Effects of task-oriented robot training on arm function, activity, and quality of life in chronic stroke patients: a randomized controlled trial

Robotic task specific training for upper limb neurorehabilitation: a mixed methods feasibility trial reporting achievable dose

PURPOSE

Robotic devices for upper-limb neurorehabilitation allow an increase in intensity of practice, often relying on video game-based training strategies with limited capacity to individualise training and integrate functional training. This study shows the development of a robotic Task Specific Training (TST) protocol and evaluate the achieved dose.

MATERIALS AND METHODS

Mixed-method study. A 3D robotic device for the upper limb, was made available to therapists for use during neurorehabilitation sessions. A first phase allowed clinicians to define a dedicated session protocol for TST. In a second phase the protocol was applied and the achieved dose was measured.

RESULTS

First phase (N = 5): a specific protocol, using deweighting for assessment, followed by customised passive movements and then active movement practice was developed. Second phase: the protocol was successfully applied with all participants (N = 10). Intervention duration: 4.5 ± 0.8 weeks, session frequency: 1.4 ± 0.2sessions/week, session length: 42 ± 9mins, session density: 39 ± 13%, intensity: 214 ± 84 movements/session, difficulty: dn = 0.77 ± 0.1 (normalised reaching distance) and Ɵ = 6.3 ± 23° (transverse reaching angle). Sessions' density and intensity were consistent across participants but clear differences of difficulty were observed. No changes in metrics were observed over the intervention.

CONCLUSIONS

Robotic systems can support TST with high therapy intensity by modulating the practice difficulty to participants' needs and capabilities.

Effect of task-oriented training assisted by force feedback hand rehabilitation robot on finger grasping function in stroke patients with hemiplegia: a randomised controlled trial

BACKGROUND

Over 80% of patients with stroke experience finger grasping dysfunction, affecting independence in activities of daily living and quality of life. In routine training, task-oriented training is usually used for functional hand training, which may improve finger grasping performance after stroke, while augmented therapy may lead to a better treatment outcome. As a new technology-supported training, the hand rehabilitation robot provides opportunities to improve the therapeutic effect by increasing the training intensity. However, most hand rehabilitation robots commonly applied in clinics are based on a passive training mode and lack the sensory feedback function of fingers, which is not conducive to patients completing more accurate grasping movements. A force feedback hand rehabilitation robot can compensate for these defects. However, its clinical efficacy in patients with stroke remains unknown. This study aimed to investigate the effectiveness and added value of a force feedback hand rehabilitation robot combined with task-oriented training in stroke patients with hemiplegia.

METHODS

In this single-blinded randomised controlled trial, 44 stroke patients with hemiplegia were randomly divided into experimental (n = 22) and control (n = 22) groups. Both groups received 40 min/day of conventional upper limb rehabilitation training. The experimental group received 20 min/day of task-oriented training assisted by a force feedback rehabilitation robot, and the control group received 20 min/day of task-oriented training assisted by therapists. Training was provided for 4 weeks, 5 times/week. The Fugl-Meyer motor function assessment of the hand part (FMA-Hand), Action Research Arm Test (ARAT), grip strength, Modified Ashworth scale (MAS), range of motion (ROM), Brunnstrom recovery stages of the hand (BRS-H), and Barthel index (BI) were used to evaluate the effect of two groups before and after treatment.

RESULTS

Intra-group comparison: In both groups, the FMA-Hand, ARAT, grip strength, AROM, BRS-H, and BI scores after 4 weeks of treatment were significantly higher than those before treatment (p < 0.05), whereas there was no significant difference in finger flexor MAS scores before and after treatment (p > 0.05). Inter-group comparison: After 4 weeks of treatment, the experimental group's FMA-Hand total score, ARAT, grip strength, and AROM were significantly better than those of the control group (p < 0.05). However, there were no statistically significant differences in the scores of each sub-item of the FMA-Hand after Bonferroni correction (p > 0.007). In addition, there were no statistically significant differences in MAS, BRS-H, and BI scores (p > 0.05).

CONCLUSION

Hand performance improved in patients with stroke after 4 weeks of task-oriented training. The use of a force feedback hand rehabilitation robot to support task-oriented training showed additional value over conventional task-oriented training in stroke patients with hand dysfunction.

CLINICAL TRIAL REGISTRATION INFORMATION

NCT05841108.

Technological Advances in Stroke Rehabilitation: Robotics and Virtual Reality

Robotic technology and virtual reality (VR) have been widely studied technologies in stroke rehabilitation over the last few decades. Both technologies have typically been considered as ways to enhance recovery through promoting intensive, repetitive, and engaging therapies. In this review, we present the current evidence from interventional clinical trials that employ either robotics, VR, or a combination of both modalities to facilitate post-stroke recovery. Broadly speaking, both technologies have demonstrated some success in improving post-stroke outcomes and complementing conventional therapy. However, more high-quality, randomized, multicenter trials are required to confirm our current understanding of their role in precision stroke recovery.

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

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

Effectiveness of task-specific training using assistive devices and task-specific usual care on upper limb performance after stroke: a systematic review and meta-analysis

PURPOSE

Task-specific rehabilitation is a key indicator for successful rehabilitation to improve the upper limb performance after stroke. Assistive robotic and non-robotic devices are emerging to provide rehabilitation therapy; however, the effectiveness of task-specific training programs using assistive training devices compared with task-specific usual care training has not been summarized yet. Therefore, the effectiveness of task-specific training using assistive arm devices (TST-AAD) compared with task-specific usual care (TSUC) on the upper limb performance of patients with a stroke was investigated. To assess task specificity, a set of criteria was proposed: participation, program, relevant, repeated, randomized, reconstruction and reinforced.

MATERIALS AND METHODS

Out of 855 articles, 17 fulfilled the selection criteria. A meta-analysis was performed on the Fugl-Meyer Assessment scores in the subacute and chronic stages after stroke and during follow-up.

RESULTS AND CONCLUSION

Both TST-AAD and TSUC improved the upper limb performance after stroke. In the sub-acute phase after stroke, TST-AAD was more effective than TSUC in reducing the upper limb impairment, although findings were based on only three studies. In the chronic phase, TST-AAD and TSUC showed similar effectiveness. No differences between the two types of training were found at the follow-up measurements. Future studies should describe training, device usage and criteria of task specificity in a standardized way to ease comparison.Implications for rehabilitationArm or hand function is often undertreated in stroke patients, assistive training devices may be able to improve the upper limb performance.Task-specific training using assistive devices is effective in improving the upper limb performance after stroke.Task-specific training using assistive devices seems to be more effective in reducing impairment compared with task specific usual care in the subacute phase after stroke, but they are equally effective in the chronic phase of stroke.

Care robot research and development plan for disability and aged care in Korea: A mixed-methods user participation study

The population of Korea is aging rapidly, and this has led to a care burden for caregivers. Without adequate caregivers to address the increased burden, people with significant disabilities and older adults with disabilities who have greatly reduced mobility are at risk. The aim of this study was to determine suitable types of care robots for care applications in Korea and formulate a strategy for a future care robot R&D plan through a user participation study. We categorized nine types of care robots that are suitable for the care needs in Korea. By adopting a mixed research methodology involving user participation, we conducted discussions with caregivers, care receivers, and other stakeholders under a public-private-people partnership model. We also identified five primary strategies for care robot R&D: (1) intensive investment to match the needs of people with very severe disabilities to care robot technologies, particularly for transfer, repositioning, toileting, and feeding; (2) translational research and technology development; (3) realization of smart-care through fourth industrial revolution (i.e., digital) technologies; (4) user-centered research with stakeholders; and (5) building of a care robot ecosystem. The formulated plan would be shared with other developers and clinical experts to drive development of suitable care robots.

Combining robot-assisted therapy with virtual reality or using it alone? A systematic review on health-related quality of life in neurological patients

BACKGROUND

In the field of neurorehabilitation, robot-assisted therapy (RAT) and virtual reality (VR) have so far shown promising evidence on multiple motor and functional outcomes. The related effectiveness on patients' health-related quality of life (HRQoL) has been investigated across neurological populations but still remains unclear. The present study aimed to systematically review the studies investigating the effects of RAT alone and with VR on HRQoL in patients with different neurological diseases.

METHODS

A systematic review of the studies evaluating the impact of RAT alone and combined with VR on HRQoL in patients affected by neurological diseases (i.e., stroke, multiple sclerosis, spinal cord injury, Parkinson's Disease) was conducted according to PRISMA guidelines. Electronic searches of PubMed, Web of Science, Cochrane Library, CINAHL, Embase, and PsychINFO (2000-2022) were performed. Risk of bias was evaluated through the National Institute of Health Quality Assessment Tool. Descriptive data regarding the study design, participants, intervention, rehabilitation outcomes, robotic device typology, HRQoL measures, non-motor factors concurrently investigated, and main results were extracted and meta-synthetized.

RESULTS

The searches identified 3025 studies, of which 70 met the inclusion criteria. An overall heterogeneous configuration was found regarding the study design adopted, intervention procedures and technological devices implemented, rehabilitation outcomes (i.e., related to both upper and lower limb impairment), HRQoL measures administered, and main evidence. Most of the studies reported significant effects of both RAT and RAT plus VR on patients HRQoL, whether they adopted generic or disease-specific HRQoL measures. Significant post-intervention within-group changes were mainly found across neurological populations, while fewer studies reported significant between-group comparisons, and then, mostly in patients with stroke. Longitudinal investigations were also observed (up to 36 months), but significant longitudinal effects were exclusively found in patients with stroke or multiple sclerosis. Finally, concurrent evaluations on non-motor outcomes beside HRQoL included cognitive (i.e., memory, attention, executive functions) and psychological (i.e., mood, satisfaction with the treatment, device usability, fear of falling, motivation, self-efficacy, coping, and well-being) variables.

CONCLUSIONS

Despite the heterogeneity observed among the studies included, promising evidence was found on the effectiveness of RAT and RAT plus VR on HRQoL. However, further targeted short- and long-term investigations, are strongly recommended for specific HRQoL subcomponents and neurological populations, through the adoption of defined intervention procedures and disease-specific assessment methodology.

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

Background

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

Methods

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

Results

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

Conclusions

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

Systematic review registration

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Tenodesis-Induced-Grip exoskeleton robot (TIGER) for assisting upper extremity functions in stroke patients: a randomized control study

PURPOSE

This study was aimed toward developing a lightweight assisting tenodesis-induced-grip exoskeleton robot (TIGER) and to examine the performance of the TIGER in stroke patients with hemiplegia.

METHODS

This was a single-blinded, randomized control trial with pre-treatment, immediate post-treatment, and 12-week follow-up assessments. Thirty-four stroke patients were recruited and randomized to either an experimental or control group, where each participant in both groups underwent 40 min of training. In addition to a 20-min bout of regular task-specific motor training, each participant in the experimental group received 20 min of TIGER training, and the controls received 20 min of traditional occupational therapy in each treatment session. Primary outcomes based on the Fugl-Meyer Motor Assessment of Upper Extremity (FMA-UE) were recorded.

RESULTS

Thirty-two patients (94.1%) completed the study: 17 and 15 patients in the experimental and control groups, respectively. Significant beneficial effects were found on the total score (ANCOVA, p = 0.006), the wrist score (ANCOVA, p = 0.037), and the hand score (ANCOVA, p = 0.006) for the FMA-UE in the immediate post-treatment assessment of the participants receiving the TIGER training.

CONCLUSION

The TIGER has beneficial effects on remediating upper limb impairments in chronic stroke patients. Clinical trial registration: ClinicalTrials.gov; identifier NCT03713476Implications for rehabilitationBased on use-dependent plasticity concepts, robot training with the more distal segments of the upper extremities has a beneficial effect in patients with chronic stroke.A novel lightweight assisting tenodesis-induced-grip exoskeleton robot (TIGER) system using a mechanism involving musculotendinous coordination of the wrist and hand was proposed in this study.Between-group differences in changes in the upper limb motor performance were observed in the experimental group as compared to patients in the control group. For patients with chronic stroke, receiving 20 min of TIGER training in conjunction with 20 min of task-specific motor training led to clinically important changes in motor control and functioning of the affected upper limb.

A Systematic Review of Wearable Sensors for Monitoring Physical Activity

This article reviews the use of wearable sensors for the monitoring of physical activity (PA) for different purposes, including assessment of gait and balance, prevention and/or detection of falls, recognition of various PAs, conduction and assessment of rehabilitation exercises and monitoring of neurological disease progression. The article provides in-depth information on the retrieved articles and discusses study shortcomings related to demographic factors, i.e., age, gender, healthy participants vs patients, and study conditions. It is well known that motion patterns change with age and the onset of illnesses, and that the risk of falling increases with age. Yet, studies including older persons are rare. Gender distribution was not even provided in several studies, and others included only, or a majority of, men. Another shortcoming is that none of the studies were conducted in real-life conditions. Hence, there is still important work to be done in order to increase the usefulness of wearable sensors in these areas. The article highlights flaws in how studies based on previously collected datasets report on study samples and the data collected, which makes the validity and generalizability of those studies low. Exceptions exist, such as the promising recently reported open dataset FallAllD, wherein a longitudinal study with older adults is ongoing.

Efficacy of a technology-based client-centred training system in neurological rehabilitation: a randomised controlled trial

Background

A client-centred task-oriented approach has advantages towards motivation and adherence to therapy in neurorehabilitation, but it is costly to integrate in practice. An intelligent Activity-based Client-centred Training (i-ACT), a low-cost Kinect-based system, was developed which integrates a client-centred and task-oriented approach. The objectives were (1) to investigate the effect of additional i-ACT training on functioning. And (2) to assess whether training with i-ACT resulted in more goal oriented training.

Methods

A single-blind randomised controlled trial was performed in 4 Belgian rehabilitation centres with persons with central nervous system deficits. Participants were randomly allocated through an independent website-based code generator using blocked randomisation (n = 4) to an intervention or control group. The intervention group received conventional care and additional training with i-ACT for 3 × 45 min/week during 6 weeks. The control group received solely conventional care. Functional ability and performance, quality of life (QoL), fatigue, trunk movement, and shoulder active range of motion (AROM) were assessed at baseline, after 3 weeks and 6 weeks of training, and 6 weeks after cessation of training. Data were analysed using non-parametric within and between group analysis.

Results

47 persons were randomised and 45 analysed. Both intervention (n = 25) and control (n = 22) group improved over time on functional ability and performance as measured by the Wolf Motor Function Test, Manual Ability Measure-36, and Canadian Occupational Performance Measure, but no major differences were found between the groups on these primary outcome measures. Regarding QoL, fatigue, trunk movement, and shoulder AROM, no significant between group differences were found. High adherence for i-ACT training was found (i.e. 97.92%) and no adverse events, linked to i-ACT, were reported. In the intervention group the amount of trained personal goals (88%) was much higher than in the control group (46%).

Conclusions

Although additional use of i-ACT did not have a statistically significant added value regarding functional outcome over conventional therapy, additional i-ACT training provides more individualised client-centred therapy, and adherence towards i-ACT training is high. A higher intensity of i-ACT training may increase therapy effects, and should be investigated in future research.

Trial registration: ClinicalTrials.gov Identifier NCT02982811. Registered 29 November 2016.

Patient, carer, and staff perceptions of robotics in motor rehabilitation: a systematic review and qualitative meta-synthesis

BACKGROUND

In recent years, robotic rehabilitation devices have often been used for motor training. However, to date, no systematic reviews of qualitative studies exploring the end-user experiences of robotic devices in motor rehabilitation have been published. The aim of this study was to review end-users' (patients, carers and healthcare professionals) experiences with robotic devices in motor rehabilitation, by conducting a systematic review and thematic meta-synthesis of qualitative studies concerning the users' experiences with such robotic devices.

METHODS

Qualitative studies and mixed-methods studies with a qualitative element were eligible for inclusion. Nine electronic databases were searched from inception to August 2020, supplemented with internet searches and forward and backward citation tracking from the included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The CASP Qualitative Checklist was used to assess the quality of the included studies of this review.

RESULTS

The search strategy identified a total of 13,556 citations and after removing duplicates and excluding citations based on title and abstract, and full text screening, 30 studies were included. All studies were considered of acceptable quality. We developed six analytical themes: logistic barriers; technological challenges; appeal and engagement; supportive interactions and relationships; benefits for physical, psychological, and social function(ing); and expanding and sustaining therapeutic options.

CONCLUSIONS

Despite experiencing technological and logistic challenges, participants found robotic devices acceptable, useful and beneficial (physically, psychologically, and socially), as well as fun and interesting. Having supportive relationships with significant others and positive therapeutic relationships with healthcare staff were considered the foundation for successful rehabilitation and recovery.

European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus

BACKGROUND

Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN).

METHODS

Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources.

RESULTS

In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week.

CONCLUSIONS

The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.

Developing an intelligent activity-based client-centred training system with a user-centred approach

BACKGROUND

In neurorehabilitation, clinicians and managers are searching for new client-centred task-oriented applications which can be administered without extra costs and effort of therapists, and increase the client's motivation.

OBJECTIVE

To develop and evaluate a prototype of an intelligent activity-based client-centred training (i-ACT) system based on Microsoft Kinect®.

METHODS

Within an iterative user centred process, the i-ACT prototype was developed and necessary features were established for use in neurological settings. After the test trial with a high fidelity prototype, the value, usefulness, and credibility were evaluated.

RESULTS

Seven therapists participated in focus groups and 54 persons with neurological problems participated in test trials. A prototype was established based on the user's experience. Results show that clients and therapists acknowledge the value and usefulness (clients 5.71/7; therapists 4.86/7), and credibility (clients 21.00/27; therapists 14.50/27) of i-ACT.

CONCLUSIONS

Therapists want to be able to record an endless range of movements and activities which enables individualised exercise programs for persons with disabilities. For therapists it is important that the system provides feedback about the quality of movement and not only results. In future work, clinical trials will be performed towards feasibility and effectiveness of i-ACT in neurorehabilitation and other rehabilitation domains.

Effect of Robot-Assisted Therapy on Participation of People with Limited Upper Limb Functioning: A Systematic Review with GRADE Recommendations

Background

Previous studies have suggested that robot-assisted therapy (RT) is effective in treating impairment and that it may also improve individuals' participation.

Objective

To investigate the effect of RT on the participation of individuals with limited upper limb functioning (PROSPERO: CRD42019133880). Data Sources: PEDro, Embase, MEDLINE, CINAHL, Cochrane, AMED, and Compendex. Inclusion Criteria. We selected randomized or quasirandomized controlled studies comparing the effects of RT with minimal or other interventions on participation of individuals with limited upper limb functioning. Data Extraction and Synthesis. Methodological quality of the included studies was assessed using the 0-10 PEDro scale, and effect estimates were reported using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and the certainty of the current evidence was assessed using the GRADE.

Results

Twelve randomized controlled studies involving 845 participants were included. The estimates of medium effects between RT and minimal intervention (MI) at a short-term follow-up were pooled, but there are no short-term effects between RT and OI. Standardized differences in means were as follows: 0.6 (95% CI 0.1 to 1.2) and 0.2 (95% CI -0.0 to 0.4). There were also no effects of additional RT in the short- or medium-term follow-up periods. Standardized differences in means were as follows: -0.6 (95% CI -1.1 to -0.1) and 0.2 (95% CI -0.3 to 0.8). The methodological quality of the included studies potentially compromised the effect estimates of RT. The existing evidence was very low-quality with many confounding variables between studies.

Conclusions

For patients with upper limb neurological dysfunction, low-quality evidence supports RT over MI in terms of improving individual participation in the short term. The existing low- to very low-quality evidence does not support RT over OI in either the short- or medium-term follow-up periods with respect to community participation.

Motivation, Usability, and Credibility of an Intelligent Activity-Based Client-Centred Training System to Improve Functional Performance in Neurological Rehabilitation: An Exploratory Cohort Study

(1) Background: technology-based training systems are increasingly integrated in neurorehabilitation but are rarely combined with a client-centred task-oriented approach. To provide a low-cost client-centred task-oriented system, the intelligent activity-based client-centred task-oriented training (i-ACT) was developed. The objective was to evaluate the usability, credibility and treatment expectancy of i-ACT, and the motivation towards i-ACT use in rehabilitation over time. Additionally, this study will evaluate the upper limb treatment effects after training with i-ACT. (2) Methods: a mixed-method study was performed in four rehabilitation centres. Training with i-ACT was provided during six weeks, three times per week, forty-five minutes per day, additional to conventional care. (3) Results: seventeen persons with central nervous system diseases were included. High scores were seen in the system usability scale (score ≥ 73.8/100), credibility (score ≥ 22.0/27.0)/expectancy (score ≥ 15.8/27.0) questionnaire, and intrinsic motivation inventory (score ≥ 5.2/7.0), except the subscale pressure (score ≤ 2.0/7.0). Results from the interviews corroborate these findings and showed that clients and therapists believe in the i-ACT system as an additional training support system. Upper limb functional ability improved significantly (p < 0.05) over time on the Wolf motor function test. (4) Conclusion: i-ACT is a client-centred task-oriented usable and motivational system which has the potential to enhance upper limb functional training in persons with neurological diseases.

A Data-Driven Investigation on Surface Electromyography Based Clinical Assessment in Chronic Stroke

Background: Surface electromyography (sEMG) based robot-assisted rehabilitation systems have been adopted for chronic stroke survivors to regain upper limb motor function. However, the evaluation of rehabilitation effects during robot-assisted intervention relies on traditional manual assessments. This study aimed to develop a novel sEMG data-driven model for automated assessment. Method: A data-driven model based on a three-layer backpropagation neural network (BPNN) was constructed to map sEMG data to two widely used clinical scales, i.e., the Fugl-Meyer Assessment (FMA) and the Modified Ashworth Scale (MAS). Twenty-nine stroke participants were recruited in a 20-session sEMG-driven robot-assisted upper limb rehabilitation, which consisted of hand reaching and withdrawing tasks. The sEMG signals from four muscles in the paretic upper limbs, i.e., biceps brachii (BIC), triceps brachii (TRI), flexor digitorum (FD), and extensor digitorum (ED), were recorded before and after the intervention. Meanwhile, the corresponding clinical scales of FMA and MAS were measured manually by a blinded assessor. The sEMG features including Mean Absolute Value (MAV), Zero Crossing (ZC), Slope Sign Change (SSC), Root Mean Square (RMS), and Wavelength (WL) were adopted as the inputs to the data-driven model. The mapped clinical scores from the data-driven model were compared with the manual scores by Pearson correlation. Results: The BPNN, with 15 nodes in the hidden layer and sEMG features, i.e., MAV, ZC, SSC, and RMS, as the inputs to the model, was established to achieve the best mapping performance with significant correlations (r > 0.9, P < 0.001), according to the FMA. Significant correlations were also obtained between the mapped and manual FMA subscores, i.e., FMA-wrist/hand and FMA-shoulder/elbow, before and after the intervention (r > 0.9, P < 0.001). Significant correlations (P < 0.001) between the mapped and manual scores of MASs were achieved, with the correlation coefficients r = 0.91 at the fingers, 0.88 at the wrist, and 0.91 at the elbow after the intervention. Conclusion: An sEMG data-driven BPNN model was successfully developed. It could evaluate upper limb motor functions in chronic stroke and have potential application in automated assessment in post-stroke rehabilitation, once validated with large sample sizes. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02117089.

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

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

Haptic-Enabled Hand Rehabilitation in Stroke Patients: A Scoping Review

There is a plethora of technology-assisted interventions for hand therapy, however, less is known about the effectiveness of these interventions. This scoping review aims to explore studies about technology-assisted interventions targeting hand rehabilitation to identify the most effective interventions. It is expected that multifaceted interventions targeting hand rehabilitation are more efficient therapeutic approaches than mono-interventions. The scoping review will aim to map the existing haptic-enabled interventions for upper limb rehabilitation and investigates their effects on motor and functional recovery in patients with stroke. The methodology used in this review is based on the Arksey and O’Malley framework, which includes the following stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. Results show that using three or four different technologies was more positive than using two technologies (one technology + haptics). In particular, when standardized as a percentage of outcomes, the combination of three technologies showed better results than the combination of haptics with one technology or with three other technologies. To conclude, this study portrayed haptic-enabled rehabilitation approaches that could help therapists decide which technology-enabled hand therapy approach is best suited to their needs. Those seeking to undertake research and development anticipate further opportunities to develop haptic-enabled hand telerehabilitation platforms.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

Background

More than two-thirds of stroke patients have arm motor impairments and function deficits on hospital admission, leading to diminished quality of life and reduced social participation. Robot-assisted training (RAT) is a promising rehabilitation program for upper extremity while its effect is still controversial due to heterogeneity in clinical trials. We performed a systematic review and meta-analysis to compare robot-assisted training (RAT) versus therapist-mediated training (TMT) for arm rehabilitation after stroke.

Methods

We searched the following electronic databases: MEDLINE, EMBASE, Cochrane EBM Reviews, and Physiotherapy Evidence Database (PEDro). Studies of moderate or high methodological quality (PEDro score ≥4) were included and analyzed. We assessed the effects of RAT versus TMT for arm rehabilitation after stroke with testing the noninferiority of RAT. A small effect size of -2 score for mean difference in Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) and Cohen's d = -0.2 for standardized mean difference (SMD) were set as noninferiority margin.

Results

Thirty-five trials with 2241 participants met inclusion criteria. The effect size for arm motor impairment, capacity, activities of daily living, and social participation were 0.763 (WMD, 95% CI: 0.404 to 1.123), 0.109 (SMD, 95% CI: -0.066 to 0.284), 0.049 (SMD, 95% CI: -0.055 to 0.17), and -0.061 (SMD, 95% CI: -0.196 to 0.075), respectively.

Conclusion

This systematic review and meta-analysis demonstrated that robot-assisted training was slightly superior in motor impairment recovery and noninferior to therapist-mediated training in improving arm capacity, activities of daily living, and social participation, which supported the use of RAT in clinical practice.

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

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

The fourier M2 robotic machine combined with occupational therapy on post-stroke upper limb function and independence-related quality of life: A randomized clinical trial

Most post-stroke patients experience upper limb functionality challenges. Emergent therapies using upper limb-based robot machines present opportunities to resolve the limitations inherent in Occupational therapy such as increased therapist-patient exhaustion, monotonous methods, and so forth. The aim of this parallel trial was to compare the effects of the upper limb robotic training with matched Occupational therapy training on upper limb function and independence-related quality of life in post-stroke patients within the Brunnstrom arm motor recovery stages 1 to 4. During one-year (2018-2019), 50 post-stroke patients were enrolled and randomly assigned to 2 groups; robot and Occupational therapy (n = 25) and Occupational therapy (n = 25). Both groups were trained for 50-70 minutes per day, 5 days a week for 6 weeks. The Chinese-adapted Fugl-Meyer Assessment-Upper Extremity (FMA-UE) was the primary outcome measure. The secondary outcome measures were the Brunnstrom Recovery Stages Scale (BRS) and the Chinese-adapted Barthel Index (BI). The treatment effect sizes of both groups were large in the following variables; transfers (1), BI total score (2.2), FMA-UE upper limb (1.1), wrist (1.8), elbow (1), fingers (0.9), and FMA-UE total scores (1.4). The treatment group in comparison to the control group had larger BRS changes, significant improvements in upper limb function, and partial independence in activities of daily living during the baseline to post-treatment period. Robotic-assisted training with occupational therapy may improve the upper limb movement foundation blocks; however, it does not translate into complete functional independence and improved quality of life. This study has been registered at the ISRCTN registry, https://doi.org/10.1186/ISRCTN84804731.

Robot-assisted therapy for arm recovery for stroke patients: state of the art and clinical implication

Introduction: Robot-assisted therapy is an emerging approach that performs highly repetitive, intensive, task oriented and quantifiable neuro-rehabilitation. In the last decades, it has been increasingly used in a wide range of neurological central nervous system conditions implying an upper limb paresis. Results from the studies are controversial, for the many types of robots and their features often not accompanied by specific clinical indications about the target functions, fundamental for the individualized neurorehabilitation program.Areas covered: This article reviews the state of the art and perspectives of robotics in post-stroke rehabilitation for upper limb recovery. Classifications and features of robots have been reported in accordance with technological and clinical contents, together with the definition of determinants specific for each patient, that could modify the efficacy of robotic treatments. The possibility of combining robotic intervention with other therapies has also been discussed.Expert commentary: The recent wide diffusion of robots in neurorehabilitation has generated a confusion due to the commingling of technical and clinical aspects not previously clarified. Our critical review provides a possible hypothesis about how to match a robot with subject's upper limb functional abilities, but also highlights the need of organizing a clinical consensus conference about the robotic therapy.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Breaking Proportional Recovery After Stroke

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

Robot-Assisted Reaching Performance of Chronic Stroke and Healthy Individuals in a Virtual Versus a Physical Environment: A Pilot Study

The aim of the current study was to examine the role of environment, whether virtual or physical, on robot-assisted reaching movements in chronic stroke and healthy individuals, within a single session. Twenty-three subjects participated in the current study divided into three groups: nine chronic stroke individuals able to perform a reaching task with no need for the robot assistance, nine chronic stroke individuals who needed robot assistance to complete the reaching task, and five healthy individuals. The task was to reach six target buttons in two identical physical and virtual environments. The outcomes consisted of specific kinematic measures (amount of movement completion without robot assistance, mean speed, peak speed, straightness, and shakiness) and a custom questionnaire to assess how the stroke subjects perceived and experienced the reaching task in both environments. The results showed no differences between the two environments in terms of the outcome measures in any of the groups. Our findings suggest that the choice of environment, whether physical or virtual, is not a key factor in designing a simple robot-assisted reaching task for stroke survivors. Further studies are required for more complex environments and tasks as well as robot-assisted training protocols.

Changes in actual arm-hand use in stroke patients during and after clinical rehabilitation involving a well-defined arm-hand rehabilitation program: A prospective cohort study

Introduction

Improvement of arm-hand function and arm-hand skill performance in stroke patients is reported by many authors. However, therapy content often is poorly described, data on actual arm-hand use are scarce, and, as follow-up time often is very short, little information on patients’ mid- and long-term progression is available. Also, outcome data mainly stem from either a general patient group, unstratified for the severity of arm-hand impairment, or a very specific patient group.

Objectives

To investigate to what extent the rate of improvement or deterioration of actual arm-hand use differs between stroke patients with either a severely, moderately or mildly affected arm-hand, during and after rehabilitation involving a well-defined rehabilitation program.

Methods

Design: single–armed prospective cohort study. Outcome measure: affected arm-hand use during daily tasks (accelerometry), expressed as ‘Intensity-of arm-hand-use’ and ‘Duration-of-arm-hand-use’ during waking hours. Measurement dates: at admission, clinical discharge and 3, 6, 9, and 12 months post-discharge. Statistics: Two-way repeated measures ANOVAs.

Results

Seventy-six patients (63 males); mean age: 57.6 years (sd:10.6); post-stroke time: 29.8 days (sd:20.1) participated. Between baseline and 1-year follow-up, Intensity-of-arm-hand-use on the affected side increased by 51%, 114% and 14% (p < .000) in the mildly, moderately and severely affected patients, respectively. Similarly, Duration-of-arm-hand-use increased by 26%, 220% and 161% (p < .000). Regarding bimanual arm-hand use: Intensity-of-arm-hand-use increased by 44%, 74% and 30% (p < .000), whereas Duration-of-arm-hand-use increased by 10%, 22% and 16% (p < .000).

Conclusion

Stroke survivors with a severely, moderately or mildly affected arm-hand showed different, though (clinically) important, improvements in actual arm-hand use during the rehabilitation phase. Intensity-of-arm-hand-use and Duration-of-arm-hand-use significantly improved in both unimanual and bimanual tasks/skills. These improvements were maintained until at least 1 year post-discharge.

Analysis of the Factors Related to the Effectiveness of Transcranial Current Stimulation in Upper Limb Motor Function Recovery after Stroke: a Systematic Review

Transcranial direct current stimulation is one of the non-invasive techniques whose main mechanism of action is based on its modulation of cortical excitability. The objective of this study is to analyze the variables (i.e, demographics, clinicals, stimulation parameters) that could influence into the responses during rehabilitation of the upper extremity in patients with stroke. Our systematic review has been performed by searching full-text articles published from January 2008 to December 2018 in Embase, Medline, PubMed and Cochrane Library databases. Studies with adult patients with ischemic or hemorrhagic stroke at any stage of evolution were included. We compared interventions with any type of transcranial direct current stimulation (anodal, cathodal or bihemispheric, also known as dual) regarding improvement of upper extremity motor function. We included 14 studies with 368 patients, of whom almost 89% have ischemic etiology and more than half are males. Most patients were considered subacute or chronic, while only two studies were selected with patients in the acute phase. Different methods of using transcranial direct current stimulation with several complementary therapies were identified, such as virtual reality, robot therapy, Occupational Therapy, Physiotherapy, Constraint Induced Movement Therapy or Peripheral Nerve Stimulation. In conclusion, there is not significant evidence due to heterogeneity of clinical data and therapies. Clinical studies with greater number of participants and protocols standardized could outline this assessment in future studies.

Stroke Patients' Acceptance of a Smart Garment for Supporting Upper Extremity Rehabilitation

The objective is to evaluate to which extent that Zishi a garment equipped with sensors that can support posture monitoring can be used in upper extremity rehabilitation training of stroke patients. Seventeen stroke survivors (mean age: 55 years old, SD =13.5) were recruited in three hospitals in Shanghai. Patients performed 4 tasks (analytical shoulder flexion, functional shoulder flexion placing a cooking pot, analytical flexion in the scapular plane, and functional flexion in the scapular plane placing a bottle of water) with guided feedback on a tablet that was provided through inertial sensors embedded in the Zishi system at the scapula and the thoracic spine region. After performing the training tasks, patients completed four questionnaires for assessing their motivation, their acceptance of the system, its credibility, and usability. The study participants were highly motivated to train with Zishi and the system was rated high usability, while the subjects had moderate confidence with technology supported training in comparison with the training with therapists. The patients respond positively to using Zishi to support rehabilitation training in a clinical setting. Further developments need to address more on engaging and adaptive feedback. This paper paves the way for larger scale effectiveness studies.

The Combined Use of Transcranial Direct Current Stimulation and Robotic Therapy for the Upper Limb

Neurologic disorders such as stroke and cerebral palsy are leading causes of long-term disability and can lead to severe incapacity and restriction of daily activities due to lower and upper limb impairments. Intensive physical and occupational therapy are still considered main treatments, but new adjunct therapies to standard rehabilitation that may optimize functional outcomes are being studied. Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that polarizes underlying brain regions through the application of weak direct currents through electrodes on the scalp, modulating cortical excitability. Increased interest in this technique can be attributed to its low cost, ease of use, and effects on human neural plasticity. Recent research has been performed to determine the clinical potential of tDCS in diverse conditions such as depression, Parkinson's disease, and motor rehabilitation after stroke. tDCS helps enhance brain plasticity and seems to be a promising technique in rehabilitation programs. A number of robotic devices have been developed to assist in the rehabilitation of upper limb function after stroke. The rehabilitation of motor deficits is often a long process requiring multidisciplinary approaches for a patient to achieve maximum independence. These devices do not intend to replace manual rehabilitation therapy; instead, they were designed as an additional tool to rehabilitation programs, allowing immediate perception of results and tracking of improvements, thus helping patients to stay motivated. Both tDSC and robot-assisted therapy are promising add-ons to stroke rehabilitation and target the modulation of brain plasticity, with several reports describing their use to be associated with conventional therapy and the improvement of therapeutic outcomes. However, more recently, some small clinical trials have been developed that describe the associated use of tDCS and robot-assisted therapy in stroke rehabilitation. In this article, we describe the combined methods used in our institute for improving motor performance after stroke.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Assessment of the Efficacy of ReoGo-J Robotic Training Against Other Rehabilitation Therapies for Upper-Limb Hemiplegia After Stroke: Protocol for a Randomized Controlled Trial

Background: Stroke patients experience chronic hemiparesis in their upper extremities leaving negative effects on quality of life. Robotic therapy is one method to recover arm function, but its research is still in its infancy. Research questions of this study is to investigate how to maximize the benefit of robotic therapy using ReoGo-J for arm hemiplegia in chronic stroke patients.

Methods: Design of this study is a multi-center parallel group trial following the prospective, randomized, open-label, blinded endpoint (PROBE) study model. Participants and setting will be 120 chronic stroke patients (over 6 months post-stroke) will be randomly allocated to three different rehabilitation protocols. In this study, the control group will receive 20 min of standard rehabilitation (conventional occupational therapy) and 40 min of self-training (i.e., sanding, placing and stretching). The robotic therapy group will receive 20 min of standard rehabilitation and 40 min of robotic therapy using ReoGo®-J device. The combined therapy group will receive 40 min of robotic therapy and 20 min of constraint-induced movement therapy (protocol to improve upper-limb use in ADL suggests). This study employs the Fugl-Meyer Assessment upper-limb score (primary outcome), other arm function measures and the Stroke Impact Scale score will be measured at baseline, 5 and 10 weeks of the treatment phase. In analysis of this study, we use the mixed effects model for repeated measures to compare changes in outcomes between groups at 5 and 10 Weeks. The registration number of this study is UMIN000022509.

Conclusions: This study is a feasible, multi-site randomized controlled trial to examine our hypothesis that combined training protocol could maximize the benefit of robotic therapy and best effective therapeutic strategy for patients with upper-limb hemiparesis.

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

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

The effects of error-augmentation versus error-reduction paradigms in robotic therapy to enhance upper extremity performance and recovery post-stroke: a systematic review

Despite upper extremity function playing a crucial role in maintaining one's independence in activities of daily living, upper extremity impairments remain one of the most prevalent post-stroke deficits. To enhance the upper extremity motor recovery and performance among stroke survivors, two training paradigms in the fields of robotics therapy involving modifying haptic feedback were proposed: the error-augmentation (EA) and error-reduction (ER) paradigms. There is a lack of consensus, however, as to which of the two paradigms yields superior training effects. This systematic review aimed to determine (i) whether EA is more effective than conventional repetitive practice; (ii) whether ER is more effective than conventional repetitive practice and; (iii) whether EA is more effective than ER in improving post-stroke upper extremity motor recovery and performance. The study search and selection process as well as the ratings of methodological quality of the articles were conducted by two authors separately, and the results were then compared and discussed among the two reviewers. Findings were analyzed and synthesized using the level of evidence. By August 1st 2017, 269 articles were found after searching 6 databases, and 13 were selected based on criteria such as sample size, type of participants recruited, type of interventions used, etc. Results suggest, with a moderate level of evidence, that EA is overall more effective than conventional repetitive practice (motor recovery and performance) and ER (motor performance only), while ER appears to be no more effective than conventional repetitive practice. However, intervention effects as measured using clinical outcomes were under most instance not 'clinically meaningful' and effect sizes were modest. While stronger evidence is required to further support the efficacy of error modification therapies, the influence of factors related to the delivery of the intervention (such as intensity, duration) and personal factors (such as stroke severity and time of stroke onset) deserves further investigations as well.

The Effects of Upper-Limb Training Assisted with an Electromyography-Driven Neuromuscular Electrical Stimulation Robotic Hand on Chronic Stroke

Background

Impaired hand dexterity is a major disability of the upper limb after stroke. An electromyography (EMG)-driven neuromuscular electrical stimulation (NMES) robotic hand was designed previously, whereas its rehabilitation effects were not investigated.

Objectives

This study aims to investigate the rehabilitation effectiveness of the EMG-driven NMES-robotic hand-assisted upper-limb training on persons with chronic stroke.

Method

A clinical trial with single-group design was conducted on chronic stroke participants (n = 15) who received 20 sessions of EMG-driven NMES-robotic hand-assisted upper-limb training. The training effects were evaluated by pretraining, posttraining, and 3-month follow-up assessments with the clinical scores of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), the Wolf Motor Function Test, the Motor Functional Independence Measure, and the Modified Ashworth Scale (MAS). Improvements in the muscle coordination across the sessions were investigated by EMG parameters, including EMG activation level and Co-contraction Indexes (CIs) of the target muscles in the upper limb.

Results

Significant improvements in the FMA shoulder/elbow and wrist/hand scores (P < 0.05), the ARAT (P < 0.05), and in the MAS (P < 0.05) were observed after the training and sustained 3 months later. The EMG parameters indicated a significant decrease of the muscle activation level in flexor digitorum (FD) and biceps brachii (P < 0.05), as well as a significant reduction of CIs in the muscle pairs of FD and triceps brachii and biceps brachii and triceps brachii (P < 0.05).

Conclusion

The upper-limb training integrated with the assistance from the EMG-driven NMES-robotic hand is effective for the improvements of the voluntary motor functions and the muscle coordination in the proximal and distal joints. Furthermore, the motor improvement after the training could be maintained till 3 months later.

Trial registration

ClinicalTrials.gov. NCT02117089; date of registration: April 10, 2014.

Hand Rehabilitation Robotics on Poststroke Motor Recovery

The recovery of hand function is one of the most challenging topics in stroke rehabilitation. Although the robot-assisted therapy has got some good results in the latest decades, the development of hand rehabilitation robotics is left behind. Existing reviews of hand rehabilitation robotics focus either on the mechanical design on designers' view or on the training paradigms on the clinicians' view, while these two parts are interconnected and both important for designers and clinicians. In this review, we explore the current literature surrounding hand rehabilitation robots, to help designers make better choices among varied components and thus promoting the application of hand rehabilitation robots. An overview of hand rehabilitation robotics is provided in this paper firstly, to give a general view of the relationship between subjects, rehabilitation theories, hand rehabilitation robots, and its evaluation. Secondly, the state of the art hand rehabilitation robotics is introduced in detail according to the classification of the hardware system and the training paradigm. As a result, the discussion gives available arguments behind the classification and comprehensive overview of hand rehabilitation robotics.

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

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

Markerless motion capture systems as training device in neurological rehabilitation: a systematic review of their use, application, target population and efficacy

Background

Client-centred task-oriented training is important in neurological rehabilitation but is time consuming and costly in clinical practice. The use of technology, especially motion capture systems (MCS) which are low cost and easy to apply in clinical practice, may be used to support this kind of training, but knowledge and evidence of their use for training is scarce. The present review aims to investigate 1) which motion capture systems are used as training devices in neurological rehabilitation, 2) how they are applied, 3) in which target population, 4) what the content of the training and 5) efficacy of training with MCS is.

Methods

A computerised systematic literature review was conducted in four databases (PubMed, Cinahl, Cochrane Database and IEEE). The following MeSH terms and key words were used: Motion, Movement, Detection, Capture, Kinect, Rehabilitation, Nervous System Diseases, Multiple Sclerosis, Stroke, Spinal Cord, Parkinson Disease, Cerebral Palsy and Traumatic Brain Injury. The Van Tulder’s Quality assessment was used to score the methodological quality of the selected studies. The descriptive analysis is reported by MCS, target population, training parameters and training efficacy.

Results

Eighteen studies were selected (mean Van Tulder score = 8.06 ± 3.67). Based on methodological quality, six studies were selected for analysis of training efficacy. Most commonly used MCS was Microsoft Kinect, training was mostly conducted in upper limb stroke rehabilitation. Training programs varied in intensity, frequency and content. None of the studies reported an individualised training program based on client-centred approach.

Conclusion

Motion capture systems are training devices with potential in neurological rehabilitation to increase the motivation during training and may assist improvement on one or more International Classification of Functioning, Disability and Health (ICF) levels. Although client-centred task-oriented training is important in neurological rehabilitation, the client-centred approach was not included. Future technological developments should take up the challenge to combine MCS with the principles of a client-centred task-oriented approach and prove efficacy using randomised controlled trials with long-term follow-up.

Trial registration

Prospero registration number 42016035582.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-017-0270-x) contains supplementary material, which is available to authorized users.

Robotic approaches for the rehabilitation of upper limb recovery after stroke: a systematic review and meta-analysis

This systematic review with a meta-analysis of studies was carried out to evaluate the effectiveness of robotic training (RT) and conventional training (CT) in improving the motor recovery of paretic upper limbs in stroke patients. Numerous electronic databases were searched from January 2000 to May 2016. Finally, 13 randomized-controlled trials fulfilled the inclusion criteria and were included in the three meta-analyses. The first meta-analysis carried out for those studies using RT for stroke patients indicated a significant improvement in the RT groups. The second meta-analysis suggested that the upper limb function (measured by Fugl-Meyer test) was significantly improved when RT was used with CT compared with CT alone. The third meta-analysis noted a significant difference in motor recovery between the CT-only and RT groups (RT only or RT combined with CT) in the chronic stages of stroke, but not in the acute or subacute stages. However, the RT group also showed a higher Fugl-Meyer score in patients at both the acute and the subacute stage. RT appeared to have positive outcomes to enhance motor recovery of the paralyzed upper limb. Robotic devices were believed to provide more assistance to patients to help support the weight of the upper limb; thus, active movement training can begin in the early rehabilitation stage. These novel devices may also help those chronic patients to achieve better rehabilitation goals. As a summary, RT could be used in addition to CT to help both therapists and patients in the management of the paralyzed upper limb.

Exercising daily living activities in robot-mediated therapy

[Purpose] Investigation of the efficacy of robot-mediated therapy of the upper limb in patients with chronic stroke, in task-oriented training activities of daily living in real environment. [Subjects and Methods] 20 patients, each more than one year post-stroke (13-71 months) received 20 sessions of upper limb robot-mediated therapy. No other treatment was given. Each therapy session consisted of a passive motion and an active task therapy. During the active therapy, subjects exercised 5 activities of daily living. Assessments of the subjects were blind, and conducted one month prior to, at the start, at the end, and three months after the therapy course. The following outcome measures were recorded: Fugl-Meyer Scale-upper extremity subsection, Modified Ashworth Scale, Action Research Arm Test, Functional Independence Measure, Barthel Index. [Results] Significant improvements were observed between the start and the end of the therapy, except for Modified Ashworth Scale and Barthel Index. Results still held up at the follow-up visit three months later. [Conclusion] Practicing activities of daily living in real environment with robot-mediated physical therapy can improve the motor and functional ability of patients, even with relatively good initial functions, and even years post-stroke.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term Rehabilitation in Patients With Acquired Brain Injury

BACKGROUND

Patients with acquired brain injury who have been discharged from inpatient neurological rehabilitation often continue to suffer from limited independence, participation, and quality of life. Participation-focused outpatient treatment (in German: teilhabeorientierte ambulan.

METHODS

In a randomized, controlled trial, 53 patients who had sustained an acquired brain injury approximately four years earlier were allotted to two different sequences of treatment (26 TEAM/control, 27 control/TEAM). The primary endpoint was the achievement of an individual participation goal one month after the start of treatment. The secondary endpoints included independence in everyday activities, health-related quality of life, participation, and need for nursing care. The intervention was four weeks long and was carried out on an outpatient basis (19.4 ± 1.3 hours per week). Patients in the control group were treated in a manner resembling usual current care. All endpoints were evaluated in a per-protocol (PP) analysis of data from 47 patients. For confirmation, an intention-to-treat (ITT) analysis was also carried out for the primary endpoint and for independence in everyday activities.

RESULTS

According to the PP analysis, TEAM patients achieved their individual participation goals at 1 month more frequently than control patients receiving standard treatment (61% vs. 21%; p = 0.008) and improved more with respect to independence in everyday activities. The difference between TEAM and standard treatment was +7.3 points on the FIM (Functional Independence Measure) scale (95% confidence interval [2.8; 11.8]; p = 0.0024). The superiority of TEAM was confirmed by the ITT analysis (achievement of the participation goal, TEAM vs. standard treatment: 54% vs. 19%, p = 0.0103). Moreover, improvements were seen at 12 months in quality of life, participation, and the need for nursing care.

CONCLUSION

The TEAM rehabilitation program can help patients in the chronic phase of acquired brain injury achieve participation goals that are relevant to everyday life. An adjustment of the care structure in Germany to include such intensive goal-oriented rehabilitation programs would lead to a more effective mobilization of these patients' potential for long-term rehabilitation.