The effect of arm support combined with rehabilitation games on upper-extremity function in subacute stroke: a randomized controlled trial

Evaluation of a passive wearable arm ExoNET

Wearable ExoNETs offer a novel, wearable solution to support and facilitate upper extremity gravity compensation in healthy, unimpaired individuals. In this study, we investigated the safety and feasibility of gravity compensating ExoNETs on 10 healthy, unimpaired individuals across a series of tasks, including activities of daily living and resistance exercises. The direct muscle activity and kinematic effects of gravity compensation were compared to a sham control and no device control. Mixed effects analysis revealed significant reductions in muscle activity at the biceps, triceps and medial deltoids with effect sizes of -3.6%, -4.5%, and -7.2% rmsMVC, respectively, during gravity support. There were no significant changes in movement kinematics as evidenced by minimal change in coverage metrics at the wrist. These findings reveal the potential for the ExoNET to serve as an alternative to existing bulky and encumbering devices in post-stroke rehabilitation settings and pave the way for future clinical trials.

Utility and usability of a wearable system and progressive-challenge cued exercise program for encouraging use of the more involved arm at-home after stroke-a feasibility study with case reports

BACKGROUND

Understanding the role of adherence to home exercise programs for survivors of stroke is critical to ensure patients perform prescribed exercises and maximize effectiveness of recovery.

METHODS

Survivors of hemiparetic stroke with impaired motor function were recruited into a 7-day study designed to test the utility and usability of a low-cost wearable system and progressive-challenge cued exercise program for encouraging graded-challenge exercise at-home. The wearable system comprised two wrist-worn MetaMotionR+ activity monitors and a custom smartphone app. The progressive-challenge cued exercise program included high-intensity activities (one repetition every 30 s) dosed at 1.5 h per day, embedded within 8 h of passive activity monitoring per day. Utility was assessed using measures of system uptime and cue response rate. Usability and user experience were assessed using well-validated quantitative surveys of system usability and user experience. Self-efficacy was assessed at the end of each day on a visual analog scale that ranged from 0 to 100.

RESULTS

The system and exercise program had objective utility: system uptime was 92 ± 6.9% of intended hours and the rate of successful cue delivery was 99 ± 2.7%. The system and program also were effective in motivating cued exercise: activity was detected within 5-s of the cue 98 ± 3.1% of the time. As shown via two case studies, accelerometry data can accurately reflect graded-challenge exercise instructions and reveal differentiable activity levels across exercise stages. User experience surveys indicated positive overall usability in the home settings, strong levels of personal motivation to use the system, and high degrees of satisfaction with the devices and provided training. Self-efficacy assessments indicated a strong perception of proficiency across participants (95 ± 5.0).

CONCLUSIONS

This study demonstrates that a low-cost wearable system providing frequent haptic cues to encourage graded-challenge exercise after stroke can have utility and can provide an overall positive user experience in home settings. The study also demonstrates how combining a graded exercise program with all-day activity monitoring can provide insight into the potential for wearable systems to assess adherence to-and effectiveness of-home-based exercise programs on an individualized basis.

Effectiveness of an Intensive, Functional, and Gamified Rehabilitation Program on Upper Limb Function in People With Stroke (EnteRtain): A Multicenter Randomized Clinical Trial

BACKGROUND1

Despite a growing interest in gaming rehabilitation for upper limb (UL) recovery post-stroke, studies investigating the effects of game-based rehabilitation incorporating functional games are lacking.

OBJECTIVE

To investigate the efficacy of an intensive, functional, gamified rehabilitation program compared to task-based training on UL motor function in acute/sub-acute stroke survivors.

METHODS

This randomized, multicenter, single-blind, clinical trial comprises 120 participants with unilateral stroke who were randomized to receive either gamified training (n = 64) using the ArmAble™ [experimental group (EG)] or task-based training (n = 56) in conjunction with conventional therapy for 2 hours per day, 6 days per week for 2 weeks, followed by UL rehabilitation for another 4 weeks at home. Primary outcomes evaluated by a blinded assessor included the Fugl-Meyer Assessment-Upper Extremity (FM-UE), and Action Research Arm Test (ARAT). Data were analyzed using a linear mixed-effect regression model.

RESULTS

The mean (standard deviation) age of the participants was 54.4 ± 11.7 years (78.1% men) in the EG and 57.7 ± 10.9 years (73.2% men) in the comparator group (CG). The median (interquartile range) time since stroke was 30.0 (54.0) days in the EG and 22.5 (45.0) days in the CG. Following the 2-week intervention, a statistically significant improvement was observed in the EG for the FM-UE [between-group mean differences (95% confidence interval): -3.9 (-6.5, -1.3); P = .003]; but not for the ARAT [-2.9 (-5.8, 0.0); P = .051]. Gains at 6 weeks were significantly greater in the EG for both FM-UE [-3.9 (-6.5, -1.3); P = .003]; and ARAT [-3.0 (-5.9, -0.0); P = .046].

CONCLUSION

Gamified rehabilitation using the ArmAble™ device has shown immediate and short-term improvement in UL function after acute/sub-acute stroke.

CLINICAL TRIALS REGISTRY NUMBER

CTRI/2020/09/027651.

Virtual Reality Intervention and Its Impact on Upper Extremity Function in the Stroke Population: A Scoping Review

The aim of this scoping review was to examine virtual reality (VR) interventions used within rehabilitation and their effect on the functional outcomes of individuals with stroke. Specifically, this study sought to determine the impact of VR on the upper extremity (UE) use of participants as it relates to body function, occupational participation, and overall UE function (UEfxn). Twenty-six articles were selected for inclusion and results were extracted to determine common themes of outcomes among the effects of VR intervention (VRI). Thematic analysis included details about the VRIs used, as well as the change in UE outcomes post-VRI. Overall, positive change in UEfxn was found across many of the studies, indicating that VR technologies may be an effective intervention technique for individuals, poststroke. Findings of this review encourage clinicians to conduct further research regarding VR technology for UE rehabilitation poststroke.

Neurofunctional correlates of a neurorehabilitation system based on eye movements in chronic stroke impairment levels: A pilot study

INTRODUCTION

Rehabilitation after a stroke is widely considered fundamental to improve secondary functional impairments. Accessible methods based on motor learning, motor transfer and virtual environments are necessary to help to improve stroke patients' quality of life.

OBJECTIVES

Continuing the line of our previous studies, this work investigated the effect of our new and innovative game-based virtual reality training using the control of virtual objects with gaze in three chronic stroke survivors.

METHODS

All participants performed an eye-controlled virtual training task for 4 weeks. Pre- and post-training evaluation were carried out with the Fugl-Meyer Assessment for upper extremity scale as well as performing a tracking task inside an MRI scanner with a MRI-compatible eye-tracker or a joystick.

RESULTS

Neural results for each participant show the increase of activity in the motor cortex, basal ganglia and cerebellum for both effectors (hand or eye).

CONCLUSION

These promising results have a potential application as a new game-based neurorehabilitation approach to enhance the motor activity of stroke patients.

Utility and Usability of Two Forms of Supplemental Vibrotactile Kinesthetic Feedback for Enhancing Movement Accuracy and Efficiency in Goal-Directed Reaching

Recent advances in wearable sensors and computing have made possible the development of novel sensory augmentation technologies that promise to enhance human motor performance and quality of life in a wide range of applications. We compared the objective utility and subjective user experience for two biologically inspired ways to encode movement-related information into supplemental feedback for the real-time control of goal-directed reaching in healthy, neurologically intact adults. One encoding scheme mimicked visual feedback encoding by converting real-time hand position in a Cartesian frame of reference into supplemental kinesthetic feedback provided by a vibrotactile display attached to the non-moving arm and hand. The other approach mimicked proprioceptive encoding by providing real-time arm joint angle information via the vibrotactile display. We found that both encoding schemes had objective utility in that after a brief training period, both forms of supplemental feedback promoted improved reach accuracy in the absence of concurrent visual feedback over performance levels achieved using proprioception alone. Cartesian encoding promoted greater reductions in target capture errors in the absence of visual feedback (Cartesian: 59% improvement; Joint Angle: 21% improvement). Accuracy gains promoted by both encoding schemes came at a cost in terms of temporal efficiency; target capture times were considerably longer (1.5 s longer) when reaching with supplemental kinesthetic feedback than without. Furthermore, neither encoding scheme yielded movements that were particularly smooth, although movements made with joint angle encoding were smoother than movements with Cartesian encoding. Participant responses on user experience surveys indicate that both encoding schemes were motivating and that both yielded passable user satisfaction scores. However, only Cartesian endpoint encoding was found to have passable usability; participants felt more competent using Cartesian encoding than joint angle encoding. These results are expected to inform future efforts to develop wearable technology to enhance the accuracy and efficiency of goal-directed actions using continuous supplemental kinesthetic feedback.

Motivation as a Measurable Outcome in Stroke Rehabilitation: A Systematic Review of the Literature

Motivated behaviours are thought to lead to enhanced performances. In the neurorehabilitation field, motivation has been demonstrated to be a link between cognition and motor performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: "assessment" OR "scale" AND "motivation" AND "stroke" AND "rehabilitation". In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.

Effect of different modalities of artificial intelligence rehabilitation techniques on patients with upper limb dysfunction after stroke-A network meta-analysis of randomized controlled trials

Background

This study aimed to observe the effects of six different types of AI rehabilitation techniques (RR, IR, RT, RT + VR, VR and BCI) on upper limb shoulder-elbow and wrist motor function, overall upper limb function (grip, grasp, pinch and gross motor) and daily living ability in subjects with stroke. Direct and indirect comparisons were drawn to conclude which AI rehabilitation techniques were most effective in improving the above functions.

Methods

From establishment to 5 September 2022, we systematically searched PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI, VIP and Wanfang. Only randomized controlled trials (RCTs) that met the inclusion criteria were included. The risk of bias in studies was evaluated using the Cochrane Collaborative Risk of Bias Assessment Tool. A cumulative ranking analysis by SUCRA was performed to compare the effectiveness of different AI rehabilitation techniques for patients with stroke and upper limb dysfunction.

Results

We included 101 publications involving 4,702 subjects. According to the results of the SUCRA curves, RT + VR (SUCRA = 84.8%, 74.1%, 99.6%) was most effective in improving FMA-UE-Distal, FMA-UE-Proximal and ARAT function for subjects with upper limb dysfunction and stroke, respectively. IR (SUCRA = 70.5%) ranked highest in improving FMA-UE-Total with upper limb motor function amongst subjects with stroke. The BCI (SUCRA = 73.6%) also had the most significant advantage in improving their MBI daily living ability.

Conclusions

The network meta-analysis (NMA) results and SUCRA rankings suggest RT + VR appears to have a greater advantage compared with other interventions in improving upper limb motor function amongst subjects with stroke in FMA-UE-Proximal and FMA-UE-Distal and ARAT. Similarly, IR had shown the most significant advantage over other interventions in improving the FMA-UE-Total upper limb motor function score of subjects with stroke. The BCI also had the most significant advantage in improving their MBI daily living ability. Future studies should consider and report on key patient characteristics, such as stroke severity, degree of upper limb impairment, and treatment intensity/frequency and duration.

Systematic review registration

www.crd.york.ac.uk/prospero/#recordDetail, identifier: CRD42022337776.

Superior treatment efficacy of neuromodulation rehabilitation for upper limb recovery after stroke: a meta-analysis

BACKGROUND

This study aims to explore the treatment efficacy of different motor rehabilitation interventions for upper limb impairment recovery.

RESEARCH DESIGN & METHODS

Publications were searched in PubMed and Embase. 4 grouped motor rehabilitation treatments (training, technological intervention, pharmacological intervention, and neuromodulation) were compared. The change of the Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE) was applied to assess upper limb function after stroke.

RESULTS

56 studies including 5292 patients were identified. A significant difference was found among the 4 groups (P = 0.02). Neuromodulation interventions had the best treatment efficacy among the 4 types of interventions (P < 0.01). Among neuromodulation interventions, acupuncture, electric, or magnetic intervention all had therapeutic efficacy for stroke upper limb recovery, without significant subgroup difference (P = 0.34). Stroke patients with mild upper limb impairment might not benefit from motor rehabilitation (P = 0.14).

CONCLUSION

Neuromodulation interventions might have the best therapeutic efficacy among motor rehabilitation treatments for upper limb impairment after stroke. It is a potential treatment direction for upper limb recovery among stroke patients. However, since a large proportion of the original studies are low to very low-quality evidence, large-scale RCTs should be conducted in the future to validate current findings and assess treatment effects based on patient characteristics.

Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

INTRODUCTION

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).

METHODS

This study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.

RESULTS

The most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70-6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47-7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = - 0.58-4.72, P = 0.13), CONCLUSIONS: VAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

A Systematic Review on Serious Games in Attention Rehabilitation and Their Effects

Attention is a basic and main mental task and can play an important role in the functioning of other brain abilities such as intelligence, memory, learning, and perception, and its deficit occurs in 80% of patients with traumatic brain injury. The use of game-based tools for rehabilitation is rapidly expanding. Cognitive rehabilitation via video games is an emerging hot topic in cognitive science. Serious games serve a specific purpose in addition to entertainment. They can be more engaging than exercises since they replace reward and motivation systems with real-world motivations as a complement for rehabilitation activities. This study was aimed at identifying and categorizing serious computer games used for attention rehabilitation and evaluating their effects. Six electronic databases (Scopus, PubMed, ISI, Embase, IEEE, and Cochrane) were searched in August 2021. The search strategy consisted of three main concepts of “serious game”, “cognitive deficits”, and “cognitive rehabilitation”. The inclusion criteria were (1) journal articles, (2) English language, (3) being published in the last 10 years, (4) human participants, and (5) game-based intervention. In the 30 included studies, 22 unique games were utilized for attention rehabilitation. Lumosity (20%), Brain Age (Dr. Kawashima's Brain Training) (10%), and MoHRS (6.66%) were the most common games among the studies. There were (57%) casual, (23%) action, (10%) simulation, and (10%) multiple genres. Of the 47 tools used in the studies, 5 utilized cross-modal oddball attention tasks, 4 utilized game performance, 3 utilized the paced auditory serial additional test (PASAT), and the rest employed other tools. A total of 73 outcome measures were related to attention, 42 measures did not have significant results, 30 were significantly improved, 1 was significantly deteriorated, and 4 articles did not have any specific measures for attention evaluation. Thus, the results revealed the positive effect of serious games on attention. However, issues such as absence of scientific teams, the variety of the disorders that cause defects, the variety of criteria, differences in measurements, lack of long-term follow-up, insufficient RCT studies, and small sample sizes should be considered when designing, developing, and using game-based systems to prevent bias.

Serious Games Strategies With Cable-Driven Robots for Bimanual Rehabilitation: A Randomized Controlled Trial With Post-Stroke Patients

Cable-driven robots can be an ideal fit for performing post-stroke rehabilitation due to their specific features. For example, they have small and lightweight moving parts and a relatively large workspace. They also allow safe human-robot interactions and can be easily adapted to different patients and training protocols. However, the existing cable-driven robots are mostly unilateral devices that can allow only the rehabilitation of the most affected limb. This leaves unaddressed the rehabilitation of bimanual activities, which are predominant within the common Activities of Daily Living (ADL). Serious games can be integrated with cable-driven robots to further enhance their features by providing an interactive experience and by generating a high level of engagement in patients, while they can turn monotonous and repetitive therapy exercises into entertainment tasks. Additionally, serious game interfaces can collect detailed quantitative treatment information such as exercise time, velocities, and force, which can be very useful to monitor a patient’s progress and adjust the treatment protocols. Given the above-mentioned strong advantages of both cable driven robots, bimanual rehabilitation and serious games, this paper proposes and discusses a combination of them, in particular, for performing bilateral/bimanual rehabilitation tasks. The main design characteristics are analyzed for implementing the design of both the hardware and software components. The hardware design consists of a specifically developed cable-driven robot. The software design consists of a specifically developed serious game for performing bimanual rehabilitation exercises. The developed software also includes BiEval. This specific software allows to quantitatively measure and assess the rehabilitation therapy effects. An experimental validation is reported with 15 healthy subjects and a RCT (Randomized Controlled Trial) has been performed with 10 post-stroke patients at the Physiotherapy’s Clinic of the Federal University of Uberlândia (Minas Gerais, Brazil). The RCT results demonstrate the engineering feasibility and effectiveness of the proposed cable-driven robot in combination with the proposed BiEval software as a valuable tool to augment the conventional physiotherapy protocols and for providing reliable measurements of the patient’s rehabilitation performance and progress. The clinical trial was approved by the Research Ethics Committee of the UFU (Brazil) under the CAAE N° 00914818.5.0000.5152 on plataformabrasil@saude.gov.br.

Quantifying Quality of Reaching Movements Longitudinally Post-Stroke: A Systematic Review

Background

Disambiguation of behavioral restitution from compensation is important to better understand recovery of upper limb motor control post-stroke and subsequently design better interventions. Measuring quality of movement (QoM) during standardized performance assays and functional tasks using kinematic and kinetic metrics potentially allows for this disambiguation.

Objectives

To identify longitudinal studies that used kinematic and/or kinetic metrics to investigate post-stroke recovery of reaching and assess whether these studies distinguish behavioral restitution from compensation.

Methods

A systematic literature search was conducted using the databases PubMed, Embase, Scopus, and Wiley/Cochrane Library up to July 1st, 2020. Studies were identified if they performed longitudinal kinematic and/or kinetic measurements during reaching, starting within the first 6 months post-stroke.

Results

Thirty-two longitudinal studies were identified, which reported a total of forty-six different kinematic metrics. Although the majority investigated improvements in kinetics or kinematics to quantify recovery of QoM, none of these studies explicitly addressed the distinction between behavioral restitution and compensation. One study obtained kinematic metrics for both performance assays and a functional task.

Conclusions

Despite the growing number of kinematic and kinetic studies on post-stroke recovery, longitudinal studies that explicitly seek to delineate between behavioral restitution and compensation are still lacking in the literature. To rectify this situation, future studies should measure kinematics and/or kinetics during performance assays to isolate restitution and during a standardized functional task to determine the contributions of restitution and compensation.

Serious games for upper limb rehabilitation after stroke: a meta-analysis

BACKGROUND

Approximately two thirds of stroke survivors maintain upper limb (UL) impairments and few among them attain complete UL recovery 6 months after stroke. Technological progress and gamification of interventions aim for better outcomes and constitute opportunities in self- and tele-rehabilitation.

OBJECTIVES

Our objective was to assess the efficacy of serious games, implemented on diverse technological systems, targeting UL recovery after stroke. In addition, we investigated whether adherence to neurorehabilitation principles influenced efficacy of games specifically designed for rehabilitation, regardless of the device used.

METHOD

This systematic review was conducted according to PRISMA guidelines (PROSPERO registration number: 156589). Two independent reviewers searched PubMed, EMBASE, SCOPUS and Cochrane Central Register of Controlled Trials for eligible randomized controlled trials (PEDro score ≥ 5). Meta-analysis, using a random effects model, was performed to compare effects of interventions using serious games, to conventional treatment, for UL rehabilitation in adult stroke patients. In addition, we conducted subgroup analysis, according to adherence of included studies to a consolidated set of 11 neurorehabilitation principles.

RESULTS

Meta-analysis of 42 trials, including 1760 participants, showed better improvements in favor of interventions using serious games when compared to conventional therapies, regarding UL function (SMD = 0.47; 95% CI = 0.24 to 0.70; P < 0.0001), activity (SMD = 0.25; 95% CI = 0.05 to 0.46; P = 0.02) and participation (SMD = 0.66; 95% CI = 0.29 to 1.03; P = 0.0005). Additionally, long term effect retention was observed for UL function (SMD = 0.42; 95% CI = 0.05 to 0.79; P = 0.03). Interventions using serious games that complied with at least 8 neurorehabilitation principles showed better overall effects. Although heterogeneity levels remained moderate, results were little affected by changes in methods or outliers indicating robustness.

CONCLUSION

This meta-analysis showed that rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components. Irrespective of the technological device used, higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of serious games. Future development of stroke-specific rehabilitation interventions should further take into consideration the consolidated set of neurorehabilitation principles.

Kinematic of the Position and Orientation Synchronization of the Posture of a n DoF Upper-Limb Exoskeleton with a Virtual Object in an Immersive Virtual Reality Environment

Exoskeletons are an external structural mechanism with joints and links that work in tandem with the user, which increases, reinforces, or restores human performance. Virtual Reality can be used to produce environments, in which the intensity of practice and feedback on performance can be manipulated to provide tailored motor training. Will it be possible to combine both technologies and have them synchronized to reach better performance? This paper consists of the kinematics analysis for the position and orientation synchronization between an n DoF upper-limb exoskeleton pose and a projected object in an immersive virtual reality environment using a VR headset. To achieve this goal, the exoskeletal mechanism is analyzed using Euler angles and the Pieper technique to obtain the equations that lead to its orientation, forward, and inverse kinematic models. This paper extends the author’s previous work by using an early stage upper-limb exoskeleton prototype for the synchronization process.

VIRTUAL REALITY TRAINING THROUGH NINTENDO WII GAMES IN STROKE PATIENTS: A RANDOMISED CLINICAL TRIAL (Preprint)

Background

Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial.

Objective

The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke.

Methods

It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22.

Results

The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted.

Conclusions

VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability.

Trial Registration

Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view

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.

Development of a Planar Haptic Robot With Minimized Impedance

Several studies have reported that stroke survivors displayed improved voluntary planar movements when forces supporting the upper limb increased, and when impeding forces decreased. Earlier haptic devices interacting with the human upper limb were potentially impacted by undesired residual friction force and device inertia. To explore natural, undisturbed voluntary motor control in stroke survivors, we describe the development of a Decoupled-Operational space Robot for wide Impedance Switching (DORIS) with minimized mechanical impedances. This design is based on a novel decoupling mechanism separating the end effector from a manipulator. While the user manipulates the end effector freely inside the workspace of the decoupling mechanism, to which a manipulator of the robot is attached, the robot detects such change in position using a lightweight linkage system. The manipulator of the robot then follows such movements of the end effector swiftly. Consequently, the user can explore the extended workspace, which can be as large as the manipulator's workspace. Since the end effector is mechanically decoupled from the manipulators and actuators, the user can remain unaffected by the mechanical impedances of the manipulator. Mechanical impedances perceived by the user and bandwidth of the control system were estimated. The developed robot was capable of detecting larger maximum acceleration and larger jerk of the reaching movement in chronic stroke survivors with hemiparesis. We propose that this device can be utilized for evaluating voluntary motor control of the upper limb while minimizing the impact of robot inertia and friction forces on limb behavior.

Generalizability of Results from Randomized Controlled Trials in Post-Stroke Physiotherapy

Purpose: The randomized controlled trial (RCT) is considered a reliable experimental design, able to detect the effect of an intervention. However, a criticism frequently levelled at RCTs by clinicians is their lack of generalizability. This study aimed to evaluate the generalizability of findings from RCTs of physiotherapy interventions for individuals with stroke. Method: A sample of RCTs of physiotherapy interventions after stroke indexed in the PEDro database was selected, and the reported inclusion and exclusion criteria were analyzed. Results: We reviewed 100 articles, which included 7,366 participants (41.6% women, with a mean weighted age of 65.5 years). The most frequent criteria for exclusion were comorbidity (83%), cognitive impairments (69%), communication skills (55%), recurrent stroke (53%), low functional level (47%) and being elderly (25%). Conclusions: A variety of cohorts of individuals who have had a stroke are excluded from RCTs published in the field of physiotherapy. Because they represent a substantial proportion of the real-world population with stroke, and consequently treated in clinical practice, more vulnerable cohorts of participants should be included in RCTs.

Kinematic parameters obtained with the ArmeoSpring for upper-limb assessment after stroke: a reliability and learning effect study for guiding parameter use

BACKGROUND

After stroke, kinematic measures obtained with non-robotic and robotic devices are highly recommended to precisely quantify the sensorimotor impairments of the upper-extremity and select the most relevant therapeutic strategies. Although the ArmeoSpring exoskeleton has demonstrated its effectiveness in stroke motor rehabilitation, its interest as an assessment tool has not been sufficiently documented. The aim of this study was to investigate the psychometric properties of selected kinematic parameters obtained with the ArmeoSpring in post-stroke patients.

METHODS

This study involved 30 post-stroke patients (mean age = 54.5 ± 16.4 years; time post-stroke = 14.7 ± 26.7 weeks; Upper-Extremity Fugl-Meyer Score (UE-FMS) = 40.7 ± 14.5/66) who participated in 3 assessment sessions, each consisting of 10 repetitions of the 'horizontal catch' exercise. Five kinematic parameters (task and movement time, hand path ratio, peak velocity, number of peak velocity) and a global Score were computed from raw ArmeoSpring' data. Learning effect and retention were analyzed using a 2-way repeated-measures ANOVA, and reliability was investigated using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC).

RESULTS

We observed significant inter- and intra-session learning effects for most parameters except peak velocity. The measures performed in sessions 2 and 3 were significantly different from those of session 1. No additional significant difference was observed after the first 6 trials of each session and successful retention was also highlighted for all the parameters. Relative reliability was moderate to excellent for all the parameters, and MDC values expressed in percentage ranged from 42.6 to 102.8%.

CONCLUSIONS

After a familiarization session, the ArmeoSpring can be used to reliably and sensitively assess motor impairment and intervention effects on motor learning processes after a stroke. Trial registration The study was approved by the local hospital ethics committee in September 2016 and was registered under number 05-0916.

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

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

The Impact of Rehabilitation-oriented Virtual Reality Device in Patients With Ischemic Stroke in the Early Subacute Recovery Phase: Study Protocol for a Phase III, Single-Blinded, Randomized, Controlled Clinical Trial

BACKGROUND AND RATIONALE

Stroke is considered the most common cause of adult disability. Intensive rehabilitation protocols outperform nonintensive counterparts. The subacute stroke phase represents a potential window to recovery. Virtual reality (VR) has been shown to provide a more stimulating environment, allowing for increased patient compliance. However, the quality of current literature comparing VR with standard therapies is limited. Our aim is to measure the impact of VR versus standard therapy on the recovery of the upper limb motor function in patients with stroke in the early subacute recovery phase.

METHOD

This is a randomized, controlled trial that will assign 262 patients to tailor-made standard rehabilitation (TMSR) or TMSR plus immersive VR device. The trial will be conducted in an urban rehabilitation clinic in the United States with expertise in the management of poststroke patients. Patients will be 18 to 70 years of age and in the early subacute period (30-90 days post ischemic stroke). The primary outcome will be the change of Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score, measured at baseline and 13 weeks after randomization. The secondary outcome will be the change in the UK Functional Independence Measure and Functional Assessment Measure (UK FIM-FAM) score at the same time points.

DISCUSSION

If the use of VR in the rehabilitation of patients with stroke proves to have a significant impact on their motor recovery, it will constitute an extremely important step into decreasing the functional impairment associated with stroke and the related health care expense burden.

Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review

BACKGROUND

With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness.

OBJECTIVE

This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors.

METHODS

Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs.

RESULTS

In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants' stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P≤.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years.

CONCLUSIONS

This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery.

TRIAL REGISTRATION

PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=57715.

Rehabilitation of the upper arm early after stroke: Video games versus conventional rehabilitation. A randomized controlled trial

BACKGROUND

Few rehabilitation methods have proven their efficacy in increasing sensori-motor recovery and/or function of the upper limb (UL) after stroke. Video games (VGs) are promising tools in this indication.

OBJECTIVE

To compare UL rehabilitation by using VGs and conventional rehabilitation (CR) in patients with sub-acute stroke.

DESIGN

Single-blind, multicentric trial, with central randomization and stratification by center.

SETTING

Physical and rehabilitation medicine departments of 2 university hospitals.

PARTICIPANTS

Adults within 3 months after a first vascular cerebral accident, with UL Fugl Meyer Score (UL-FMS)<30/66 and without major cognitive impairment.

INTERVENTION

A 45-min additional session of conventional occupational therapy (OT) or a VG-based OT session as add-on therapy to usual rehabilitation programs, 5 days/week for 6 weeks.

MAIN OUTCOME MEASURES

Primary outcome: UL-FMS. Secondary outcome: Box and Block Test (BBT), Wolf Motor Function test (WMFT), Motor Activity Log (MAL), Barthel Index and quality of life (SF-36).

RESULTS

We included 51 patients (20 women) at a mean (SD) of 27.2 (19.4) days post-stroke (mean age 58 years [range 24-83]), 26 in the CR group and 25 in the VG group (23 in each group at 6-month follow-up). The mean duration of the additional rehabilitation session was similar in both groups: 29.3 (4.3) vs 28.0 (4.4) min in CR and VG groups. Shoulder pain occurred in 4 patients in the VG group versus 7 in the CR group. At day 45, gain in UL-FMS did not significantly differ between the groups (CR mean 17.8 [14.6] vs VG 24.1 [14.8]; P=0.10), whereas gain in BBT was doubled in the VG group (CR 7.4 [12.2] vs VG 15.7 [16.3]; P=0.02). At 6-month follow-up, the study was inconclusive about between-group differences in UL-FMS, BBT and other criteria. Post-hoc analysis showed that gains in UL-FMS or BBT were significantly higher in the VG than CR group for patients included within 30 days post-stroke.

CONCLUSION

In general, we cannot conclude that video gaming and conventional OT led to different long-term sensorimotor recovery of the UL after sub-acute stroke. However, when applied within the first month after stroke, video gaming was more efficient than conventional rehabilitation on both sensorimotor recovery and gross grasping function.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01554449).

Effects of virtual reality-based planar motion exercises on upper extremity function, range of motion, and health-related quality of life: a multicenter, single-blinded, randomized, controlled pilot study

Background

Virtual reality (VR)-based rehabilitation is considered a beneficial therapeutic option for stroke rehabilitation. This pilot study assessed the clinical feasibility of a newly developed VR-based planar motion exercise apparatus (Rapael Smart Board™ [SB]; Neofect Inc., Yong-in, Korea) for the upper extremities as an intervention and assessment tool.

Methods

This single-blinded, randomized, controlled trial included 26 stroke survivors. Patients were randomized to the intervention group (SB group) or control (CON) group. During one session, patients in the SB group completed 30 min of intervention using the SB and an additional 30 min of standard occupational therapy; however, those in the CON group completed the same amount of conventional occupational therapy. The primary outcome was the change in the Fugl–Meyer assessment (FMA) score, and the secondary outcomes were changes in the Wolf motor function test (WMFT) score, active range of motion (AROM) of the proximal upper extremities, modified Barthel index (MBI), and Stroke Impact Scale (SIS) score. A within-group analysis was performed using the Wilcoxon signed-rank test, and a between-group analysis was performed using a repeated measures analysis of covariance. Additionally, correlations between SB assessment data and clinical scale scores were analyzed by repeated measures correlation. Assessments were performed three times (baseline, immediately after intervention, and 1 month after intervention).

Results

All functional outcome measures (FMA, WMFT, and MBI) showed significant improvements (p < 0.05) in the SB and CON groups. AROM showed greater improvements in the SB group, especially regarding shoulder abduction and internal rotation. There was a significant effect of time × group interactions for the SIS overall score (p = 0.038). Some parameters of the SB assessment, such as the explored area ratio, mean reaching distance, and smoothness, were significantly associated with clinical upper limb functional measurements with moderate correlation coefficients.

Conclusions

The SB was available for improving upper limb function and health-related quality of life and useful for assessing upper limb ability in stroke survivors.

Trial registration

The study was registered with the clinical research information service (CRIS) (KCT0003783, registered 15 April 2019; retrospectively registered).

Interaction Modalities Used on Serious Games for Upper Limb Rehabilitation: A Systematic Review

This systematic review aims to analyze the state-of-the-art regarding interaction modalities used on serious games for upper limb rehabilitation. A systematic search was performed in IEEE Xplore and Web of Science databases. PRISMA and QualSyst protocols were used to filter and assess the articles. Articles must meet the following inclusion criteria: they must be written in English; be at least four pages in length; use or develop serious games; focus on upper limb rehabilitation; and be published between 2007 and 2017. Of 121 articles initially retrieved, 33 articles met the inclusion criteria. Three interaction modalities were found: vision systems (42.4%), complementary vision systems (30.3%), and no-vision systems (27.2%). Vision systems and no-vision systems obtained a similar mean QualSyst (86%) followed by complementary vision systems (85.7%). Almost half of the studies used vision systems as the interaction modality (42.4%) and used the Kinect sensor to collect the body movements (48.48%). The shoulder was the most treated body part in the studies (19%). A key limitation of vision systems and complementary vision systems is that their device performances might be affected by lighting conditions. A main limitation of the no-vision systems is that the range-of-motion in angles of the body movement might not be measured accurately. Due to a limited number of studies, fruitful areas for further research could be the following: serious games focused on finger rehabilitation and trauma injuries, game difficulty adaptation based on user's muscle strength and posture, and multisensor data fusion on interaction modalities.

Differences in muscle activity and fatigue of the upper limb between Task-Specific training and robot assisted training among individuals post stroke

OBJECTIVE

To compare the activity and fatigue of upper extremity muscles, pain levels, subject satisfaction levels, perceived exertion, and number of repetitions in Task-Specific Training (TST) compared with Robot-Assisted Training (RAT) in individuals post-stroke.

METHODS

Twenty sub-acute post stroke subjects (16 men; median (interquartile range) age 64.0 (71.5-57.0) years) received two 30-min treatment sessions, one TST and one RAT. Before each session, the Visual Analogue Scale (VAS) was administered. Activity levels and fatigue of six muscles were monitored using surface electromyography and the number of repetitions was counted. After each session, the subjective assessment questionnaire of treatment, the Borg scale and VAS were administered.

RESULTS

During TST, the Anterior Deltoid, Upper Trapezius and Biceps were more active, while during the RAT, the Triceps was more active. The Triceps activity increased during TST towards the end of the session. The pain levels increased after TST and the number of repetitions was higher compared to RAT. There were no significant differences in muscle fatigue, perceived physical exertion and subject satisfaction levels between both treatment sessions.

CONCLUSION

This is the first study to explore the biomechanics of both treatment methods and might therefore shed light on the mechanisms behind their positive outcomes. Due to the differences in the biomechanics of the treatments, a combination of both treatments may be beneficial to the activation of different muscle groups, thereby contributing to the rehabilitation program post stroke.

Upper limb robot-assisted rehabilitation versus physical therapy on subacute stroke patients: A follow-up study

This study aims to analyse the long-term effects (6 months follow-up) of upper limb Robot-assisted Therapy (RT) compared to Traditional physical Therapy (TT), in subacute stroke patients. Although the literature on upper-limb rehabilitation with robots shows increasing evidence of its effectiveness in stroke survivors, the length of time for which the re-learned motor abilities could be maintained is still understudied. A randomized controlled follow-up study was conducted on 48 subacute stroke patients who performed the upper-limb therapy using a planar end-effector robotic system (Experimental Group-EG) or TT (Control Group-CG). The clinical assessments were collected at T0 (baseline), T1 (end of treatment) and T2 (6 months follow-up): Upper Limb part of Fugl-Meyer assessment (FM-UL), total passive Range Of Motion (pROM), Modified Ashworth Scale Shoulder (MAS-S) and Elbow (MAS-E). At T1, the intra-group analysis showed significant gain of FM-UL in both EG and CG, while significant improvement in MAS-S, MAS-E, and pROM were found in the EG only. At T2, significant increase in MAS-S were revealed only in the CG. In FM-UL, pROM and MAS-E the improvements obtained at the end of treatment seem to be maintained at 6 months follow-up in both groups. The inter-groups analysis of FM-UL values at T1 and T2 demonstrated significant differences in favour of EG. In conclusion, upper limb Robot-assisted Therapy may lead a greater reduction of motor impairment in subacute stroke patients compared to Traditional Therapy. The gains observed at the end of treatment persisted over time. No serious adverse events related to the study occurred.

Upper limb strength training in subacute stroke patients: study protocol of a randomised controlled trial

BACKGROUND

Stroke patients are often affected by arm paresis, have functional impairments and receive help from professional or informal caregivers. Progressive resistance training is a common intervention for functional impairments after paresis. Randomised controlled trials (RCT) showed benefits for functional recovery after resistance training. However, there is a lack of evidence for strength training in subacute stroke patients. The aim of this study is to investigate safety and effectiveness of arm strength training in subacute stroke patients.

METHODS

We will conduct a prospective, assessor-blinded RCT of people with subacute stroke. We will randomly assign patients to one of two parallel groups in a 1:1 ratio and will use concealed allocation. The intervention group will receive, in addition to standard treatment, high-intensity arm training (three times per week, over three weeks; 60 min each session; with a total of nine additional sessions). The control group will receive, in addition to standard treatment, low-intensity arm training (same quantity, frequency and treatment time as the intervention group). Standard treatment for the affected arm includes mobilisation, stretching, therapeutic positioning, arm and hand motor training, strengthening exercises, mechanical assisted training, functional training and task-oriented training. The primary efficacy endpoint will be grip strength. Secondary outcome measures will be Modified Ashworth Scale, Motricity Index, Fugl-Meyer Assessment for the upper limb, Box and Block Test and Goal Attainment Scale for individual participatory goals. We will measure primary and secondary outcomes with blinded assessors at baseline and immediately after three weeks of additional therapy. Based on our sample size calculation, 78 patients will be recruited from our rehabilitation hospital in two and a half years. Drop-out rates and adverse events will be systematically recorded.

DISCUSSION

This study attempts to close the evidence gap for effects of arm strength training in subacute stroke patients. The results of this trial will provide robust evidence for effects and safety of high-intensity arm training for people with stroke.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00012484 . Registered on 26 May 2017.

Bio-Cooperative Approach for the Human-in-the-Loop Control of an End-Effector Rehabilitation Robot

The design of patient-tailored rehabilitative protocols represents one of the crucial factors that influence motor recovery mechanisms, such as neuroplasticity. This approach, including the patient in the control loop and characterized by a control strategy adaptable to the user's requirements, is expected to significantly improve functional recovery in robot-aided rehabilitation. In this paper, a novel 3D bio-cooperative robotic platform is developed. A new arm-weight support system is included into an operational robotic platform for 3D upper limb robot-aided rehabilitation. The robotic platform is capable of adapting therapy characteristics to specific patient needs, thanks to biomechanical and physiological measurements, and thus closing the subject in the control loop. The level of arm-weight support and the level of the assistance provided by the end-effector robot are varied on the basis of muscular fatigue and biomechanical indicators. An assistance-as-needed approach is applied to provide the appropriate amount of assistance. The proposed platform has been experimentally validated on 10 healthy subjects; they performed 3D point-to-point tasks in two different conditions, i.e., with and without assistance-as-needed. The results have demonstrated the capability of the proposed system to properly adapt to real needs of the patients. Moreover, the provided assistance was shown to reduce the muscular fatigue without negatively influencing motion execution.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

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.

Play seriously: Effectiveness of serious games and their features in motor rehabilitation. A meta-analysis

BACKGROUND

Evidence for the effectiveness of serious games (SGs) and their various features is inconsistent in the motor rehabilitation field, which makes evidence based development of SGs a rare practice.

OBJECTIVE

To investigate the effectiveness of SGs in motor rehabilitation for upper limb and movement/balance and to test the potential moderating role of SGs features like feedback, activities, characters and background.

METHODS

We ran a meta-analysis including 61 studies reporting randomized controlled trials (RCTs), controlled trials (CTs) or case series designs in which at least one intervention for motor rehabilitation included the use of SGs as standalone or in combination.

RESULTS

There was an overall moderate effect of SGs on motor indices, d = 0.59, [95% CI, 0.48, 0.71], p <  0.001. Regarding the game features, only two out of 17 moderators were statistically different in terms of effect sizes: type of activity (combination of group with individual activities had the highest effects), and realism of the scenario (fantasy scenarios had the highest effects).

CONCLUSIONS

While we showed that SGs are more effective in improving motor upper limb and movement/balance functions compared to conventional rehabilitation, there were no consistent differences between various game features in their contribution to effects. Further research should systematically investigate SGs features that might have added value in improving effectiveness.

Virtual reality for stroke rehabilitation

BACKGROUND

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

OBJECTIVES

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

MAIN RESULTS

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

PRIMARY OUTCOME

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

SECONDARY OUTCOMES

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

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.

Is robot-assisted therapy effective in upper extremity recovery in early stage stroke? -a systematic literature review

[Purpose] The aim of this study was to systematically investigate the effects of robot-assisted therapy on the upper extremity in acute and subacute stroke patients. [Subjects and Methods] The papers retrieved were evaluated based on the following inclusion criteria: 1) design: randomized controlled trials; 2) population: stroke patients 3) intervention: robot-assisted therapy; and 4) year of publication: May 2012 to April 2016. Databased searched were: EMBASE, PubMed and COCHRAN databases. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies. [Results] Of the 637 articles searched, six studies were included in this systematic review. The PEDro scores range from 7 to 9 points. [Conclusion] This review confirmed that the robot-assisted therapy with three-dimensional movement and a high degree of freedom had positive effects on the recovery of upper extremity motor function in patients with early-stage stroke. We think that the robot-assisted therapy could be used to improve upper extremity function for early stage stroke patients in clinical setting.

Motivation, expectations, and usability of a driven gait orthosis in stroke patients and their therapists

BACKGROUND

In the development of efficacious driven gait orthoses (DGO), it is an added value to consider patients' and therapists' perspectives concerning robot-assisted gait training (RAGT). A better understanding of these issues may improve the process of care and outcome.

OBJECTIVES

This study aimed to examine stroke patients' motivation and expectations of RAGT, and therapists' expectations and perspectives on the usability of RAGT. Additionally, the differences in expectations between stroke patients and their therapists were analyzed.

METHODS

A cross sectional, multi-center, three-group trial was conducted. Included were (1) stroke patients who have experience with RAGT (i.e. the stroke user group), (2) stroke patients who have no experience with RAGT (i.e. the stroke non-user group), and (3) therapists who have experience with RAGT (i.e. the therapist user group). The Intrinsic Motivation Inventory (IMI), Credibility/Expectancy Questionnaire (CEQ), and Usefulness, Satisfaction and Ease of Use Questionnaire (USE) were used. Descriptive statistics and non-parametric Kruskal-Wallis tests were conducted.

RESULTS

In total, 46 subjects were assessed (stroke user group: n = 23, stroke non-user group: n = 14, therapist user group: n = 9). IMI subscale scores ranged from 42 to 88%. Mean credibility and expectancy ranged from 80 to 85% and 57 to 72%, respectively, with no significant differences between groups. USE subscale scores ranged from 61 to 72%.

CONCLUSIONS

Stroke user group patients seem quite motivated to train with the DGO and both patients and therapists reasonably believe that this training could improve gait functioning. Therapists are moderately satisfied with the usability of the DGO, but there is room for improvement with respect to usefulness and ease of use.

A wearable soft-robotic glove enables hand support in ADL and rehabilitation: A feasibility study on the assistive functionality

Background

Elderly people frequently experience a decline in hand function, due to ageing or diseases. This leads to decreased independence in activities of daily living (ADL). Assistive technology may enhance independence.

Objectives

The objective of this paper was to explore user acceptance of an affordable wearable soft-robotic glove (ironHand (iH) system), that supports grip and hand opening in ADL. In addition, functional performance with the iH system was explored.

Methods

For this study 28 elderly people used the iH system across two sessions. During these sessions, participants performed six functional tasks with and without the iH system. Outcome measures were System Usability Scale (SUS), Intrinsic Motivation Inventory (IMI) and performance time of the functional tasks.

Results

User acceptance scored highly, with a mean SUS score of at least 63.4 (SD = 19.0) and a mean IMI score of 5.1 points (SD = 0.97 points). Functional task performance improved across repetitions both with and without the glove (p ≤ 0.017), but all functional tasks were performed faster without the glove (p ≤ 0.032).

Conclusion

Participants perceived the iH system as useful, pleasant and meaningful. The learning curve in functional performance time (improvements across repetitions) is promising, since it suggests there is room for improved performance when a longer acquaintance period is applied.

Effects of virtual reality for stroke individuals based on the International Classification of Functioning and Health: a systematic review

OBJECTIVE

This review determines the effects of virtual reality interventions for stroke subjects based on the International Classification of Functioning, Disability,and Health (ICF) framework. Virtual reality is a promising tool for therapy for stroke rehabilitation, but the effects of virtual reality interventions on post-stroke patients based on the specific ICF domains (Body Structures, Body Functions, Activity, and Participation) have not been investigated.

METHOD

A systematic review was conducted, including trials with adults with a clinical diagnosis of a chronic, subacute, or acute stroke. Eligible trials had to include studies with an intervention protocol and follow-up, with a focus on upper limbs and/or lower limbs and/or balance. The Physiotherapy Evidence Database (PEDro) was used to assess the methodological quality of randomized controlled trials. Each trial was separated according to methodological quality into a high-quality trial (PEDro ≥ 6) and a low-quality trial (PEDro ≤ 6). Only high-quality trials were analyzed specifically based on the outcome of these trials.

RESULTS

In total, 54 trials involving 1811 participants were included. Of the papers included and considered high quality, 14 trials evaluated areas of the Body Structures component, 20 trials of the Body Functions domain, 17 trials of the Activity component, and 8 trials of the Participation domain. In relation to ICF Part 2, four trials evaluated areas of the Personal Factors component and one trial evaluated domains of the Environmental Factors component.

DISCUSSION

The effects of virtual reality on stroke rehabilitation based on the ICF framework are positive in Body Function and Body Structure. However, the results in the domains Activity and Participation are inconclusive. More high-quality clinical trials are needed to confirm the effectiveness of virtual reality in the domains of Activity and Participation.

Feasibility of Using an Arm Weight-Supported Training System to Improve Hand Function Skills in Children With Hemiplegia

OBJECTIVE

This investigation was a pilot feasibility trial evaluating the use of an arm-weight-supported training device to improve upper-extremity function in children with hemiplegia.

METHOD

A single-group within-subject design was used. Participants were 6 children ages 7-17 yr with upper-extremity weakness secondary to hemiplegia. The intervention consisted of 15-18 treatment sessions using an arm-weight-supported training device with the affected upper extremity. Fine motor function was assessed using the Jebsen-Taylor Hand Function Test, the Box and Block Test, and the Assisting Hand Assessment. We examined participants' interactions with the device and assessment scores pre- and postintervention.

RESULTS

Five of the 6 children exhibited some changes after the therapy. The system required significant modifications to ensure appropriate positioning.

CONCLUSION

The arm-weight-supported system may be viable for therapeutic use. Future studies should use randomized controlled designs and compare effectiveness of weight-supported training with that of other rehabilitation strategies.

Effects of training with a passive hand orthosis and games at home in chronic stroke: a pilot randomised controlled trial

OBJECTIVES

To compare user acceptance and arm and hand function changes after technology-supported training at home with conventional exercises in chronic stroke. Secondly, to investigate the relation between training duration and clinical changes.

DESIGN

A randomised controlled trial.

SETTING

Training at home, evaluation at research institute.

SUBJECTS

Twenty chronic stroke patients with severely to mildly impaired arm and hand function.

INTERVENTIONS

Participants were randomly assigned to six weeks (30 minutes per day, six days a week) of self-administered home-based arm and hand training using either a passive dynamic wrist and hand orthosis combined with computerised gaming exercises (experimental group) or prescribed conventional exercises from an exercise book (control group).

MAIN MEASURES

Main outcome measures are the training duration for user acceptance and the Action Research Arm Test for arm and hand function. Secondary outcomes are the Intrinsic Motivation Inventory, Fugl-Meyer assessment, Motor Activity Log, Stroke Impact Scale and grip strength.

RESULTS

The control group reported a higher training duration (189 versus 118 minutes per week, P = 0.025). Perceived motivation was positive and equal between groups ( P = 0.935). No differences in clinical outcomes over training between groups were found (P ⩾ 0.165). Changes in Box and Block Test correlated positively with training duration ( P = 0.001).

CONCLUSIONS

Both interventions were accepted. An additional benefit of technology-supported arm and hand training over conventional arm and hand exercises at home was not demonstrated. Training duration in itself is a major contributor to arm and hand function improvements.

Play-based interventions improve physical function for people with adult-acquired brain injury: a systematic review and meta-analysis of randomised controlled trials

Objective:

To undertake a systematic review and meta-analysis of the effectiveness of play-based interventions compared to traditional therapy in rehabilitation of adults with adult-acquired brain injury.

Data sources:

The search was performed using Medline; Cinahl Plus; Health Source (Nursing/Academic Edition); Psychology and behavioural sciences collection; Biomedical reference collection (basic).

Review methods:

Studies included were randomised controlled trials that investigated the effect of play-based interventions on physical function of adults with adult acquired brain injury. Two independent reviewers identified eligible studies and assessed methodological quality using a modified Downs and Black. Meta-analysis compared standardised differences in means, to determine effect sizes for grouped functional outcome measures. The GRADE scoring system was used to determine the level of clinical evidence.

Results:

Thirty studies met the inclusion criteria, 13 were considered high quality and 17 moderate quality. Studies predominantly involved post-stroke participants, with only three studies including participants with traumatic brain injury. When compared to traditional therapy, dose-matched studies of play-based interventions showed a significant effect on independence (Effect size (ES) = 0.6) and physical performance (ES = 0.43), as measured using the Fugl –Meyer. For non-dose matched studies, play-based interventions showed a significant improvement for balance (ES = 0.76) compared with traditional therapy. In all studies that measured participant enjoyment, play-based therapy was rated as more enjoyable than traditional therapy.

Conclusion:

Play-based interventions for people with adult acquired brain injury are more effective in improving balance and independence, which may be due to them being more enjoyable than traditional therapy.

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.

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke

Background

Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke.

Methods

A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up.

Results

Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log.

Conclusions

Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings.

Trial registration

This study has been registered at the Netherlands Trial Registry (NTR): NTR3669.