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Colamarino E, Morone G, Toppi J, Riccio A, Cincotti F, Mattia D, Pichiorri F. A Scoping Review of Technology-Based Approaches for Upper Limb Motor Rehabilitation after Stroke: Are We Really Targeting Severe Impairment? J Clin Med 2024; 13:5414. [PMID: 39336901 PMCID: PMC11432574 DOI: 10.3390/jcm13185414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/05/2024] [Accepted: 09/08/2024] [Indexed: 09/30/2024] Open
Abstract
Technology-based approaches for upper limb (UL) motor rehabilitation after stroke are mostly designed for severely affected patients to increase their recovery chances. However, the available randomized controlled trials (RCTs) focused on the efficacy of technology-based interventions often include patients with a wide range of motor impairment. This scoping review aims at overviewing the actual severity of stroke patients enrolled in RCTs that claim to specifically address UL severe motor impairment. The literature search was conducted on the Scopus and PubMed databases and included articles from 2008 to May 2024, specifically RCTs investigating the impact of technology-based interventions on UL motor functional recovery after stroke. Forty-eight studies were selected. They showed that, upon patients' enrollment, the values of the UL Fugl-Meyer Assessment and Action Research Arm Test covered the whole range of both scales, thus revealing the non-selective inclusion of severely impaired patients. Heterogeneity in terms of numerosity, characteristics of enrolled patients, trial design, implementation, and reporting was present across the studies. No clear difference in the severity of the included patients according to the intervention type was found. Patient stratification upon enrollment is crucial to best direct resources to those patients who will benefit the most from a given technology-assisted approach (personalized rehabilitation).
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Affiliation(s)
- Emma Colamarino
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, 00185 Rome, Italy; (E.C.); (J.T.); (F.C.)
- IRCCS Fondazione Santa Lucia, 00179 Rome, Italy; (A.R.); (D.M.); (F.P.)
| | - Giovanni Morone
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Jlenia Toppi
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, 00185 Rome, Italy; (E.C.); (J.T.); (F.C.)
- IRCCS Fondazione Santa Lucia, 00179 Rome, Italy; (A.R.); (D.M.); (F.P.)
| | - Angela Riccio
- IRCCS Fondazione Santa Lucia, 00179 Rome, Italy; (A.R.); (D.M.); (F.P.)
| | - Febo Cincotti
- Department of Computer, Control, and Management Engineering “Antonio Ruberti”, Sapienza University of Rome, 00185 Rome, Italy; (E.C.); (J.T.); (F.C.)
- IRCCS Fondazione Santa Lucia, 00179 Rome, Italy; (A.R.); (D.M.); (F.P.)
| | - Donatella Mattia
- IRCCS Fondazione Santa Lucia, 00179 Rome, Italy; (A.R.); (D.M.); (F.P.)
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Banyai AD, Brișan C. Robotics in Physical Rehabilitation: Systematic Review. Healthcare (Basel) 2024; 12:1720. [PMID: 39273744 PMCID: PMC11395122 DOI: 10.3390/healthcare12171720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 08/25/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
As the global prevalence of motor disabilities continues to rise, there is a pressing need for advanced solutions in physical rehabilitation. This systematic review examines the progress and challenges of implementing robotic technologies in the motor rehabilitation of patients with physical disabilities. The integration of robotic technologies such as exoskeletons, assistive training devices, and brain-computer interface systems holds significant promise for enhancing functional recovery and patient autonomy. The review synthesizes findings from the most important studies, focusing on the clinical effectiveness of robotic interventions in comparison to traditional rehabilitation methods. The analysis reveals that robotic therapies can significantly improve motor function, strength, co-ordination, and dexterity. Robotic systems also support neuroplasticity, enabling patients to relearn lost motor skills through precise, controlled, and repetitive exercises. However, the adoption of these technologies is hindered by high costs, the need for specialized training, and limited accessibility. Key insights from the review highlight the necessity of personalizing robotic therapies to meet individual patient needs, alongside addressing technical, economic, social, and cultural barriers. The review also underscores the importance of continued research to optimize these technologies and develop effective implementation strategies. By overcoming these challenges, robotic technologies can revolutionize motor rehabilitation, improving quality of life and social integration for individuals with motor disabilities.
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Affiliation(s)
- Adriana Daniela Banyai
- Department of Mechatronics and Machine Dynamics, Technical University of Cluj-Napoca, 400114 Cluj-Napoca, Romania
| | - Cornel Brișan
- Department of Mechatronics and Machine Dynamics, Technical University of Cluj-Napoca, 400114 Cluj-Napoca, Romania
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Teasell R, Fleet JL, Harnett A. Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy. Phys Med Rehabil Clin N Am 2024; 35:339-351. [PMID: 38514222 DOI: 10.1016/j.pmr.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.
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Affiliation(s)
- Robert Teasell
- Parkwood Institute Research, Parkwood Institute, D4-101A, 550 Wellington Road, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, D4-101A, 550 Wellington Road, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Amber Harnett
- Parkwood Institute Research, Parkwood Institute, B3-123, 550 Wellington Road, London, Ontario N6C 0A7, Canada
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Berger DJ, d’Avella A. Myoelectric control and virtual reality to enhance motor rehabilitation after stroke. Front Bioeng Biotechnol 2024; 12:1376000. [PMID: 38665814 PMCID: PMC11043476 DOI: 10.3389/fbioe.2024.1376000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
Effective upper-limb rehabilitation for severely impaired stroke survivors is still missing. Recent studies endorse novel motor rehabilitation approaches such as robotic exoskeletons and virtual reality systems to restore the function of the paretic limb of stroke survivors. However, the optimal way to promote the functional reorganization of the central nervous system after a stroke has yet to be uncovered. Electromyographic (EMG) signals have been employed for prosthetic control, but their application to rehabilitation has been limited. Here we propose a novel approach to promote the reorganization of pathological muscle activation patterns and enhance upper-limb motor recovery in stroke survivors by using an EMG-controlled interface to provide personalized assistance while performing movements in virtual reality (VR). We suggest that altering the visual feedback to improve motor performance in VR, thereby reducing the effect of deviations of the actual, dysfunctional muscle patterns from the functional ones, will actively engage patients in motor learning and facilitate the restoration of functional muscle patterns. An EMG-controlled VR interface may facilitate effective rehabilitation by targeting specific changes in the structure of muscle synergies and in their activations that emerged after a stroke-offering the possibility to provide rehabilitation therapies addressing specific individual impairments.
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Affiliation(s)
- Denise Jennifer Berger
- Laboratory of Neuromotor Physiology, IRCCS Fondazione Santa Lucia, Rome, Italy
- Department of Systems Medicine, Centre of Space Bio-medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea d’Avella
- Laboratory of Neuromotor Physiology, IRCCS Fondazione Santa Lucia, Rome, Italy
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
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5
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Vidaurre C, Irastorza-Landa N, Sarasola-Sanz A, Insausti-Delgado A, Ray AM, Bibián C, Helmhold F, Mahmoud WJ, Ortego-Isasa I, López-Larraz E, Lozano Peiteado H, Ramos-Murguialday A. Challenges of neural interfaces for stroke motor rehabilitation. Front Hum Neurosci 2023; 17:1070404. [PMID: 37789905 PMCID: PMC10543821 DOI: 10.3389/fnhum.2023.1070404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 08/28/2023] [Indexed: 10/05/2023] Open
Abstract
More than 85% of stroke survivors suffer from different degrees of disability for the rest of their lives. They will require support that can vary from occasional to full time assistance. These conditions are also associated to an enormous economic impact for their families and health care systems. Current rehabilitation treatments have limited efficacy and their long-term effect is controversial. Here we review different challenges related to the design and development of neural interfaces for rehabilitative purposes. We analyze current bibliographic evidence of the effect of neuro-feedback in functional motor rehabilitation of stroke patients. We highlight the potential of these systems to reconnect brain and muscles. We also describe all aspects that should be taken into account to restore motor control. Our aim with this work is to help researchers designing interfaces that demonstrate and validate neuromodulation strategies to enforce a contingent and functional neural linkage between the central and the peripheral nervous system. We thus give clues to design systems that can improve or/and re-activate neuroplastic mechanisms and open a new recovery window for stroke patients.
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Affiliation(s)
- Carmen Vidaurre
- TECNALIA, Basque Research and Technology Alliance (BRTA), San Sebastian, Spain
- Ikerbasque Science Foundation, Bilbao, Spain
| | | | | | | | - Andreas M. Ray
- Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Carlos Bibián
- Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Florian Helmhold
- Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Wala J. Mahmoud
- Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Iñaki Ortego-Isasa
- TECNALIA, Basque Research and Technology Alliance (BRTA), San Sebastian, Spain
| | - Eduardo López-Larraz
- Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
- Bitbrain, Zaragoza, Spain
| | | | - Ander Ramos-Murguialday
- TECNALIA, Basque Research and Technology Alliance (BRTA), San Sebastian, Spain
- Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
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6
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Johansen T, Sørensen L, Kolskår KK, Strøm V, Wouda MF. Effectiveness of robot-assisted arm exercise on arm and hand function in stroke survivors - A systematic review and meta-analysis. J Rehabil Assist Technol Eng 2023; 10:20556683231183639. [PMID: 37426037 PMCID: PMC10327418 DOI: 10.1177/20556683231183639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
Objective: To examine the treatment effect of commercially available robotic-assisted devices, compared to traditional occupational- and physiotherapy on arm and hand function in persons with stroke. Methods: A systematic literature search was conducted in Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials up to January 2022. Randomized controlled trials (RCT's) involving persons with stroke of all ages and robot-assisted exercise as method for arm and hand function, compared to traditional therapy methods were included. Three authors performed the selection independently. The quality of evidence across studies was assessed using GRADE. Results: Eighteen RCT's were included in the study. A random effects meta-analysis showed a statistically significantly higher treatment effect in the robotic-assisted exercise group (p=<0.0001) compared to the traditional treatment group, with a total effect size of 0.44 (CI = 0.22-0.65). Heterogeneity was high, measured with I2 of 65%). Subgroup analyses showed no significant effects of the type of robotic device, treatment frequency or duration of intervention. Discussion and conclusion: Even though the analysis showed significant improvement in arm and hand function in favor of the robotic-assisted exercise group, the results in this systematic review should be interpreted with caution. This is due to high heterogeneity among the studies included and the presence of possible publication bias. Results of this study highlight the need for larger and more methodological robust RCT's, with a focus on reporting training intensity during robotic exercise.
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Affiliation(s)
- Truls Johansen
- Department of Research, Sunnaas Rehabilitation Hospital, Oslo, Norway
| | - Linda Sørensen
- Department of Research, Sunnaas Rehabilitation Hospital, Oslo, Norway
- Department of Innovation, Sunnaas Rehabilitation Hospital, Oslo, Norway
| | - Knut K Kolskår
- Department of Research, Sunnaas Rehabilitation Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Vegard Strøm
- Department of Research, Sunnaas Rehabilitation Hospital, Oslo, Norway
| | - Matthijs F Wouda
- Department of Research, Sunnaas Rehabilitation Hospital, Oslo, Norway
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7
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Biomarkers for rhythmic and discrete dynamic primitives in locomotion. Sci Rep 2022; 12:20165. [PMID: 36424422 PMCID: PMC9691711 DOI: 10.1038/s41598-022-24565-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022] Open
Abstract
Rehabilitation can promote brain plasticity and improve motor control after central nervous system injuries. Our working model is that motor control is encoded using dynamic primitives: submovements, oscillations, and mechanical impedances. We hypothesize that therapies focusing on these primitives can achieve greater motor recovery. At the observational level, these primitives lead to discrete and rhythmic movements. Here, we propose two novel biomarkers to evaluate rhythmic and discrete movements in gait based on the feet forward position: the smoothness of their relative position, using the mean-squared jerk ratio (MSJR), to assess rhythmicity; and the angle between principal components of consecutive trajectories (dPCA), to detect discrete movements amidst rhythmic motion. We applied these methods to kinematic data collected with healthy individuals during experiments employing the MIT-Skywalker: level-ground walking at five speeds, with and without imposed ankle stiffness; walking at constant speed on ascending, descending, and laterally tilted slopes; and performing sidesteps. We found a decrease in MSJR as speed increases, related to increased rhythmicity, even with imposed stiffness. Rhythmicity seems unaffected by the terrain perturbations imposed. Finally, dPCA successfully detects sidesteps, discrete events amidst rhythmic movement. These biomarkers appear to accurately assess rhythmic and discrete movements during walking and can potentially improve clinical evaluation and rehabilitation of neurological patients.
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8
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Zhi JF, Liao QH, He YB, Xu WW, Zhu DW, Shao LH. Superior treatment efficacy of neuromodulation rehabilitation for upper limb recovery after stroke: a meta-analysis. Expert Rev Neurother 2022; 22:875-888. [PMID: 36242781 DOI: 10.1080/14737175.2022.2137405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Jian-Feng Zhi
- Department of Rehabilitation Medicine, the First People's Hospital of Jiashan/Jiashan Branch of the Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Qing-Hong Liao
- Department of Rehabilitation Medicine, the First People's Hospital of Jiashan/Jiashan Branch of the Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Yu-Bo He
- Department of Rehabilitation Medicine, the First People's Hospital of Jiashan/Jiashan Branch of the Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Wen-Wen Xu
- Department of Rehabilitation Medicine, the First People's Hospital of Jiashan/Jiashan Branch of the Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Dan-Wei Zhu
- Department of Rehabilitation Medicine, the First People's Hospital of Jiashan/Jiashan Branch of the Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Lin-Hong Shao
- Department of Rehabilitation Medicine, the First People's Hospital of Jiashan/Jiashan Branch of the Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
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9
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Qin Y, Li M, Li Y, Lu Y, Shi X, Cui G, Zhao H, Yang K. Brain-computer interface training for motor recovery after stroke. Hippokratia 2022. [DOI: 10.1002/14651858.cd015065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yu Qin
- Evidence-Based Medicine Center, School of Basic Medical Sciences; Lanzhou University; Lanzhou China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province; Lanzhou University; Lanzhou China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences; Lanzhou University; Lanzhou China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province; Lanzhou University; Lanzhou China
| | - Yanfei Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences; Lanzhou University; Lanzhou China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province; Lanzhou University; Lanzhou China
| | - Yaqin Lu
- Department of Rehabilitation Medicine; Gansu Province Central Hospital; Lanzhou China
| | - Xiue Shi
- Shaanxi Kangfu Hospital; Xi'an China
| | - Gecheng Cui
- Evidence Based Social Science Research Center, School of Public Health; Lanzhou University; Lanzhou China
| | - Haitong Zhao
- Evidence Based Social Science Research Center, School of Public Health; Lanzhou University; Lanzhou China
| | - KeHu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences; Lanzhou University; Lanzhou China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province; Lanzhou University; Lanzhou China
- Evidence Based Social Science Research Center, School of Public Health; Lanzhou University; Lanzhou China
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10
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Dimyan MA, Harcum S, Ermer E, Boos AF, Conroy SS, Liu F, Horn LB, Xu H, Zhan M, Chen H, Whitall J, Wittenberg GF. Baseline Predictors of Response to Repetitive Task Practice in Chronic Stroke. Neurorehabil Neural Repair 2022; 36:426-436. [PMID: 35616437 DOI: 10.1177/15459683221095171] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Repetitive task practice reduces mean upper extremity motor impairment in populations of patients with chronic stroke, but individual response is highly variable. A method to predict meaningful reduction in impairment in response to training based on biomarkers and other data collected prior to an intervention is needed to establish realistic rehabilitation goals and to effectively allocate resources. OBJECTIVES To identify prognostic factors and better understand the biological substrate for reductions in arm impairment in response to repetitive task practice among patients with chronic (≥6 months) post-stroke hemiparesis. METHODS The intervention is a form of repetitive task practice using a combination of robot-assisted therapy and functional arm use in real-world tasks. Baseline measures include the Fugl-Meyer Assessment, Wolf Motor Function Test, Action Research Arm Test, Stroke Impact Scale, questionnaires on pain and expectancy, MRI, transcranial magnetic stimulation, kinematics, accelerometry, and genomic testing. RESULTS Mean increase in FM-UE was 4.6 ± 1.0 SE, median 2.5. Approximately one-third of participants had a clinically meaningful response to the intervention, defined as an increase in FM ≥ 5. The selected logistic regression model had a receiver operating curve with AUC = .988 (Std Error = .011, 95% Wald confidence limits: .967-1) showed little evidence of overfitting. Six variables that predicted response represented impairment, functional, and genomic measures. CONCLUSION A simple weighted sum of 6 baseline factors can accurately predict clinically meaningful impairment reduction after outpatient intensive practice intervention in chronic stroke. Reduction of impairment may be a critical first step to functional improvement. Further validation and generalization of this model will increase its utility in clinical decision-making.
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Affiliation(s)
- Michael A Dimyan
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, MD, USA.,Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.,Geriatrics Research, Education and Clinical Center and Maryland Exercise and Robotics Center of Excellence, Veterans Affairs Medical Center, Older Americans Independence Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stacey Harcum
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Elsa Ermer
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, MD, USA.,Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amy F Boos
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Susan S Conroy
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Fang Liu
- Rehab & Neural Engineering Labs, Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linda B Horn
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Huichun Xu
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Min Zhan
- Department of Epidemiology and Preventative Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hegang Chen
- Department of Epidemiology and Preventative Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jill Whitall
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - George F Wittenberg
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, MD, USA.,Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.,Geriatrics Research, Education and Clinical Center and Maryland Exercise and Robotics Center of Excellence, Veterans Affairs Medical Center, Older Americans Independence Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA.,Geriatrics Research, Education and Clinical Center, Human Engineering Research Laboratory, VA Maryland Health Care System, Pittsburgh, PA, USA
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11
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Liu Y, Guo S, Yang Z, Hirata H, Tamiya T. A Home-based Tele-rehabilitation System with Enhanced Therapist-patient Remote Interaction: A Feasibility Study. IEEE J Biomed Health Inform 2022; 26:4176-4186. [PMID: 35594225 DOI: 10.1109/jbhi.2022.3176276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
As a promising alternative to hospital-based manual therapy, robot-assisted tele-rehabilitation therapy has shown significant benefits in reducing the therapist's workload and accelerating the patient's recovery process. However, existing telerobotic systems for rehabilitation face barriers to implementing appropriate therapy treatment due to the lack of effective therapist-patient interactive capabilities. In this paper, we develop a home-based tele-rehabilitation system that implements two alternative training methods, including a haptic-enabled guided training that allows the therapist to adjust the intensity of therapeutic movements provided by the rehabilitation device and a surface electromyography (sEMG)-based supervised training that explores remote assessment of the patient's kinesthetic awareness. Preliminary experiments were conducted to demonstrate the feasibility of the proposed alternative training methods and evaluate the functionality of the developed tele-rehabilitation system. Results showed that the proposed tele-rehabilitation system enabled therapist-in-the-loop to dynamically adjust the rehabilitation intensity and provided more interactivity in therapist-patient remote interaction.
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12
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Caimmi M, Giovanzana C, Gasperini G, Molteni F, Molinari Tosatti L. Robot Fully Assisted Upper-Limb Functional Movements Against Gravity to Drive Recovery in Chronic Stroke: A Pilot Study. Front Neurol 2022; 12:782094. [PMID: 35350582 PMCID: PMC8957862 DOI: 10.3389/fneur.2021.782094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022] Open
Abstract
Background Stroke is becoming more and more a disease of chronically disabled patients, and new approaches are needed for better outcomes. An intervention based on robot fully assisted upper-limb functional movements is presented. Objectives To test the immediate and sustained effects of the intervention in reducing impairment in chronic stroke and to preliminarily verify the effects on activity. Methodology Nineteen patients with mild-to-severe impairment underwent 12 40-min rehabilitation sessions, 3 per week, of robot-assisted reaching and hand-to-mouth movements. The primary outcome measure was the Fugl-Meyer Assessment (FMA) at T1, immediately after treatment (n = 19), and at T2, at a 6-month follow-up (n = 10). A subgroup of 11 patients was also administered the Wolf Motor Function Test Time (WMFT TIME) and Functional Ability Scale (WMFT FAS) and Motor Activity Log (MAL) Amount Of Use (AOU), and Quality Of Movement (QOM). Results All patients were compliant with the treatment. There was improvement on the FMA with a mean difference with respect to the baseline of 6.2 points at T1, after intervention (n = 19, 95% CI = 4.6–7.8, p < 0.0002), and 5.9 points at T2 (n = 10, 95% CI = 3.6–8.2, p < 0.005). Significant improvements were found at T1 on the WMFT FAS (n = 11, +0.3/5 points, 95% CI = 0.2–0.4, p < 0.004), on the MAL AOU (n = 11, +0.18/5, 95% CI = 0.07–0.29, p < 0.02), and the MAL QOM (n = 11, +0.14/5, 95% CI = 0.08–0.20, p < 0.02). Conclusions Motor benefits were observed immediately after intervention and at a 6-month follow-up. Reduced impairment would appear to translate to increased activity. Although preliminary, the results are encouraging and lay the foundation for future studies to confirm the findings and define the optimal dose-response curve. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT03208634.
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Affiliation(s)
- Marco Caimmi
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council of Italy, Milan, Italy
| | - Chiara Giovanzana
- Villa Beretta Rehabilitation Centre, Valduce Hospital, Costa Masnaga, Italy
| | - Giulio Gasperini
- Villa Beretta Rehabilitation Centre, Valduce Hospital, Costa Masnaga, Italy
| | - Franco Molteni
- Villa Beretta Rehabilitation Centre, Valduce Hospital, Costa Masnaga, Italy
| | - Lorenzo Molinari Tosatti
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council of Italy, Milan, Italy
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13
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Huber SK, Knols RH, Arnet P, de Bruin ED. Motor-cognitive intervention concepts can improve gait in chronic stroke, but their effect on cognitive functions is unclear: A systematic review with meta-analyses. Neurosci Biobehav Rev 2021; 132:818-837. [PMID: 34815131 DOI: 10.1016/j.neubiorev.2021.11.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 11/30/2022]
Abstract
Motor-cognitive intervention concepts are promising to counteract residual gait and cognitive impairments in chronic stroke. There is, however, considerable variation in motor-cognitive intervention types, which may lead to different effects. This systematic review strived to summarize and compare the effects of different motor-cognitive intervention concepts on gait and cognitive functions in chronic stroke. The systematic search identified twenty-nine articles, which were allocated to three types of motor-cognitive training concepts; SEQUENTIAL, SIMULTANEOUS-ADDITIONAL, and SIMULTANEOUS-INCORPORATED. Random-effects meta-analyses revealed that motor-cognitive interventions may be better than non-combined training approaches for improving gait function in chronic stroke (e.g. gait speed: g = 0.43, 95 % CI [0.22, 0.64], p < 0.0001). SIMULTANEOUS-INCORPORATED motor-cognitive training seems the most promising concept. As very few articles measured both, spatiotemporal gait parameters and cognitive outcomes, future studies are warranted to investigate the effects of motor-cognitive intervention concepts on gait control and cognitive functions in chronic stroke.
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Affiliation(s)
- Simone K Huber
- Physiotherapy and Occupational Therapy Research Center, Directorate of Research and Education, University Hospital Zurich, Zurich, Switzerland; Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland.
| | - Ruud H Knols
- Physiotherapy and Occupational Therapy Research Center, Directorate of Research and Education, University Hospital Zurich, Zurich, Switzerland; Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland; Physiotherapy Occupational Therapy, Nursing and Allied Health Professions Office, University Hospital Zurich, Zurich, Switzerland
| | - Patrick Arnet
- Physiotherapy and Occupational Therapy Research Center, Directorate of Research and Education, University Hospital Zurich, Zurich, Switzerland; Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Eling D de Bruin
- Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland; Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; OST - Eastern Swiss University of Applied Sciences, Department of Health, St.Gallen, Switzerland
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14
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Clark B, Whitall J, Kwakkel G, Mehrholz J, Ewings S, Burridge J. The effect of time spent in rehabilitation on activity limitation and impairment after stroke. Cochrane Database Syst Rev 2021; 10:CD012612. [PMID: 34695300 PMCID: PMC8545241 DOI: 10.1002/14651858.cd012612.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation. OBJECTIVES To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation. SEARCH METHODS We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs. MAIN RESULTS The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants. Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06). AUTHORS' CONCLUSIONS An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.
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Affiliation(s)
- Beth Clark
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jill Whitall
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, Maryland, USA
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences and Amsterdam, Amsterdam Neurosciences, VU University Medical Center, Amsterdam, Netherlands
| | - Jan Mehrholz
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
| | - Sean Ewings
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Jane Burridge
- Research Group, Faculty of Health Sciences, University of Southampton, Southampton, UK
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15
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Baldan F, Turolla A, Rimini D, Pregnolato G, Maistrello L, Agostini M, Jakob I. Robot-assisted rehabilitation of hand function after stroke: Development of prediction models for reference to therapy. J Electromyogr Kinesiol 2021; 57:102534. [PMID: 33618325 DOI: 10.1016/j.jelekin.2021.102534] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 02/05/2021] [Accepted: 02/11/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Recovery of hand function after stroke represents the hardest target for clinicians. Robot-assisted therapy has been proved to be effective for hand recovery. Nevertheless, studies aimed to refer patients to the best therapy are missing. METHODS With the aim to identify which clinical features are predictive for referring to robot-assisted hand therapy, 174 stroke patients were assessed with: Fugl-Meyer Assessment (FMA), Functional Independence Measure (FIM), Reaching Performance Scale (RPS), Box and Block Test (BBT), Modified Ashworth Scale (MAS), Nine Hole Pegboard Test (NHPT). Moreover, patients ability to control the robot with residual force and surface EMG (sEMG) independently, was checked. ROC curves were calculated to determine which of the measures were the predictors of the event. RESULTS sEMG control (AUC = 0.925) was significantly determined by FMA upper extremity (FMUE) (>24/66) and sensation (>23/24) sections, MAS at Flexor Carpi (<3/4) and total MAS (>4/20). Force control (AUC = 0.928) was correlated only with FMUE (>24/66). CONCLUSIONS FMUE and MAS were the best predictors of preserved ability to control the device by two different modalities. This finding opens the possibility to plan specific therapies aimed at maximizing the highest functional outcome achievable after stroke.
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Affiliation(s)
- Francesca Baldan
- Laboratory of Rehabilitation Technologies, IRCCS San Camillo Hospital, Venice, Italy.
| | - Andrea Turolla
- Laboratory of Rehabilitation Technologies, IRCCS San Camillo Hospital, Venice, Italy
| | - Daniele Rimini
- Medical Physics Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Giorgia Pregnolato
- Laboratory of Rehabilitation Technologies, IRCCS San Camillo Hospital, Venice, Italy
| | - Lorenza Maistrello
- Laboratory of Rehabilitation Technologies, IRCCS San Camillo Hospital, Venice, Italy
| | - Michela Agostini
- Laboratory of Rehabilitation Technologies, IRCCS San Camillo Hospital, Venice, Italy
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16
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Merians AS, Fluet GG, Qiu Q, Yarossi M, Patel J, Mont AJ, Saleh S, Nolan KJ, Barrett AM, Tunik E, Adamovich SV. Hand Focused Upper Extremity Rehabilitation in the Subacute Phase Post-stroke Using Interactive Virtual Environments. Front Neurol 2020; 11:573642. [PMID: 33324323 PMCID: PMC7726202 DOI: 10.3389/fneur.2020.573642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/14/2020] [Indexed: 01/14/2023] Open
Abstract
Introduction: Innovative motor therapies have attempted to reduce upper extremity impairment after stroke but have not made substantial improvement as over 50% of people post-stroke continue to have sensorimotor deficits affecting their self-care and participation in daily activities. Intervention studies have focused on the role of increased dosing, however recent studies have indicated that timing of rehabilitation interventions may be as important as dosing and importantly, that dosing and timing interact in mediating effectiveness. This study is designed to empirically test dosing and timing. Methods and Analysis: In this single-blinded, interventional study, subjects will be stratified on two dimensions, impairment level (Fugl-Meyer Upper Extremity Assessment (FM) and presence or absence of Motor Evoked Potentials (MEPs) as follows; (1) Severe, FM score 10-19, MEP+, (2) Severe, FM score 10-19, MEP-, (3) Moderate, FM score 20-49, MEP+, (4) Moderate, FM score 20-49, MEP-. Subjects not eligible for TMS will be assigned to either group 2 (if severe) or group 3 (if moderate). Stratified block randomization will then be used to achieve a balanced assignment. Early Robotic/VR Therapy (EVR) experimental group will receive in-patient usual care therapy plus an extra 10 h of intensive upper extremity therapy focusing on the hand using robotically facilitated rehabilitation interventions presented in virtual environments and initiated 5-30 days post-stroke. Delayed Robotic/VR Therapy (DVR) experimental group will receive the same intervention but initiated 30-60 days post-stroke. Dose-matched usual care group (DMUC) will receive an extra 10 h of usual care initiated 5-30 days post-stroke. Usual Care Group (UC) will receive the usual amount of physical/occupational therapy. Outcomes: There are clinical, neurophysiological, and kinematic/kinetic measures, plus measures of daily arm use and quality of life. Primary outcome is the Action Research Arm Test (ARAT) measured at 4 months post-stroke. Discussion: Outcome measures will be assessed to determine whether there is an early time period in which rehabilitation will be most effective, and whether there is a difference in the recapture of premorbid patterns of movement vs. the development of an efficient, but compensatory movement strategy. Ethical Considerations: The IRBs of New Jersey Institute of Technology, Rutgers University, Northeastern University, and Kessler Foundation reviewed and approved all study protocols. Study was registered in https://ClinicalTrials.gov (NCT03569059) prior to recruitment. Dissemination will include submission to peer-reviewed journals and professional presentations.
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Affiliation(s)
- Alma S. Merians
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Gerard G. Fluet
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Qinyin Qiu
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Mathew Yarossi
- Movement Neuroscience Laboratory, Department of Physical Therapy, Movement and Rehabilitation Science, Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
- SPIRAL Group, Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, United States
| | - Jigna Patel
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Ashley J. Mont
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, United States
| | - Soha Saleh
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Karen J. Nolan
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - AM Barrett
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, United States
| | - Eugene Tunik
- Movement Neuroscience Laboratory, Department of Physical Therapy, Movement and Rehabilitation Science, Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
- Department of Bioengineering, College of Engineering, Northeastern University, Boston, MA, United States
- Department of Electrical and Computer Engineering, College of Engineering, Northeastern University, Boston, MA, United States
| | - Sergei V. Adamovich
- Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, United States
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17
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Dawson J, Engineer ND, Prudente CN, Pierce D, Francisco G, Yozbatiran N, Tarver WB, Casavant R, Kline DK, Cramer SC, Van de Winckel A, Kimberley TJ. Vagus Nerve Stimulation Paired With Upper-Limb Rehabilitation After Stroke: One-Year Follow-up. Neurorehabil Neural Repair 2020; 34:609-615. [DOI: 10.1177/1545968320924361] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background. Vagus nerve stimulation (VNS) paired with rehabilitation may improve upper-limb impairment and function after ischemic stroke. Objective. To report 1-year safety, feasibility, adherence, and outcome data from a home exercise program paired with VNS using long-term follow-up data from a randomized double-blind study of rehabilitation therapy paired with Active VNS (n = 8) or Control VNS (n = 9). Methods. All people were implanted with a VNS device and underwent 6 weeks in clinic therapy with Control or Active VNS followed by home exercises through day 90. Thereafter, participants and investigators were unblinded. The Control VNS group then received 6 weeks in-clinic Active VNS (Cross-VNS group). All participants then performed an individualized home exercise program with self-administered Active VNS. Data from this phase are reported here. Outcome measures were Fugl-Meyer Assessment—Upper Extremity (FMA-UE), Wolf Motor Function Test (Functional and Time), Box and Block Test, Nine-Hole Peg Test, Stroke Impact Scale, and Motor Activity Log. Results. There were no VNS treatment–related serious adverse events during the long-term therapy. Two participants discontinued prior to receiving the full crossover VNS. On average, participants performed 200 ± 63 home therapy sessions, representing device use on 57.4% of home exercise days available for each participant. Pooled analysis revealed that 1 year after randomization, the FMA-UE score increased by 9.2 points (95% CI = 4.7 to 13.7; P = .001; n = 15). Other functional measures were also improved at 1 year. Conclusions. VNS combined with rehabilitation is feasible, with good long-term adherence, and may improve arm function after ischemic stroke.
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Affiliation(s)
| | | | - Cecília N. Prudente
- MicroTransponder, Inc, Austin, TX, USA
- University of Minnesota, Minneapolis, MN, USA
| | | | - Gerard Francisco
- The University of Texas Health Science Center at Houston (UTHealth), TX, USA
| | - Nuray Yozbatiran
- The University of Texas Health Science Center at Houston (UTHealth), TX, USA
| | | | | | - Danielle K. Kline
- University of Minnesota, Minneapolis, MN, USA
- Massachusetts General Hospital, Boston MA, USA
| | - Steven C. Cramer
- University of California, Los Angeles, CA, USA
- California Rehabilitation Institute, Los Angeles, CA, USA
| | | | - Teresa J. Kimberley
- University of Minnesota, Minneapolis, MN, USA
- Massachusetts General Hospital, Boston MA, USA
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18
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Coscia M, Wessel MJ, Chaudary U, Millán JDR, Micera S, Guggisberg A, Vuadens P, Donoghue J, Birbaumer N, Hummel FC. Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke. Brain 2020; 142:2182-2197. [PMID: 31257411 PMCID: PMC6658861 DOI: 10.1093/brain/awz181] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/14/2019] [Accepted: 05/12/2019] [Indexed: 01/27/2023] Open
Abstract
Upper limb motor deficits in severe stroke survivors often remain unresolved over extended time periods. Novel neurotechnologies have the potential to significantly support upper limb motor restoration in severely impaired stroke individuals. Here, we review recent controlled clinical studies and reviews focusing on the mechanisms of action and effectiveness of single and combined technology-aided interventions for upper limb motor rehabilitation after stroke, including robotics, muscular electrical stimulation, brain stimulation and brain computer/machine interfaces. We aim at identifying possible guidance for the optimal use of these new technologies to enhance upper limb motor recovery especially in severe chronic stroke patients. We found that the current literature does not provide enough evidence to support strict guidelines, because of the variability of the procedures for each intervention and of the heterogeneity of the stroke population. The present results confirm that neurotechnology-aided upper limb rehabilitation is promising for severe chronic stroke patients, but the combination of interventions often lacks understanding of single intervention mechanisms of action, which may not reflect the summation of single intervention’s effectiveness. Stroke rehabilitation is a long and complex process, and one single intervention administrated in a short time interval cannot have a large impact for motor recovery, especially in severely impaired patients. To design personalized interventions combining or proposing different interventions in sequence, it is necessary to have an excellent understanding of the mechanisms determining the effectiveness of a single treatment in this heterogeneous population of stroke patients. We encourage the identification of objective biomarkers for stroke recovery for patients’ stratification and to tailor treatments. Furthermore, the advantage of longitudinal personalized trial designs compared to classical double-blind placebo-controlled clinical trials as the basis for precise personalized stroke rehabilitation medicine is discussed. Finally, we also promote the necessary conceptual change from ‘one-suits-all’ treatments within in-patient clinical rehabilitation set-ups towards personalized home-based treatment strategies, by adopting novel technologies merging rehabilitation and motor assistance, including implantable ones.
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Affiliation(s)
- Martina Coscia
- Wyss Center for Bio and Neuroengineering, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - Maximilian J Wessel
- Defitech Chair in Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), School of Life Sciences, Swiss Federal Institute of Technology (EPFL), 1202 Geneva, Switzerland.,Defitech Chair in Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), School of Life Sciences, Swiss Federal Institute of Technology (EPFL Valais), Clinique Romande de Réadaptation, 1951 Sion, Switzerland
| | - Ujwal Chaudary
- Wyss Center for Bio and Neuroengineering, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - José Del R Millán
- Defitech Chair in Brain-Machine Interface, Center for Neuroprosthetics, School of Engineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, 1015, Switzerland
| | - Silvestro Micera
- Bertarelli Foundation Chair in Translational Neuroengineering, Center for Neuroprosthetics and Institute of Bioengineering, School of Engineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, 1015, Switzerland.,Translational Neural Engineering Area, The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, 56025, Italy
| | - Adrian Guggisberg
- Clinical Neuroscience, University of Geneva Medical School, 1202 Geneva, Switzerland
| | | | - John Donoghue
- Wyss Center for Bio and Neuroengineering, Chemin des Mines 9, 1202 Geneva, Switzerland.,Department of Neuroscience, Brown University, Providence, RI 02906, USA
| | - Niels Birbaumer
- Wyss Center for Bio and Neuroengineering, Chemin des Mines 9, 1202 Geneva, Switzerland.,Institute of Medical Psychology and Behavioral Neurobiology, University Tuebingen, Germany
| | - Friedhelm C Hummel
- Defitech Chair in Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), School of Life Sciences, Swiss Federal Institute of Technology (EPFL), 1202 Geneva, Switzerland.,Defitech Chair in Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), School of Life Sciences, Swiss Federal Institute of Technology (EPFL Valais), Clinique Romande de Réadaptation, 1951 Sion, Switzerland.,Clinical Neuroscience, University of Geneva Medical School, 1202 Geneva, Switzerland
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19
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Karamians R, Proffitt R, Kline D, Gauthier LV. Effectiveness of Virtual Reality- and Gaming-Based Interventions for Upper Extremity Rehabilitation Poststroke: A Meta-analysis. Arch Phys Med Rehabil 2020; 101:885-896. [DOI: 10.1016/j.apmr.2019.10.195] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 12/14/2022]
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20
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Harcum S, Conroy SS, Boos A, Ermer E, Xu H, Zhan M, Chen H, Whitall J, Dimyan MA, Wittenberg GF. Methods for an Investigation of Neurophysiological and Kinematic Predictors of Response to Upper Extremity Repetitive Task Practice in Chronic Stroke. Arch Rehabil Res Clin Transl 2019; 1. [PMID: 32292910 PMCID: PMC7155389 DOI: 10.1016/j.arrct.2019.100024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective To demonstrate the feasibility of algorithmic prediction using a model of baseline arm movement, genetic factors, demographic characteristics, and multimodal assessment of the structure and function of motor pathways. To identify prognostic factors and the biological substrate for reductions in arm impairment in response to repetitive task practice. Design This prospective single-group interventional study seeks to predict response to a repetitive task practice program using an intent-to-treat paradigm. Response is measured as a change of ≥5 points on the Upper Extremity Fugl-Meyer from baseline to final evaluation (at the end of training). Setting General community. Participants Anticipated enrollment of community-dwelling adults with chronic stroke (N = 96; onset≥6mo) and moderate to severe residual hemiparesis of the upper limb as defined by a score of 10-45 points on the Upper Extremity Fugl-Meyer. Intervention The intervention is a form of repetitive task practice using a combination of robot-assisted therapy coupled with functional arm use in real-world tasks administered over 12 weeks. Main Outcome Measures Upper Extremity Fugl-Meyer Assessment (primary outcome), Wolf Motor Function Test, Action Research Arm Test, Stroke Impact Scale, questionnaires on pain and expectancy, magnetic resonance imaging, transcranial magnetic stimulation, arm kinematics, accelerometry, and a saliva sample for genetic testing. Results Methods for this trial are outlined, and an illustration of interindividual variability is provided by example of 2 participants who present similarly at baseline but achieve markedly different outcomes. Conclusion This article presents the design, methodology, and rationale of an ongoing study to develop a predictive model of response to a standardized therapy for stroke survivors with chronic hemiparesis. Applying concepts from precision medicine to neurorehabilitation is practicable and needed to establish realistic rehabilitation goals and to effectively allocate resources.
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Affiliation(s)
- Stacey Harcum
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, Maryland
| | - Susan S Conroy
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, Maryland
| | - Amy Boos
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elsa Ermer
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Huichun Xu
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Min Zhan
- Department of Epidemiology and Preventative Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hegang Chen
- Department of Epidemiology and Preventative Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jill Whitall
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, Maryland.,Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael A Dimyan
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, Maryland.,Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - George F Wittenberg
- VA Maryland Health Care System, Baltimore VA Medical Center, Baltimore, Maryland.,Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland.,VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Geriatrics Research, Education, and Clinical Center Et Maryland Exercise and Robotics Center of Excellence, Veterans Affairs Medical Center, Older Americans Independence Center, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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21
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Daly JJ, McCabe JP, Holcomb J, Monkiewicz M, Gansen J, Pundik S. Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke. Neurorehabil Neural Repair 2019; 33:523-537. [PMID: 31131743 PMCID: PMC6625035 DOI: 10.1177/1545968319846120] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background. Effective treatment methods are needed for moderate/severely impairment chronic stroke. Objective. The questions were the following: (1) Is there need for long-dose therapy or is there a mid-treatment plateau? (2) Are the observed gains from the prior-studied protocol retained after treatment? Methods. Single-blind, stratified/randomized design, with 3 applied technology treatment groups, combined with motor learning, for long-duration treatment (300 hours of treatment). Measures were Arm Motor Ability Test time and coordination-function (AMAT-T, AMAT-F, respectively), acquired pre-/posttreatment and 3-month follow-up (3moF/U); Fugl-Meyer (FM), acquired similarly with addition of mid-treatment. Findings. There was no group difference in treatment response (P ≥ .16), therefore data were combined for remaining analyses (n = 31; except for FM pre/mid/post, n = 36). Pre-to-Mid-treatment and Mid-to-Posttreatment gains of FM were statistically and clinically significant (P < .0001; 4.7 points and P < .001; 5.1 points, respectively), indicating no plateau at 150 hours and benefit of second half of treatment. From baseline to 3moF/U: (1) FM gains were twice the clinically significant benchmark, (2) AMAT-F gains were greater than clinically significant benchmark, and (3) there was statistically significant improvement in FM (P < .0001); AMAT-F (P < .0001); AMAT-T (P < .0001). These gains indicate retained clinically and statistically significant gains at 3moFU. From posttreatment to 3moF/U, gains on FM were maintained. There were statistically significant gains in AMAT-F (P = .0379) and AMAT-T P = .003.
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Affiliation(s)
- Janis J. Daly
- Malcom Randall Gainesville DVA Medical
Center, Gainesville, FL, USA
- College of Medicine, University of
Florida, Gainesville, FL, USA
| | | | | | | | - Jennifer Gansen
- Louis Stokes Cleveland VA Medical
Center, Cleveland, OH, USA
| | - Svetlana Pundik
- Louis Stokes Cleveland VA Medical
Center, Cleveland, OH, USA
- Case Western Reserve University School
of Medicine, Cleveland, OH, USA
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22
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Duret C, Grosmaire AG, Krebs HI. Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach. Front Neurol 2019; 10:412. [PMID: 31068898 PMCID: PMC6491567 DOI: 10.3389/fneur.2019.00412] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/04/2019] [Indexed: 01/15/2023] Open
Abstract
Robot-mediated therapy is an innovative form of rehabilitation that enables highly repetitive, intensive, adaptive, and quantifiable physical training. It has been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis. Multiple studies collated in a growing number of review articles showed the positive effects on motor impairment, less clearly on functional limitations. After describing the current status of robotic therapy after upper limb paresis due to stroke, this overview addresses basic principles related to robotic therapy applied to upper limb paresis. We demonstrate how this innovation is an evidence-based approach in that it meets both the improved clinical and more fundamental knowledge-base about regaining effective motor function after stroke and the need of more objective, flexible and controlled therapeutic paradigms.
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Affiliation(s)
- Christophe Duret
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, Boissise-Le-Roi, France.,Centre Hospitalier Sud Francilien, Neurologie, Corbeil-Essonnes, France
| | - Anne-Gaëlle Grosmaire
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, Boissise-Le-Roi, France
| | - Hermano Igo Krebs
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States.,Department of Neurology, University of Maryland, Baltimore, MD, United States.,Department of Physical Medicine and Rehabilitation, Fujita Health University, Nagoya, Japan.,Institute of Neuroscience, University of Newcastle, Newcastle upon Tyne, United Kingdom.,Department of Mechanical Sciences and Bioengineering, Osaka University, Osaka, Japan.,Wolfson School of Mechanical, Electrical, and Manufacturing Engineering, Loughborough University, Loughborough, United Kingdom
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23
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Hung CS, Hsieh YW, Wu CY, Chen YJ, Lin KC, Chen CL, Yao KG, Liu CT, Horng YS. Hybrid Rehabilitation Therapies on Upper-Limb Function and Goal Attainment in Chronic Stroke. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2019; 39:116-123. [PMID: 30834812 DOI: 10.1177/1539449218825438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined the treatment effects between unilateral hybrid therapy (UHT; unilateral robot-assisted therapy [RT] + modified constraint-induced movement therapy) and bilateral hybrid therapy (BHT; bilateral RT + bilateral arm training) compared with RT. Thirty patients with chronic stroke were randomized to UHT, BHT, or RT groups. Preliminary efficacy was assessed using the Fugl-Meyer Assessment (FMA), the Chedoke Arm and Hand Activity Inventory (CAHAI), and the goal attainment scaling (GAS). Possible adverse effects of abnormal muscle tone, pain, and fatigue were recorded. All groups showed large improvements in motor recovery and individual goals. Significant between-group differences were found on GAS favoring the hybrid groups but not on FMA and CAHAI. No adverse effects were reported. Hybrid therapies are safe and applicable interventions for chronic stroke and favorable for improving individual functional goals. Treatment effects on motor recovery and functional activity might be similar among the three groups.
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Affiliation(s)
| | - Yu-Wei Hsieh
- 2 Chang Gung University, Taoyuan.,3 Chang Gung Memorial Hospital, Linkou
| | - Ching-Yi Wu
- 2 Chang Gung University, Taoyuan.,3 Chang Gung Memorial Hospital, Linkou
| | | | - Keh-Chung Lin
- 5 National Taiwan University, Taipei.,6 National Taiwan University Hospital, Taipei
| | - Chia-Ling Chen
- 2 Chang Gung University, Taoyuan.,3 Chang Gung Memorial Hospital, Linkou
| | | | - Chien-Ting Liu
- 7 Taipei Tzu Chi Hospital, Taipei.,8 Tzu Chi University, Hualien
| | - Yi-Shiung Horng
- 7 Taipei Tzu Chi Hospital, Taipei.,8 Tzu Chi University, Hualien
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24
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Modular Design and Decentralized Control of the Recupera Exoskeleton for Stroke Rehabilitation. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9040626] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Robot-assisted therapy has become increasingly popular and useful in post-stroke neurorehabilitation. This paper presents an overview of the design and control of the dual-arm Recupera exoskeleton to provide intense therapist-guided as well as self training for sensorimotor rehabilitation of the upper body. The exoskeleton features a lightweight design, high level of modularity, decentralized computing, and various levels of safety implementation. Due to its modularity, the system can be used as a wheel-chair mounted system or as a full-body system. Both systems enable a wide range of therapies while efficiently grounding the weight of the system and without compromising the patient’s mobility. Furthermore, two rehabilitation therapies implemented on the exoskeleton system, namely teach & replay therapy and mirror therapy, are presented along with experimental results.
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25
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López-Larraz E, Sarasola-Sanz A, Irastorza-Landa N, Birbaumer N, Ramos-Murguialday A. Brain-machine interfaces for rehabilitation in stroke: A review. NeuroRehabilitation 2018; 43:77-97. [PMID: 30056435 DOI: 10.3233/nre-172394] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Motor paralysis after stroke has devastating consequences for the patients, families and caregivers. Although therapies have improved in the recent years, traditional rehabilitation still fails in patients with severe paralysis. Brain-machine interfaces (BMI) have emerged as a promising tool to guide motor rehabilitation interventions as they can be applied to patients with no residual movement. OBJECTIVE This paper reviews the efficiency of BMI technologies to facilitate neuroplasticity and motor recovery after stroke. METHODS We provide an overview of the existing rehabilitation therapies for stroke, the rationale behind the use of BMIs for motor rehabilitation, the current state of the art and the results achieved so far with BMI-based interventions, as well as the future perspectives of neural-machine interfaces. RESULTS Since the first pilot study by Buch and colleagues in 2008, several controlled clinical studies have been conducted, demonstrating the efficacy of BMIs to facilitate functional recovery in completely paralyzed stroke patients with noninvasive technologies such as the electroencephalogram (EEG). CONCLUSIONS Despite encouraging results, motor rehabilitation based on BMIs is still in a preliminary stage, and further improvements are required to boost its efficacy. Invasive and hybrid approaches are promising and might set the stage for the next generation of stroke rehabilitation therapies.
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Affiliation(s)
- E López-Larraz
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - A Sarasola-Sanz
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany.,International Max Planck Research School (IMPRS) for Cognitive and Systems Neuroscience, University of Tübingen, Tübingen, Germany.,Neurotechnology, Tecnalia Research & Innovation, San Sebastián, Spain
| | - N Irastorza-Landa
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany.,International Max Planck Research School (IMPRS) for Cognitive and Systems Neuroscience, University of Tübingen, Tübingen, Germany.,IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - N Birbaumer
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany.,Wyss Center for Bio and Neuro Engineering, Geneva, Switzerland
| | - A Ramos-Murguialday
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany.,Neurotechnology, Tecnalia Research & Innovation, San Sebastián, Spain
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26
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Gassert R, Dietz V. Rehabilitation robots for the treatment of sensorimotor deficits: a neurophysiological perspective. J Neuroeng Rehabil 2018; 15:46. [PMID: 29866106 PMCID: PMC5987585 DOI: 10.1186/s12984-018-0383-x] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/07/2018] [Indexed: 11/30/2022] Open
Abstract
The past decades have seen rapid and vast developments of robots for the rehabilitation of sensorimotor deficits after damage to the central nervous system (CNS). Many of these innovations were technology-driven, limiting their clinical application and impact. Yet, rehabilitation robots should be designed on the basis of neurophysiological insights underlying normal and impaired sensorimotor functions, which requires interdisciplinary collaboration and background knowledge. Recovery of sensorimotor function after CNS damage is based on the exploitation of neuroplasticity, with a focus on the rehabilitation of movements needed for self-independence. This requires a physiological limb muscle activation that can be achieved through functional arm/hand and leg movement exercises and the activation of appropriate peripheral receptors. Such considerations have already led to the development of innovative rehabilitation robots with advanced interaction control schemes and the use of integrated sensors to continuously monitor and adapt the support to the actual state of patients, but many challenges remain. For a positive impact on outcome of function, rehabilitation approaches should be based on neurophysiological and clinical insights, keeping in mind that recovery of function is limited. Consequently, the design of rehabilitation robots requires a combination of specialized engineering and neurophysiological knowledge. When appropriately applied, robot-assisted therapy can provide a number of advantages over conventional approaches, including a standardized training environment, adaptable support and the ability to increase therapy intensity and dose, while reducing the physical burden on therapists. Rehabilitation robots are thus an ideal means to complement conventional therapy in the clinic, and bear great potential for continued therapy and assistance at home using simpler devices. This review summarizes the evolution of the field of rehabilitation robotics, as well as the current state of clinical evidence. It highlights fundamental neurophysiological factors influencing the recovery of sensorimotor function after a stroke or spinal cord injury, and discusses their implications for the development of effective rehabilitation robots. It thus provides insights on essential neurophysiological mechanisms to be considered for a successful development and clinical inclusion of robots in rehabilitation.
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Affiliation(s)
- Roger Gassert
- Department of Health Sciences and Technology, ETH Zurich, 8092, Zurich, Switzerland.
| | - Volker Dietz
- Spinal Cord Injury Center, Balgrist University Hospital, 8008, Zurich, Switzerland
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27
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Li L, Hartigan J, Peduzzi P, Guarino P, Beed AT, Wu X, Wininger M. Clustering of Directions Improves Goodness of Fit in Kinematic Data Collected in the Transverse Plane During Robot-Assisted Rehabilitation of Stroke Patients. Front Robot AI 2018; 5:57. [PMID: 33500939 PMCID: PMC7805826 DOI: 10.3389/frobt.2018.00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/20/2018] [Indexed: 11/27/2022] Open
Abstract
The kinematic character of hand trajectory in reaching tasks varies by movement direction. Often, direction is not included as a factor in the analysis of data collected during multi-directional reach tasks; consequently, this directionally insensitive model (DI) may be prone to type-II error due to unexplained variance. On the other hand, directionally specific models (DS) that account separately for each movement direction, may reduce statistical power by increasing the amount of data groupings. We propose a clustered-by-similarity (CS) in which movement directions with similar kinematic features are grouped together, maximizing model fit by decreasing unexplained variance while also decreasing uninformative sub-groupings. We tested model quality in measuring change over time in 10 kinematic features extracted from 72 chronic stroke patients participating in the VA-ROBOTICS trial, performing a targeted reaching task over 16 movement directions (8 targets, back- and forth from center) in the horizontal plane. Across 49 participants surviving a quality control sieve, 4.3 ± 1.1 (min: 3; max: 7) clusters were found among the 16 movement directions; clusters varied between participants. Among 49 participants, and averaged across 10 features, the better-fitting model for predicting change in features was found to be CS assessed by the Akaike Information criterion (61.6 ± 7.3%), versus DS (31.0 ± 7.8%) and DI (7.1 ± 7.1%). Confirmatory analysis via Extra Sum of Squares F-test showed the DS and CS models out-performed the DI model in head-to-head (pairwise) comparison in >85% of all specimens. Thus, we find overwhelming evidence that it is necessary to adjust for direction in the models of multi-directional movements, and that clustering kinematic data by feature similarly may yield the optimal configuration for this co-variate.
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Affiliation(s)
- Ling Li
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, United States.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - John Hartigan
- Department of Statistics, Yale University, New Haven, CT, United States
| | - Peter Peduzzi
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, United States.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - Peter Guarino
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, United States.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States.,Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Alexander T Beed
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, United States.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - Xiaotian Wu
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, United States.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States.,Department of Biostatistics, Brown University, Providence, RI, United States
| | - Michael Wininger
- Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, United States.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States.,Department of Rehabilitation Sciences, University of Hartford, West Hartford, CT, United States
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28
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Beed AT, Peduzzi P, Guarino P, Wininger M. A Partitioning Algorithm for Extracting Movement Epochs from Robot-Derived Kinematic Data. Front Robot AI 2017. [DOI: 10.3389/frobt.2017.00057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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29
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Rowe JB, Chan V, Ingemanson ML, Cramer SC, Wolbrecht ET, Reinkensmeyer DJ. Robotic Assistance for Training Finger Movement Using a Hebbian Model: A Randomized Controlled Trial. Neurorehabil Neural Repair 2017; 31:769-780. [PMID: 28803535 PMCID: PMC5894506 DOI: 10.1177/1545968317721975] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Robots that physically assist movement are increasingly used in rehabilitation therapy after stroke, yet some studies suggest robotic assistance discourages effort and reduces motor learning. OBJECTIVE To determine the therapeutic effects of high and low levels of robotic assistance during finger training. METHODS We designed a protocol that varied the amount of robotic assistance while controlling the number, amplitude, and exerted effort of training movements. Participants (n = 30) with a chronic stroke and moderate hemiparesis (average Box and Blocks Test 32 ± 18 and upper extremity Fugl-Meyer score 46 ± 12) actively moved their index and middle fingers to targets to play a musical game similar to GuitarHero 3 h/wk for 3 weeks. The participants were randomized to receive high assistance (causing 82% success at hitting targets) or low assistance (55% success). Participants performed ~8000 movements during 9 training sessions. RESULTS Both groups improved significantly at the 1-month follow-up on functional and impairment-based motor outcomes, on depression scores, and on self-efficacy of hand function, with no difference between groups in the primary endpoint (change in Box and Blocks). High assistance boosted motivation, as well as secondary motor outcomes (Fugl-Meyer and Lateral Pinch Strength)-particularly for individuals with more severe finger motor deficits. Individuals with impaired finger proprioception at baseline benefited less from the training. CONCLUSIONS Robot-assisted training can promote key psychological outcomes known to modulate motor learning and retention. Furthermore, the therapeutic effectiveness of robotic assistance appears to derive at least in part from proprioceptive stimulation, consistent with a Hebbian plasticity model.
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Affiliation(s)
- Justin B Rowe
- 1 University of California at Irvine, Irvine, CA, USA
| | - Vicky Chan
- 1 University of California at Irvine, Irvine, CA, USA
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30
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Wittmann F, Held JP, Lambercy O, Starkey ML, Curt A, Höver R, Gassert R, Luft AR, Gonzenbach RR. Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system. J Neuroeng Rehabil 2016; 13:75. [PMID: 27515583 PMCID: PMC4982313 DOI: 10.1186/s12984-016-0182-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 07/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effect of rehabilitative training after stroke is dose-dependent. Out-patient rehabilitation training is often limited by transport logistics, financial resources and a lack of motivation/compliance. We studied the feasibility of an unsupervised arm therapy for self-directed rehabilitation therapy in patients' homes. METHODS An open-label, single group study involving eleven patients with hemiparesis due to stroke (27 ± 31.5 months post-stroke) was conducted. The patients trained with an inertial measurement unit (IMU)-based virtual reality system (ArmeoSenso) in their homes for six weeks. The self-selected dose of training with ArmeoSenso was the principal outcome measure whereas the Fugl-Meyer Assessment of the upper extremity (FMA-UE), the Wolf Motor Function Test (WMFT) and IMU-derived kinematic metrics were used to assess arm function, training intensity and trunk movement. Repeated measures one-way ANOVAs were used to assess differences in training duration and clinical scores over time. RESULTS All subjects were able to use the system independently in their homes and no safety issues were reported. Patients trained on 26.5 ± 11.5 days out of 42 days for a duration of 137 ± 120 min per week. The weekly training duration did not change over the course of six weeks (p = 0.146). The arm function of these patients improved significantly by 4.1 points (p = 0.003) in the FMA-UE. Changes in the WMFT were not significant (p = 0.552). ArmeoSenso based metrics showed an improvement in arm function, a high number of reaching movements (387 per session), and minimal compensatory movements of the trunk while training. CONCLUSIONS Self-directed home therapy with an IMU-based home therapy system is safe and can provide a high dose of rehabilitative therapy. The assessments integrated into the system allow daily therapy monitoring, difficulty adaptation and detection of maladaptive motor patterns such as trunk movements during reaching. TRIAL REGISTRATION Unique identifier: NCT02098135 .
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Affiliation(s)
- Frieder Wittmann
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Jeremia P Held
- Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich, Zurich, Switzerland.
| | - Olivier Lambercy
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Michelle L Starkey
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Roger Gassert
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Andreas R Luft
- Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich, Zurich, Switzerland.,Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Roman R Gonzenbach
- Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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31
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Kim JH. Brain-machine Interface in Robot-assisted Neurorehabilitation for Patients with Stroke and Upper Extremity Weakness – the Therapeutic Turning Point. BRAIN & NEUROREHABILITATION 2016. [DOI: 10.12786/bn.2016.9.e5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jung Hwan Kim
- Rehabilitation Hospital and Research Institute, National Rehabilitation Center, Seoul, Korea
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