity impairment. Flexor hypertonia (Modified Ashworth Scale) also decreased significantly due to the intervention. Motion capture found increased finger range of motion and extension ability after the intervention that continued to improve during the followup period. However, there was no change in a functional measure (Action Research Arm Test). At the followup, the high dose group had significant gains in hand displacement during a forward reach task. There were no other significant differences between groups. Future work with HEXORR II should focus on integrating it with functional task practice and incorporating grip and squeezing tasks.

Trial Registration:ClinicalTrials.gov, NCT04536987. Registered 3 September 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04536987.

Robotic Assisted Upper Limb Training Post Stroke: A Randomized Control Trial Using Combinatory Approach Toward Reducing Workforce Demands

Post stroke upper limb rehabilitation is a challenging problem with poor outcomes as 40% of survivors have functionally useless upper limbs. Robot-aided therapy (RAT) is a potential method to alleviate the effort of intensive, task-specific, repetitive upper limb exercises for both patients and therapists. The present study aims to investigate how a time matched combinatory training scheme that incorporates conventional and RAT, using H-Man, compares with conventional training toward reducing workforce demands. In a randomized control trial (NCT02188628, www.clinicaltrials.gov), 44 subacute to chronic stroke survivors with first-ever clinical stroke and predominant arm motor function deficits were recruited and randomized into two groups of 22 subjects: Robotic Therapy (RT) and Conventional Therapy (CT). Both groups received 18 sessions of 90 min; three sessions per week over 6 weeks. In each session, participants of the CT group received 90 min of 1:1 therapist-supervised conventional therapy while participants of the RT group underwent combinatory training which consisted of 60 min of minimally-supervised H-Man therapy followed by 30 min of conventional therapy. The clinical outcomes [Fugl-Meyer (FMA), Action Research Arm Test and, Grip Strength] and the quantitative measures (smoothness, time efficiency, and task error, derived from two robotic assessment tasks) were independently evaluated prior to therapy intervention (week 0), at mid-training (week 3), at the end of training (week 6), and post therapy (week 12 and 24). Significant differences within group were observed at the end of training for all clinical scales compared with baseline [mean and standard deviation of FMA score changes between baseline and week 6; RT: Δ4.41 (3.46) and CT: Δ3.0 (4.0); p < 0.01]. FMA gains were retained 18 weeks post-training [week 24; RT: Δ5.38 (4.67) and week 24 CT: Δ4.50 (5.35); p < 0.01]. The RT group clinical scores improved similarly when compared to CT group with no significant inter-group at all time points although the conventional therapy time was reduced to one third in RT group. There were no training-related adverse side effects. In conclusion, time matched combinatory training incorporating H-Man RAT produced similar outcomes compared to conventional therapy alone. Hence, this study supports a combinatory approach to improve motor function in post-stroke arm paresis. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02188628.

The adjunct of transcranial direct current stimulation to Robot-assisted therapy in upper limb post-stroke treatment

Transcranial direct current stimulation (TDCS) and robot-assisted therapy (RAT) proved to be promising interventions in post-stroke rehabilitation. However, the effects of combining the two treatments are not significantly clear. To determine the effects of combined therapy using transcranial direct current stimulation (tDCS) with robot-assisted therapy (RAT) in the impairment of the upper limb in stroke rehabilitation. The Cochrane Library, MEDLINE, Embase, Google Scholar, and Trial Registries were systematically searched for randomised controlled trials in May 2020. As the outcome, the Fugl-Meyer Assessment score (FMS) was used. A pairwise and a network meta-analysis were performed. 5 RCTs with RAT versus RAT + tDCS groups and 21 RCTs with RAT versus the control group with 892 people were analysed. Of these studies, 10 RCTs evaluated acute-subacute (<8 weeks) people, while 16 chronic people. By analysing the FMS with a pair-wise meta-analysis, we demonstrate significant improvements only in the RAT alone compared to the control (acute-subacute, SMD:4.09 (1.31, 6.87) and chronic, SMD:2.22 (0.99, 3.45)). Instead, performing a network meta-analysis, through an analysis of the surface under the cumulative ranking curve (SUCRA) we report a ranking of the effectiveness of the interventions. We assess SUCRA in acute-subacute stroke: Control:0.23, RAT + tDCS:0.31, RAT:0.96 and in chronic stroke: Control:0.06, RAT + tDCS:0.62, RAT:0.82. RAT is, respectively, 96% and 82% likely to be the best-ranked treatment. Despite the limitations, this network meta-analysis appears to demonstrate through the rank of interventions that adding tDCS to RAT is not useful in upper-limb stroke rehabilitation.

Robot-Assisted Therapy for Upper Extremity Motor Impairment After Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to review the effects of robot-assisted therapy (RT) for improving poststroke upper extremity motor impairment.

METHODS

The PubMed, Embase, Medline, and Web of Science databases were searched from inception to April 8, 2020. Randomized controlled trials that were conducted to evaluate the effects of RT on upper extremity motor impairment poststroke and that used Fugl-Meyer assessment for upper extremity scores as an outcome were included. Two authors independently screened articles, extracted data, and assessed the methodological quality of the included studies using the Physiotherapy Evidence Database (PEDro) scale. A random-effects meta-analysis was performed to pool the effect sizes across the studies.

RESULTS

Forty-one randomized controlled trials with 1916 stroke patients were included. Compared with dose-matched conventional rehabilitation, RT significantly improved the Fugl-Meyer assessment for upper extremity scores of the patients with stroke, with a small effect size (Hedges g = 0.25; 95% CI, 0.11-0.38; I2 = 45.9%). The subgroup analysis revealed that the effects of unilateral RT, but not that of bilateral RT, were superior to conventional rehabilitation (Hedges g = 0.32; 95% CI, 0.15-0.50; I2 = 55.9%). Regarding the type of robot devices, the effects of the end effector device (Hedges g = 0.22; 95% CI, 0.09-0.36; I2 = 35.4%), but not the exoskeleton device, were superior to conventional rehabilitation. Regarding the stroke stage, the between-group difference (ie, RT vs convention rehabilitation) was significant only for people with late subacute or chronic stroke (Hedges g = 0.33; 95% CI, 0.16-0.50; I2 = 34.2%).

CONCLUSION

RT might be superior to conventional rehabilitation in improving upper extremity motor impairment in people after stroke with notable upper extremity hemiplegia and limited potential for spontaneous recovery.

Novel Human-Centered Robotics: Towards an Automated Process for Neurorehabilitation

The global requirement of patient rehabilitation has surged with time due to the growing number of accidents, injuries, age-related issues, and other aspects. Parallelly, the cost of treatment and patient care also increased in a manifold. Moreover, constant monitoring and support for the patients having physical disabilities have become an ongoing challenge to the medical system. Robotics-based neurorehabilitation has reduced the human error while assisting such patients, precisely interpreting the signals, and communicating to the patient. Gradual precise application and improvement of the technology with time yielded a novel direction for patient care and support. The interdisciplinary contribution of many advanced technical branches allowed us to develop robotics-based assistance with high precision for the upper limb and the lower limb impairments. The present review summarizes the generation and background of robotic implementation for patient support, progress, present status, and future requirements.

Feasibility of Two Different EMG-Based Pattern Recognition Control Paradigms to Control a Robot After Stroke - Case Study

Stroke often results in chronic motor impairment of the upper-extremity yet neither traditional- nor robotics-based therapy has been able to affect this in a profound way. Supporting the weak affected shoulder against gravity improves reaching distance and minimizes abnormal co-contraction of the elbow, wrist, and fingers after stroke. However, it is necessary to assess the feasibility and efficacy of real-time controllers for this population as technology advances and a wearable shoulder device comes closer to reality. The aim of this study is to test two EMG-based controllers in this regard. A linear discriminant analysis based classifier was trained using extracted time domain and auto-regressive features from electromyographic data acquired during muscle effort required to move a load equivalent to 50 and 100% limb weight (abduction) and 150 and 200% limb weight (adduction). While rigidly connected to a custom lab-based robot, the participant was required to complete a series of lift and reach tasks under two different control paradigms: position-based control and force-based control. The participant successfully controlled the robot under both paradigms as indicated by first moving the robot arm into the proper vertical window and then reaching out as far as possible while remaining within the vertical window. This case study begins to assess the feasibility of using electromyographic data to classify the intended shoulder movement of a participant with stroke during a functional lift and reach type task. Next steps will assess how this type of support affects reaching function.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

An Elbow Exoskeleton for Upper Limb Rehabilitation with Series Elastic Actuator and Cable-driven Differential

Movement impairments resulting from neurologic injuries, such as stroke, can be treated with robotic exoskeletons that assist with movement retraining. Exoskeleton designs benefit from low impedance and accurate torque control. We designed a 2 degree-of-freedom tethered exoskeleton that can provide independent torque control on elbow flexion/extension and forearm supination/pronation. Two identical series elastic actuators (SEAs) are used to actuate the exoskeleton. The two SEAs are coupled through a novel cable-driven differential. The exoskeleton is compact and lightweight, with a mass of 0.9 kg. Applied RMS torque errors were less than 0.19 Nm. Benchtop tests demonstrated a torque rise time of approximately 0.1 s, a torque control bandwidth of 3.7 Hz and an impedance of less than 0.03 Nm/deg at 1 Hz. The controller can simulate a stable maximum wall stiffness of 0.45 Nm/deg. The overall performance is adequate for robotic therapy applications and the novelty of the design is discussed.

Methods for an Investigation of Neurophysiological and Kinematic Predictors of Response to Upper Extremity Repetitive Task Practice in Chronic Stroke

Objective

To demonstrate the feasibility of algorithmic prediction using a model of baseline arm movement, genetic factors, demographic characteristics, and multimodal assessment of the structure and function of motor pathways. To identify prognostic factors and the biological substrate for reductions in arm impairment in response to repetitive task practice.

Design

This prospective single-group interventional study seeks to predict response to a repetitive task practice program using an intent-to-treat paradigm. Response is measured as a change of ≥5 points on the Upper Extremity Fugl-Meyer from baseline to final evaluation (at the end of training).

Setting

General community.

Participants

Anticipated enrollment of community-dwelling adults with chronic stroke (N = 96; onset≥6mo) and moderate to severe residual hemiparesis of the upper limb as defined by a score of 10-45 points on the Upper Extremity Fugl-Meyer.

Intervention

The intervention is a form of repetitive task practice using a combination of robot-assisted therapy coupled with functional arm use in real-world tasks administered over 12 weeks.

Main Outcome Measures

Upper Extremity Fugl-Meyer Assessment (primary outcome), Wolf Motor Function Test, Action Research Arm Test, Stroke Impact Scale, questionnaires on pain and expectancy, magnetic resonance imaging, transcranial magnetic stimulation, arm kinematics, accelerometry, and a saliva sample for genetic testing.

Results

Methods for this trial are outlined, and an illustration of interindividual variability is provided by example of 2 participants who present similarly at baseline but achieve markedly different outcomes.

Conclusion

This article presents the design, methodology, and rationale of an ongoing study to develop a predictive model of response to a standardized therapy for stroke survivors with chronic hemiparesis. Applying concepts from precision medicine to neurorehabilitation is practicable and needed to establish realistic rehabilitation goals and to effectively allocate resources.

Breaking Proportional Recovery After Stroke

People with hemiparesis after stroke appear to recover 70% to 80% of the difference between their baseline and the maximum upper extremity Fugl-Meyer (UEFM) score, a phenomenon called proportional recovery (PR). Two recent commentaries explained that PR should be expected because of mathematical coupling between the baseline and change score. Here we ask, If mathematical coupling encourages PR, why do a fraction of stroke patients (the "nonfitters") not exhibit PR? At the neuroanatomical level of analysis, this question was answered by Byblow et al-nonfitters lack corticospinal tract (CST) integrity at baseline-but here we address the mathematical and behavioral causes. We first derive a new interpretation of the slope of PR: It is the average probability of scoring across remaining scale items at follow-up. PR therefore breaks when enough test items are discretely more difficult for a patient at follow-up, flattening the slope of recovery. For the UEFM, we show that nonfitters are most unlikely to recover the ability to score on the test items related to wrist/hand dexterity, shoulder flexion without bending the elbow, and finger-to-nose movement, supporting the finding that nonfitters lack CST integrity. However, we also show that a subset of nonfitters respond better to robotic movement training in the chronic phase of stroke. These persons are just able to move the arm out of the flexion synergy and pick up small blocks, both markers of CST integrity. Nonfitters therefore raise interesting questions about CST function and the basis for response to intensive movement training.

Robot-Assisted Arm Training in Chronic Stroke: Addition of Transition-to-Task Practice

Background. Robot-assisted therapy provides high-intensity arm rehabilitation that can significantly reduce stroke-related upper extremity (UE) deficits. Motor improvement has been shown at the joints trained, but generalization to real-world function has not been profound. Objective. To investigate the efficacy of robot-assisted therapy combined with therapist-assisted task training versus robot-assisted therapy alone on motor outcomes and use in participants with moderate to severe chronic stroke-related arm disability. Methods. This was a single-blind randomized controlled trial of two 12-week robot-assisted interventions; 45 participants were stratified by Fugl-Meyer (FMA) impairment (mean 21 ± 1.36) to 60 minutes of robot therapy (RT; n = 22) or 45 minutes of RT combined with 15 minutes therapist-assisted transition-to-task training (TTT; n = 23). The primary outcome was the mean FMA change at week 12 using a linear mixed-model analysis. A subanalysis included the Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS), with significance P <.05. Results. There was no significant 12-week difference in FMA change between groups, and mean FMA gains were 2.87 ± 0.70 and 4.81 ± 0.68 for RT and TTT, respectively. TTT had greater 12-week secondary outcome improvements in the log WMFT (-0.52 ± 0.06 vs -0.18 ± 0.06; P = .01) and SIS hand (20.52 ± 2.94 vs 8.27 ± 3.03; P = .03). Conclusion. Chronic UE motor deficits are responsive to intensive robot-assisted therapy of 45 or 60 minutes per session duration. The replacement of part of the robotic training with nonrobotic tasks did not reduce treatment effect and may benefit stroke-affected hand use and motor task performance.

Comparison of Two Series Elastic Actuator Designs Incorporated into a Shoulder Exoskeleton

Low impedance and torque control are critical for movement rehabilitation using robotic exoskeletons. A grounded 3 degree of freedom shoulder exoskeleton was designed for movement assistance in shoulder abduction/adduction, flexion/extension, and shoulder internal/external rotation. Two series elastic actuators designs were developed using a linear spring arrangement with a global nonlinear stiffness behavior. RMS errors during application of constant torque were less than.06 Nm in shoulder add/abd and less than.04 Nm in arm rotation as the limb was moved in sinusoidal trajectories up to 3.5 Hz. For abd/adduction, the step response rise time was.05 s, and free mode impedance peaked at.007 Nm/deg during 3.5 Hz oscillations. For arm rotation, the step response rise time was.03 s, and impedance peaked at.023 Nm/deg during 3.5 Hz oscillations. Both SEA designs had performance measurements that were similar to other SEA designs in terms of torque tracking, but with much lower impedance than previously reported.

Effects of robot-assisted therapy on upper extremity function and activities of daily living in hemiplegic patients: A single-blinded, randomized, controlled trial

BACKGROUND

Many robots can induce passive movements and passive resistance movements to facilitate recovery of upper-extremity function, but it is rare to find robots that can also enable active resistance movements.

OBJECTIVE

The purpose of this study was to investigate the effects of robot-assisted therapy on upper-extremity function and the ability to perform activities of daily living (ADL) in patients with stroke-induced hemiplegia.

METHODS

Thirty patients with stroke-induced hemiplegia were randomly assigned to the experimental and control groups, with 15 patients in each group. All subjects underwent general occupational therapy consisting of five 30-min sessions per week for 8 weeks, in addition to 30 min of robot-assisted therapy for the experimental group and 30 additional min of general occupational therapy for the control group for each session.

RESULTS

Both the experimental and control groups showed a statistically significant increase in post-treatment Fugl-Meyer assessment and modified Barthel index scores compared to the pre-treatment scores. Intergroup comparisons revealed that the experimental group showed a statistically significant greater increase in scores for all assessments than the control group did (p< 0.05).

CONCLUSION

The findings from this study showed that combining robot-assisted therapy with general occupational therapy may enhance upper-extremity function and the ability to perform ADL in patients with stroke-induced hemiplegia compared to those obtained with general occupational therapy alone.

Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke

BACKGROUND

Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke.

OBJECTIVES

To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.

SEARCH METHODS

We searched the Cochrane Stroke Group's Trials Register (last searched January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2018, Issue 1), MEDLINE (1950 to January 2018), Embase (1980 to January 2018), CINAHL (1982 to January 2018), AMED (1985 to January 2018), SPORTDiscus (1949 to January 2018), PEDro (searched February 2018), Compendex (1972 to January 2018), and Inspec (1969 to January 2018). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as manufacturers of commercial devices.

SELECTION CRITERIA

Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for people after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, used the GRADE approach to assess the quality of the body of evidence, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables.

MAIN RESULTS

We included 45 trials (involving 1619 participants) in this update of our review. Electromechanical and robot-assisted arm training improved activities of daily living scores (SMD 0.31, 95% confidence interval (CI) 0.09 to 0.52, P = 0.0005; I² = 59%; 24 studies, 957 participants, high-quality evidence), arm function (SMD 0.32, 95% CI 0.18 to 0.46, P < 0.0001, I² = 36%, 41 studies, 1452 participants, high-quality evidence), and arm muscle strength (SMD 0.46, 95% CI 0.16 to 0.77, P = 0.003, I² = 76%, 23 studies, 826 participants, high-quality evidence). Electromechanical and robot-assisted arm training did not increase the risk of participant dropout (RD 0.00, 95% CI -0.02 to 0.02, P = 0.93, I² = 0%, 45 studies, 1619 participants, high-quality evidence), and adverse events were rare.

AUTHORS' CONCLUSIONS

People who receive electromechanical and robot-assisted arm training after stroke might improve their activities of daily living, arm function, and arm muscle strength. However, the results must be interpreted with caution although the quality of the evidence was high, because there were variations between the trials in: the intensity, duration, and amount of training; type of treatment; participant characteristics; and measurements used.

Using an upper extremity exoskeleton for semi-autonomous exercise during inpatient neurological rehabilitation- a pilot study

Background

Motor deficits are the most common symptoms after stroke. There is some evidence that intensity and amount of exercises influence the degree of improvement of functions within the first 6 months after the injury.

The purpose of this pilot study was to evaluate the feasibility and acceptance of semi-autonomous exercises with an upper extremity exoskeleton in addition to an inpatient rehabilitation program. In addition, changes of motor functions were examined.

Methods

Ten stroke patients with a severe upper extremity paresis were included. They were offered to perform a semi-autonomous training with a gravity-supported, computer-enhanced device (Armeo®Spring, Hocoma AG) six times per week for 4 weeks. Feasibility was evaluated by weekly structured interviews with patients and supervisors.

Motor functions were assessed before and after the training period using the Wolf Motor Function Test (WMFT). The Wilcoxon Signed Rank Test was used for assessing pre-post differences. The Pearson correlation co-efficient was used for correlating the number of completed sessions with the change in motor function. Acceptance of the device and the level of satisfaction with the training were determined by a questionnaire based on visual analogue scales.

Results

Neither patients nor supervisors reported side effects. However, one patient had to be excluded from analysis because of transportation difficulties from the ward to the treatment facility. Therefore, analysis was based on nine patients. On average, 13.2 (55%) sessions were realized. WMFT results showed significant improvements of proximal arm functions. The number of sessions correlated with the degree of shoulder force improvement. Patients rated the exercises to be motivating, and enjoyable and would continue using the Armeo®Spring at home if they had the opportunity.

Conclusion

Using an upper extremity exoskeleton for semi-autonomous training in an inpatient setting is feasible without side effects and is positively rated by the patients. It might further support the recovery of upper extremity function.

Trial registration

The trial was retrospectively registered. Registration number ISRCTN42633681.

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

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of robotic assistive devices in the rehabilitation of adult stroke patients for recovery of impairments in the upper and lower limbs. The secondary objective is to investigate the sustainability of treatment effects associated with use of robotic devices.The specific review question to be addressed is: can robotic assistive devices help adult stroke patients regain motor movement of their upper and lower limbs?

Effectiveness of robot therapy on body function and structure in people with limited upper limb function: A systematic review and meta-analysis

Robot-Assisted Therapy (RT) is an innovative approach to neurological rehabilitation that uses intensive, repetitive, interactive, and individualized practice. This systematic review aimed to investigate the effectiveness of RT on the body function and structure of people with upper limb impairments (PROSPERO registration: CRD42017054982). A search strategy conducted on seven databases identified randomized controlled studies. Methodological quality was assessed using the PEDro scale. When possible, the data were pooled, the strength of evidence was assessed using the GRADE system, and the effect sizes were assessed using Cohen coefficient. Subgroup analyses investigated the impact on the estimated effects of the following parameters: methodological quality; portion of the assessed upper limb; duration of stroke; and intervention dose and duration. Thirty-eight studies involving 1174 participants were included. Pooled estimates revealed small effects of RT on motor control and medium effects on strength compared with other intervention (OI) at a short-term follow-up. Standardized differences in means were as follows: 0.3 (95% CI 0.1 to 0.4) and 0.5 (95% CI 0.2 to 0.8). Effects at other time points and on other investigated outcomes related to body function and structure were not found (p>0.05). The strength of the current evidence was usually low quality. Subgroup analyses suggested that the methodological quality, and duration and dose of RT may influence the estimated effects. In conclusion, RT has small effects on motor control and medium effects on strength in people with limited upper limb function. Poor methodological quality, and lower treatment dose and duration may impact negatively the estimated effects.

Assessing User Transparency with Muscle Synergies during Exoskeleton-Assisted Movements: A Pilot Study on the LIGHTarm Device for Neurorehabilitation

Exoskeleton devices for upper limb neurorehabilitation are one of the most exploited solutions for the recovery of lost motor functions. By providing weight support, passively compensated exoskeletons allow patients to experience upper limb training. Transparency is a desirable feature of exoskeletons that describes how the device alters free movements or interferes with spontaneous muscle patterns. A pilot study on healthy subjects was conducted to evaluate the feasibility of assessing transparency in the framework of muscle synergies. For such purpose, the LIGHTarm exoskeleton prototype was used. LIGHTarm provides gravity support to the upper limb during the execution of movements in the tridimensional workspace. Surface electromyography was acquired during the execution of three daily life movements (reaching, hand-to-mouth, and hand-to-nape) in three different conditions: free movement, exoskeleton-assisted (without gravity compensation), and exoskeleton-assisted (with gravity compensation) on healthy people. Preliminary results suggest that the muscle synergy framework may provide valuable assessment of user transparency and weight support features of devices aimed at rehabilitation.

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

BACKGROUND

Stroke is a leading cause of long-term disability, and rehabilitation, involving repetitive, high intensity, task-specific exercises, is the pathway to restoring motor skills. Robotic assistive devices are increasingly being used and it is hoped that with robotic devices, rehabilitation progress can be achieved for patients.

OBJECTIVES

To examine the effectiveness of robotic devices in the rehabilitation of stroke patients for upper limb mobility, lower limb mobility, and activities of daily living. The sustainability of treatment effect was also examined.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult stroke patients 18 years and over.

TYPES OF INTERVENTION(S)

Rehabilitation of stroke patients using robotic devices with assistive automation, compared to conventional physiotherapy.

OUTCOMES

Motor movements of upper limbs, walking movement of lower limbs and activities of daily living, including follow-up measurements to examine the sustainability of treatment effect.

TYPES OF STUDIES

Randomized and controlled clinical trials.

SEARCH STRATEGY

Published and unpublished studies in English were searched.

METHODOLOGICAL QUALITY

All studies meeting the review inclusion criteria were independently assessed for methodological quality by two reviewers.

DATA EXTRACTION

Quantitative data were extracted using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

DATA SYNTHESIS

Quantitative data were pooled in statistical meta-analysis. Effect sizes expressed as standardized mean difference, 95% confidence intervals and levels of heterogeneity (I) were calculated. Where statistical pooling was not possible, the findings were presented in narrative form.

RESULTS

Fifty-one studies with 1798 patients were included in this review. Thirty studies examined upper limb interventions and 21 studies evaluated lower limb gait training. Non-significant results were found for upper limb (SMD 0.07, 95% CI -0.11 to 0.26, I = 41%, P = 0.45), lower limb (SMD 0.17, 95% CI -0.15 to 0.48, I = 75%, P = 0.31) and activities of daily living (SMD 0.11, 95% CI -0.11 to 0.33, I = 66%, P = 0.32). For patients with severely impaired lower limbs, a significant difference was observed in favor of robotics (SMD 0.41, 95% CI 0.19 to 0.63, I = 28%, P = 0.0003). P-value analysis did not show significant results for the sustainability of treatment effect post intervention.

CONCLUSIONS

Robotic training is just as effective as conventional training for upper limb motor movement, lower limb walking mobility and for activities of daily living. For lower limb patients with severe impairment, robotic training produces better outcomes than conventional training. The sufficient quantity of studies included and the reasonable quality of Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence support the findings.For treatment sustainability of upper and lower limbs, robotic training is just as effective as conventional training. However, the low quality of GRADE evidence and the lower number of studies included require caution for this finding. For treatment sustainability of activities of daily living, the better quality of GRADE evidence and the larger number of studies analyzed indicate that robotic training is just as effective as conventional training.

Innovating With Rehabilitation Technology in the Real World: Promises, Potentials, and Perspectives

In this article, we discuss robotic-assisted therapy as an emerging and significant field of clinical rehabilitation and its value proposition for innovating rehabilitation clinical practice. Attempts to achieve integration among clinicians' practices and bioengineers' machines often generate new challenges and controversies. To date, the literature is indicative of a sizeable number and variety of robotic devices in the field of clinical rehabilitation, some are commercially available; however, large-scale clinical outcomes are less positive than expected. The following main themes related to integrating rehabilitation technology in real-world clinical practice will be discussed: the application of current evidence-based practice and knowledge in relation to treatment in the rehabilitation clinic, perspectives from rehabilitation professionals using robotic-aided therapy with regard to challenges, and strategies for problem solving. Lastly, we present innovation philosophies with regard to sustainability of clinical rehabilitation technologies.

Recovery of Proprioception in the Upper Extremity by Robotic Mirror Therapy: a Clinical Pilot Study for Proof of Concept

A novel robotic mirror therapy system was recently developed to provide proprioceptive stimulus to the hemiplegic arm during a mirror therapy. Validation of the robotic mirror therapy system was performed to confirm its synchronicity prior to the clinical study. The mean error angle range between the intact arm and the robot was 1.97 to 4.59 degrees. A 56-year-old male who had right middle cerebral artery infarction 11 months ago received the robotic mirror therapy for ten 30-minute sessions during 2 weeks. Clinical evaluation and functional magnetic resonance imaging (fMRI) studies were performed before and after the intervention. At the follow-up evaluation, the thumb finding test score improved from 2 to 1 for eye level and from 3 to 1 for overhead level. The Albert's test score on the left side improved from 6 to 11. Improvements were sustained at 2-month follow-up. The fMRI during the passive motion revealed a considerable increase in brain activity at the lower part of the right superior parietal lobule, suggesting the possibility of proprioception enhancement. The robotic mirror therapy system may serve as a useful treatment method for patients with supratentorial stroke to facilitate recovery of proprioceptive deficit and hemineglect.

Combining Dopaminergic Facilitation with Robot-Assisted Upper Limb Therapy in Stroke Survivors: A Focused Review

Despite aggressive conventional therapy, lasting hemiplegia persists in a large percentage of stroke survivors. The aim of this article is to critically review the rationale behind targeting multiple sites along the motor learning network by combining robotic therapy with pharmacotherapy and virtual reality–based reward learning to alleviate upper extremity impairment in stroke survivors. Methods for personalizing pharmacologic facilitation to each individual’s unique biology are also reviewed. At the molecular level, treatment with levodopa was shown to induce long-term potentiation-like and practice-dependent plasticity. Clinically, trials combining conventional therapy with levodopa in stroke survivors yielded statistically significant but clinically unconvincing outcomes because of limited personalization, standardization, and reproducibility. Robotic therapy can induce neuroplasticity by delivering intensive, reproducible, and functionally meaningful interventions that are objective enough for the rigors of research. Robotic therapy also provides an apt platform for virtual reality, which boosts learning by engaging reward circuits. The future of stroke rehabilitation should target distinct molecular, synaptic, and cortical sites through personalized multimodal treatments to maximize motor recovery.

Effects of robot-assisted upper limb rehabilitation in stroke patients: a systematic review with meta-analysis

Technology-supported training is emerging as a solution to support therapists in their efforts providing high-intensity, repetitive, and task-specific treatment, in order to enhance the recovery process. The aim of this review is to assess the effectiveness of different robotic devices (end-effector and exoskeleton robots) in comparison with any other type of intervention. Furthermore, we aim to assess whether or not better improvements are obtained in the sub-acute phase after stroke onset than in the chronic phase. A research was conducted in the electronic bibliographic databases Cochrane, MEDLINE, and EMBASE. A total of 17 studies were included: 14 randomized controlled trials, 2 systematic reviews, and one meta-analysis. Fugl-Meyer and modified Ashworth scale were selected to measure primary outcomes, i.e., motor function and muscle tone. Functional independence measure and motor activity log were selected to measure secondary outcomes, i.e., activities of daily living. In comparison with conventional therapy, the robot-assisted rehabilitation is more effective in improving upper limb motor function recovery, especially in chronic stroke patients. No significant improvements are observed in the reduction of muscle tone or daily living activities. The present systematic review shows that the use of robotic devices can positively affect the recovery of arm function in patients with stroke.

Home-Based Therapy After Stroke Using the Hand Spring Operated Movement Enhancer (HandSOME)

In previous work, we developed a lightweight wearable hand exoskeleton (Hand Spring Operated Movement Enhancer) that improves range of motion and function in laboratory testing. In this pilot study, we added the ability to log movement data for extended periods and recruited ten chronic stroke subjects to use the device during reach and grasp task practice at home for 1.5 h/day, five days per week, and for four weeks. Seven subjects completed the study, performing 448 ± 651 hand movements per training day. After training, impairment was reduced (Fugl-Meyer test; gain = 4.9 ± 4.1; p = .039) and function was improved (Action Research Arm Test; gain = 3.3 ± 2.6; p = .032). There was a significant correlation between gains in the Action Research Arm Test and the number of movements during training (r = 0.90; p = .005). Proximal arm control also improved, as evidenced by a significant reduction in the reach path ratio (p = 0.038). Five subjects responded well to the treatment, having gains of six points or more on the Fugl-Meyer or action research arm test, and achieving significant gains in digit extension (gain = 19.8 ± 10.2°; p = 0.024). However, all of the gains that were significant immediately after training were no longer significant at the three month follow-up. This treatment approach appears promising, but longer periods of home training may be needed to achieve sustainable gains.

Robot-assisted and conventional therapies produce distinct rehabilitative trends in stroke survivors

Background

Comparing the efficacy of alternative therapeutic strategies for the rehabilitation of motor function in chronically impaired individuals is often inconclusive. For example, a recent randomized clinical trial (RCT) compared robot-assisted vs. conventional therapy in 77 patients who had had chronic motor impairment after a cerebrovascular accident. While patients assigned to robotic therapy had greater improvements in the primary outcome measure (change in score on the upper extremity section of the Fugl-Meyer assessment), the absolute difference between therapies was small, which left the clinical relevance in question.

Methods

Here we revisit that study to test whether the multidimensional rehabilitative response of these patients can better distinguish between treatment outcomes. We used principal components analysis to find the correlation of changes across seven outcome measures between the start and end of 8 weeks of therapy. Permutation tests verified the robustness of the principal components found.

Results

Each therapy in fact produces different rehabilitative trends of recovery across the clinical, functional, and quality of life domains. A rehabilitative trend is a principal component that quantifies the correlations among changes in outcomes with each therapy.

Conclusions

These findings challenge the traditional emphasis of RCTs on using a single primary outcome measure to compare rehabilitative responses that are naturally multidimensional. This alternative approach to, and interpretation of, the results of RCTs may will lead to more effective therapies targeted for the multidimensional mechanisms of recovery.

Trial registration

ClinicalTrials.gov number NCT00719433. Registered July 17, 2008.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0199-5) contains supplementary material, which is available to authorized users.

Effects of Robot-Assisted Therapy for the Upper Limb After Stroke

BACKGROUND

Robot technology for poststroke rehabilitation is developing rapidly. A number of new randomized controlled trials (RCTs) have investigated the effects of robot-assisted therapy for the paretic upper limb (RT-UL).

OBJECTIVE

To systematically review the effects of poststroke RT-UL on measures of motor control of the paretic arm, muscle strength and tone, upper limb capacity, and basic activities of daily living (ADL) in comparison with nonrobotic treatment.

METHODS

Relevant RCTs were identified in electronic searches. Meta-analyses were performed for measures of motor control (eg, Fugl-Meyer Assessment of the arm; FMA arm), muscle strength and tone, upper limb capacity, and basic ADL. Subgroup analyses were applied for the number of joints involved, robot type, timing poststroke, and treatment contrast.

RESULTS

Forty-four RCTs (N = 1362) were included. No serious adverse events were reported. Meta-analyses of 38 trials (N = 1206) showed significant but small improvements in motor control (~2 points FMA arm) and muscle strength of the paretic arm and a negative effect on muscle tone. No effects were found for upper limb capacity and basic ADL. Shoulder/elbow robotics showed small but significant effects on motor control and muscle strength, while elbow/wrist robotics had small but significant effects on motor control.

CONCLUSIONS

RT-UL allows patients to increase the number of repetitions and hence intensity of practice poststroke, and appears to be a safe therapy. Effects on motor control are small and specific to the joints targeted by RT-UL, whereas no generalization is found to improvements in upper limb capacity. The impact of RT-UL started in the first weeks poststroke remains unclear. These limited findings could mainly be related to poor understanding of robot-induced motor learning as well as inadequate designing of RT-UL trials, by not applying an appropriate selection of stroke patients with a potential to recovery at baseline as well as the lack of fixed timing of baseline assessments and using an insufficient treatment contrast early poststroke.

Technology-assisted stroke rehabilitation in Mexico: a pilot randomized trial comparing traditional therapy to circuit training in a Robot/technology-assisted therapy gym

Background

Stroke rehabilitation in low- and middle-income countries, such as Mexico, is often hampered by lack of clinical resources and funding. To provide a cost-effective solution for comprehensive post-stroke rehabilitation that can alleviate the need for one-on-one physical or occupational therapy, in lower and upper extremities, we proposed and implemented a technology-assisted rehabilitation gymnasium in Chihuahua, Mexico. The Gymnasium for Robotic Rehabilitation (Robot Gym) consisted of low- and high-tech systems for upper and lower limb rehabilitation. Our hypothesis is that the Robot Gym can provide a cost- and labor-efficient alternative for post-stroke rehabilitation, while being more or as effective as traditional physical and occupational therapy approaches.

Methods

A typical group of stroke patients was randomly allocated to an intervention (n = 10) or a control group (n = 10). The intervention group received rehabilitation using the devices in the Robot Gym, whereas the control group (n = 10) received time-matched standard care. All of the study subjects were subjected to 24 two-hour therapy sessions over a period of 6 to 8 weeks. Several clinical assessments tests for upper and lower extremities were used to evaluate motor function pre- and post-intervention. A cost analysis was done to compare the cost effectiveness for both therapies.

Results

No significant differences were observed when comparing the results of the pre-intervention Mini-mental, Brunnstrom Test, and Geriatric Depression Scale Test, showing that both groups were functionally similar prior to the intervention. Although, both training groups were functionally equivalent, they had a significant age difference. The results of all of the upper extremity tests showed an improvement in function in both groups with no statistically significant differences between the groups. The Fugl-Meyer and the 10 Meters Walk lower extremity tests showed greater improvement in the intervention group compared to the control group. On the Time Up and Go Test, no statistically significant differences were observed pre- and post-intervention when comparing the control and the intervention groups. For the 6 Minute Walk Test, both groups presented a statistically significant difference pre- and post-intervention, showing progress in their performance. The robot gym therapy was more cost-effective than the traditional one-to-one therapy used during this study in that it enabled therapist to train up to 1.5 to 6 times more patients for the approximately same cost in the long term.

Conclusions

The results of this study showed that the patients that received therapy using the Robot Gym had enhanced functionality in the upper extremity tests similar to patients in the control group. In the lower extremity tests, the intervention patients showed more improvement than those subjected to traditional therapy. These results support that the Robot Gym can be as effective as traditional therapy for stroke patients, presenting a more cost- and labor-efficient option for countries with scarce clinical resources and funding.

Trial registration

ISRCTN98578807.

Upper-Limb Robotic Exoskeletons for Neurorehabilitation: A Review on Control Strategies

Since the late 1990s, there has been a burst of research on robotic devices for poststroke rehabilitation. Robot-mediated therapy produced improvements on recovery of motor capacity; however, so far, the use of robots has not shown qualitative benefit over classical therapist-led training sessions, performed on the same quantity of movements. Multidegree-of-freedom robots, like the modern upper-limb exoskeletons, enable a distributed interaction on the whole assisted limb and can exploit a large amount of sensory feedback data, potentially providing new capabilities within standard rehabilitation sessions. Surprisingly, most publications in the field of exoskeletons focused only on mechatronic design of the devices, while little details were given to the control aspects. On the contrary, we believe a paramount aspect for robots potentiality lies on the control side. Therefore, the aim of this review is to provide a taxonomy of currently available control strategies for exoskeletons for neurorehabilitation, in order to formulate appropriate questions toward the development of innovative and improved control strategies.

Sequencing bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press and trunk kinematics in patients with stroke

BACKGROUND

The combination of robot-assisted therapy (RT) and a modified form of constraint-induced therapy (mCIT) shows promise for improving motor function of patients with stroke. However, whether the changes of motor control strategies are concomitant with the improvements in motor function after combination of RT and mCIT (RT + mCIT) is unclear. This study investigated the effects of the sequential combination of RT + mCIT compared with RT alone on the strategies of motor control measured by kinematic analysis and on motor function and daily performance measured by clinical scales.

METHODS

The study enrolled 34 patients with chronic stroke. The data were derived from part of a single-blinded randomized controlled trial. Participants in the RT + mCIT and RT groups received 20 therapy sessions (90 to 105 min/day, 5 days for 4 weeks). Patients in the RT + mCIT group received 10 RT sessions for first 2 weeks and 10 mCIT sessions for the next 2 weeks. The Bi-Manu-Track was used in RT sessions to provide bilateral practice of wrist and forearm movements. The primary outcome was kinematic variables in a task of reaching to press a desk bell. Secondary outcomes included scores on the Wolf Motor Function Test, Functional Independence Measure, and Nottingham Extended Activities of Daily Living. All outcome measures were administered before and after intervention.

RESULTS

RT + mCIT and RT demonstrated different benefits on motor control strategies. RT + mCIT uniquely improved motor control strategies by reducing shoulder abduction, increasing elbow extension, and decreasing trunk compensatory movement during the reaching task. Motor function and quality of the affected limb was improved, and patients achieved greater independence in instrumental activities of daily living. Force generation at movement initiation was improved in the patients who received RT.

CONCLUSION

A combination of RT and mCIT could be an effective approach to improve stroke rehabilitation outcomes, achieving better motor control strategies, motor function, and functional independence of instrumental activities of daily living.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT01727648.

Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke

BACKGROUND

Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke.

OBJECTIVES

To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.

SEARCH METHODS

We searched the Cochrane Stroke Group's Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 3), MEDLINE (1950 to March 2015), EMBASE (1980 to March 2015), CINAHL (1982 to March 2015), AMED (1985 to March 2015), SPORTDiscus (1949 to March 2015), PEDro (searched April 2015), Compendex (1972 to March 2015), and Inspec (1969 to March 2015). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as manufacturers of commercial devices.

SELECTION CRITERIA

Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for people after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables.

MAIN RESULTS

We included 34 trials (involving 1160 participants) in this update of our review. Electromechanical and robot-assisted arm training improved activities of daily living scores (SMD 0.37, 95% confidence interval (CI) 0.11 to 0.64, P = 0.005, I² = 62%), arm function (SMD 0.35, 95% CI 0.18 to 0.51, P < 0.0001, I² = 36%), and arm muscle strength (SMD 0.36, 95% CI 0.01 to 0.70, P = 0.04, I² = 72%), but the quality of the evidence was low to very low. Electromechanical and robot-assisted arm training did not increase the risk of participant drop-out (RD 0.00, 95% CI -0.02 to 0.03, P = 0.84, I² = 0%) with moderate-quality evidence, and adverse events were rare.

AUTHORS' CONCLUSIONS

People who receive electromechanical and robot-assisted arm and hand training after stroke might improve their activities of daily living, arm and hand function, and arm and hand muscle strength. However, the results must be interpreted with caution because the quality of the evidence was low to very low, and there were variations between the trials in the intensity, duration, and amount of training; type of treatment; and participant characteristics.

Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis?

OBJECTIVE

To contrast changes in clinical and kinematic measures of upper extremity movement in response to virtually simulated and traditionally presented rehabilitation interventions in persons with upper extremity hemiparesis due to chronic stroke.

DESIGN

Non-randomized controlled trial.

SETTING

Ambulatory research facility.

PARTICIPANTS

Subjects were a volunteer sample of twenty one community-dwelling adults (mean age: 51 ± 12 years) with residual hemiparesis due to stroke more than 6 months before enrollment (mean: 74 ± 48 months), recruited at support groups. Partial range, against gravity shoulder movement and at least 10° of active finger extension were required for inclusion. All subjects completed the study without adverse events.

INTERVENTIONS

A 2 weeks, 24-hour program of robotic/virtually simulated, arm and finger rehabilitation activities was compared to the same dose of traditionally presented arm and finger activities.

RESULTS

Subjects in both groups demonstrated statistically significant improvements in the ability to interact with real-world objects as measured by the Wolf Motor Function Test (P = 0.01). The robotic/virtually simulated activity (VR) group but not the traditional, repetitive task practice (RTP) group demonstrated significant improvements in peak reaching velocity (P = 0.03) and finger extension excursion (P = 0.03). Both groups also demonstrated similar improvements in kinematic measures of reaching and grasping performance such as increased shoulder and elbow excursion along with decreased trunk excursion.

CONCLUSIONS

Kinematic measurements identified differing adaptations to training that clinical measurements did not. These adaptations were targeted in the design of four of the six simulations performed by the simulated activity group. Finer grained measures may be necessary to accurately depict the relative benefits of dose matched motor interventions.

Applications of Brain-Machine Interface Systems in Stroke Recovery and Rehabilitation

Stroke is a leading cause of disability, significantly impacting the quality of life (QOL) in survivors, and rehabilitation remains the mainstay of treatment in these patients. Recent engineering and technological advances such as brain-machine interfaces (BMI) and robotic rehabilitative devices are promising to enhance stroke neu-rorehabilitation, to accelerate functional recovery and improve QOL. This review discusses the recent applications of BMI and robotic-assisted rehabilitation in stroke patients. We present the framework for integrated BMI and robotic-assisted therapies, and discuss their potential therapeutic, assistive and diagnostic functions in stroke rehabilitation. Finally, we conclude with an outlook on the potential challenges and future directions of these neurotechnologies, and their impact on clinical rehabilitation.