Robotic Technology and Stroke Rehabilitation: Translating Research into Practice

Kinematic hand synergies differ between reach-and-grasp and functional object manipulation

Humans possess a unique ability to manipulate tools to help us navigate the world around us. This ability is facilitated by the dexterity of our hands. However, millions lose this capability annually due to conditions like limb amputation or cerebral vascular accident (i.e., stroke). This great loss of human hand function has led to increased study of human hand action. Although previous research focused on coordinated hand motion, known as synergies, during reaching and grasping, manipulation of complex objects remains understudied. Specifically, we aimed to test two hypotheses: 1) the number of synergies underlying manipulation is the same as those underlying reach-and-grasp, and 2) the identity of synergies underlying manipulation is different from those underlying reach-and-grasp. To do so, we measured human hand motion during two experiments: 1) during reach and grasp of a tool or object commonly used in wire harness installation and 2) during manipulation of those objects and tools to install a wire harness on a mock electrical cabinet. Results showed that manipulation generally required more synergies than grasp. Comparison between reach-and-grasp and manipulation revealed a decrease in synergy similarity with synergy-order. Considering that higher-order synergies become significant during manipulation, it is important that we investigate these differences; this study serves as a point of entry to doing so. If we want our prosthetic and rehabilitative devices to restore hand function to those who have lost it, we must study hand function, specifically manipulation, and not just grasping.NEW & NOTEWORTHY This study uncovers new insights into kinematic synergies during functional human hand manipulation of objects and tools, through the study of wire harness installation. It emphasizes the nuanced distinctions between functional hand manipulation and simple grasping, revealing that manipulation tasks require a greater number and distinct subset of hand synergies compared with simple grasp actions. This research marks a significant step toward appreciating the intricacies of hand coordination in complex tasks beyond grasping.

A home-based hand rehabilitation platform for hemiplegic patients after stroke: A feasibility study

Background

Patients with stroke often experience weakened upper limbs, making daily tasks difficult to perform. Although rehabilitation devices are available, patients often relapse post-discharge due to insufficient practice. We present a home-based hand telerehabilitation intervention using the iManus™ platform comprising a sensorized glove, a mobile app for the patients, and a therapist portal for monitoring patient progress.

Objectives

This research aimed to examine the feasibility, safety, and effectiveness of a home-based telerehabilitation intervention in improving hand function for individuals with mild stroke. A qualitative approach was also used to explore users' experiences, perceived benefits, and challenges associated with using the platform in a home setting.

Methods

In this single-case study, we delivered a hand telerehabilitation intervention to a chronic stroke patient with impaired hand function using the iManus™ platform. The intervention consisted of 40 home sessions over eight weeks. We assessed feasibility through user adherence and feedback obtained using a System Usability Scale (SUS) and a semi-structured interview with the participant and their informal caregiver. Safety was evaluated by monitoring pain levels using the Visual Analog Scale (VAS), and efficacy was determined by observing the changes in the fingers' range of motion using the iManus™ platform and clinical outcomes measures, namely the Fugl-Meyer Assessment (FMA) and Jebsen Taylor Hand Function Test (JTHFT).

Results

Our participant completed all the assigned sessions, with each averaging 20 min. Usability scored 77.5 out of 100 on the SUS. User feedback from the interviews revealed improved mobility and control over therapy as benefits, indicating room for improvement in the intervention's adaptability and functionality. During the intervention, the participant noted no pain increase, and the telerehabilitation platform recorded range of motion improvements for all finger and wrist joints, excluding wrist extension. The FMA scores were 43 at T0, 53 at T1, and 56 at T2, while the JTHFT scores were 223 at T0, 188 at T1, and 240 at T2.

Conclusions

This single case study demonstrated the preliminary feasibility, safety, and efficacy of a novel home-based hand intervention for stroke survivors. The participant showed improved hand functions, good adherence to the program, and reported satisfaction with the intervention. However, these results are based on a single-case study, and further large-scale studies are needed before any generalization is recommended.

Dyad motor learning in a wrist-robotic environment: Learning together is better than learning alone

OBJECTIVE

Dyad motor practice is characterized by two learners alternating between physical and observational practice, which can lead to better motor outcomes and reduce practice time compared to physical practice alone. Robot-assisted therapy has become an established neurorehabilitation tool but is limited by high therapy cost and access. Implementing dyad practice in robot-assisted rehabilitation has the potential to improve therapeutic outcomes and/or to achieve them faster. This study aims to determine the effects of dyad practice on motor performance in a wrist-robotic environment to evaluate its potential use in robotic rehabilitation settings.

METHODS

Forty-two healthy participants (18-35 years) were randomized into three groups (n = 14): Dyad practice, physical practice with rest and physical practice without rest. Participants practiced a 2 degree-of-freedom gamified wrist movement task for 20 trials using a custom-made wrist robotic device. A motor performance score (MPS) that captured temporal and spatial time-series kinematics was computed at baseline, the end of training and 24 h later to assess retention.

RESULTS

MPS did not differ between groups at baseline. All groups revealed significant performance gains by the end of training. However, dyads outperformed the other groups at the end of training (p < 0.001) and showed higher retention after 24-h (p = 0.02). Median MPS improved by 46.5% in dyads, 25.3% in physical practice-rest, and 33.6% in physical practice-no rest at the end of training compared to baseline.

CONCLUSION

Compared to physical practice alone, dyad practice leads to superior motor outcomes in a robot-assisted motor learning task. Dyads still outperformed their counterparts 24-h after practice.

IMPACT STATEMENT

Improving motor function in complex motor tasks without increasing required practice time, dyad practice can optimize therapeutic resources. This is particularly impactful in robot-assisted rehabilitation regimens as it would help to improve patients' outcomes and increase care efficiency.

Use of artificial intelligence as an instrument of evaluation after stroke: a scoping review based on international classification of functioning, disability and health concept

INTRODUCTION

To understand the current practices in stroke evaluation, the main clinical decision support system and artificial intelligence (AI) technologies need to be understood to assist the therapist in obtaining better insights about impairments and level of activity and participation in persons with stroke during rehabilitation.

METHODS

This scoping review maps the use of AI for the functional evaluation of persons with stroke; the context involves any setting of rehabilitation. Data were extracted from CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, PEDRO Web of Science, IEEE Xplore, AAAI Publications, ACM Digital Library, MathSciNet, and arXiv up to January 2021. The data obtained from the literature review were summarized in a single dataset in which each reference paper was considered as an instance, and the study characteristics were considered as attributes. The attributes used for the multiple correspondence analysis were publication year, study type, sample size, age, stroke phase, stroke type, functional status, AI type, and AI function.

RESULTS

Forty-four studies were included. The analysis showed that spasticity analysis based on ML techniques was used for the cases of stroke with moderate functional status. The techniques of deep learning and pressure sensors were used for gait analysis. Machine learning techniques and algorithms were used for upper limb and reaching analyses. The inertial measurement unit technique was applied in studies where the functional status was between mild and severe. The fuzzy logic technique was used for activity classifiers.

CONCLUSION

The prevailing research themes demonstrated the growing utility of AI algorithms for stroke evaluation.

Occupational Therapists' Perceptions of Robotics Use for Patients With Chronic Stroke

IMPORTANCE

The effectiveness of robotic therapy in stroke rehabilitation has been established by many studies, and occupational therapists should consider using robotics in their clinical practice. However, little is known about occupational therapy practitioners' experience using robotics.

OBJECTIVE

To explore occupational therapists' perceptions of the mechanisms and outcomes of occupational therapy using robotics with chronic stroke patients.

DESIGN

Qualitative study with semistructured focus group interviews. Data were analyzed using thematic analysis.

SETTING

Hospitals and institutions in Japan in which occupational therapists used robotics in their clinical practice.

PARTICIPANTS

Twenty-seven occupational therapists with experience in using robotics with chronic stroke patients as a self-training method that involved repetitive movements of a paralyzed upper extremity. Participants were interviewed in nine focus groups.

RESULTS

Five themes-(1) body function, (2) values, (3) performance skills, (4) occupational performance, and (5) participation-and 12 subthemes were identified on the basis of the Occupational Therapy Practice Framework: Domain and Process (3rd ed.). Participants indicated that robotics improved patients' body function and promoted a desire for independence, which resulted in improved occupational performance and participation in their desired occupations.

CONCLUSIONS AND RELEVANCE

Occupational therapists regarded robotics as an adjunct to other therapy, which improved patients' body function and promoted their desire for independence. What This Article Adds: Findings from this research provide insights into using robotics to enhance occupational therapy practice.

Peak Activation Shifts in the Sensorimotor Cortex of Chronic Stroke Patients Following Robot-assisted Rehabilitation Therapy

Background:

Ischemic stroke is the most common cause of complex chronic disability and the third leading cause of death worldwide. In recovering stroke patients, peak activation within the ipsilesional primary motor cortex (M1) during the performance of a simple motor task has been shown to exhibit an anterior shift in many studies and a posterior shift in other studies.

Objective:

We investigated this discrepancy in chronic stroke patients who completed a robot-assisted rehabilitation therapy program.

Methods:

Eight chronic stroke patients with an intact M1 and 13 Healthy Control (HC) volunteers underwent 300 functional magnetic resonance imaging (fMRI) scans while performing a grip task at different force levels with a robotic device. The patients were trained with the same robotic device over a 10-week intervention period and their progress was evaluated serially with the Fugl-Meyer and Modified Ashworth scales. Repeated measure analyses were used to assess group differences in locations of peak activity in the sensorimotor cortex (SM) and the relationship of such changes with scores on the Fugl-Meyer Upper Extremity (FM UE) scale.

Results:

Patients moving their stroke-affected hand had proportionally more peak activations in the primary motor area and fewer peak activations in the somatosensory cortex than the healthy controls (P=0.009). They also showed an anterior shift of peak activity on average of 5.3-mm (P<0.001). The shift correlated negatively with FM UE scores (P=0.002).

Conclusion:

A stroke rehabilitation grip task with a robotic device was confirmed to be feasible during fMRI scanning and thus amenable to be used to assess plastic changes in neurological motor activity. Location of peak activity in the SM is a promising clinical neuroimaging index for the evaluation and monitoring of chronic stroke patients.

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.

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.

Unimanual and bimanual motor performance in children with developmental coordination disorder (DCD) provide evidence for underlying motor control deficits

Much of our understanding of motor control deficits in children with developmental coordination disorder (DCD) comes from upper limb assessments focusing on the dominant limb. Here, using two robotic behavioural tasks, we investigated motor control in both the dominant and non-dominant limbs of children with DCD. Twenty-six children with diagnosed DCD (20 males; mean age 10.6 years ± 1.3 years) and 155 controls were included in this cross-sectional study. Participants completed a visually guided reaching task with their dominant and non-dominant limbs and a bimanual object hitting task. Motor performance was quantified across nine parameters. We determined the number of children with DCD who fell outside of the typical performance range of the controls on these parameters and compared the DCD and control groups using ANCOVAs, accounting for age. Children with DCD demonstrated impairments in six out of nine parameters; deficits were more commonly noted in the non-dominant limb. Interestingly, when looking at individual performance, several children with DCD performed in the range of controls. These findings indicate that children with DCD display deficits in motor control in both the dominant and non-dominant limb and highlight the importance of including detailed assessments of both limbs when investigating children with DCD. They also demonstrate the variability in motor control performance evidenced by children with DCD.

Systematic review of novel technology-based interventions for ischemic stroke

PURPOSE

To identify novel technologies pertinent to the prevention, diagnosis, treatment, and rehabilitation of ischemic stroke, and recommend the technologies that show the most promise in advancing ischemic stroke care.

METHOD

A systematic literature search on PubMed and Medscape was performed. Articles were assessed based on pre-determined criteria. Included journal articles were evaluated for specific characteristics and reviewed according to a structured paradigm. A search on www.clinicaltrials.gov was performed to identify pre-clinical ischemic stroke technological interventions. All clinical trial results were included. An additional search on PubMed was conducted to identify studies on robotic neuroendovascular procedures.

RESULTS

Thirty journal articles and five clinical trials were analyzed. Articles were categorized as follows: six studies pertinent to pre-morbidity and prevention of ischemic stroke, three studies relevant to the diagnosis of ischemic stroke, 16 studies about post-ischemic stroke rehabilitation, and five studies on robotic neuroendovascular interventions.

CONCLUSIONS

Novel technologies across the spectrum of ischemic stroke care were identified, and the ones that appear to have the most clinical utility are recommended. Future investigation of the feasibility and long-term efficacy of the recommended technologies in clinical settings is warranted.

Robot enhanced stroke therapy optimizes rehabilitation (RESTORE): a pilot study

BACKGROUND

Robotic rehabilitation after stroke provides the potential to increase and carefully control dosage of therapy. Only a small number of studies, however, have examined robotic therapy in the first few weeks post-stroke. In this study we designed robotic upper extremity therapy tasks for the bilateral Kinarm Exoskeleton Lab and piloted them in individuals with subacute stroke. Pilot testing was focused mainly on the feasibility of implementing these new tasks, although we recorded a number of standardized outcome measures before and after training.

METHODS

Our team developed 9 robotic therapy tasks to incorporate feedback, intensity, challenge, and subject engagement as well as addressing both unimanual and bimanual arm activities. Subacute stroke participants were assigned to a robotic therapy (N = 9) or control group (N = 10) in a matched-group manner. The robotic therapy group completed 1-h of robotic therapy per day for 10 days in addition to standard therapy. The control group participated only in standard of care therapy. Clinical and robotic assessments were completed prior to and following the intervention. Clinical assessments included the Fugl-Meyer Assessment of Upper Extremity (FMA UE), Action Research Arm Test (ARAT) and Functional Independence Measure (FIM). Robotic assessments of upper limb sensorimotor function included a Visually Guided Reaching task and an Arm Position Matching task, among others. Paired sample t-tests were used to compare initial and final robotic therapy scores as well as pre- and post-clinical and robotic assessments.

RESULTS

Participants with subacute stroke (39.8 days post-stroke) completed the pilot study. Minimal adverse events occurred during the intervention and adding 1 h of robotic therapy was feasible. Clinical and robotic scores did not significantly differ between groups at baseline. Scores on the FMA UE, ARAT, FIM, and Visually Guided Reaching improved significantly in the robotic therapy group following completion of the robotic intervention. However, only FIM and Arm Position Match improved over the same time in the control group.

CONCLUSIONS

The Kinarm therapy tasks have the potential to improve outcomes in subacute stroke. Future studies are necessary to quantify the benefits of this robot-based therapy in a larger cohort.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04201613, Registered 17 December 2019-Retrospectively Registered, https://clinicaltrials.gov/ct2/show/NCT04201613 .

Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems

BACKGROUND

We know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury.

METHODS

A Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to use the device, human capital costs of locomotor training, device demand, and the number of training sessions per person with SCI.

RESULTS

Robotic exoskeletons for over-ground training decreased hospital costs associated with delivering locomotor training in the base case analysis. This analysis assumed no difference in intervention effectiveness across locomotor training strategies. Providing robotic exoskeleton overground training for 10% of locomotor training sessions over the course of the year (range 226-397 sessions) results in decreased annual locomotor training costs (i.e., net savings) between $1114 to $4784 per annum. The base case shows small savings that are sensitive to parameters of the BIA model which were tested in one-way sensitivity analyses, scenarios analyses, and probability sensitivity analyses. The base case scenario was more sensitive to clinical utilization parameters (e.g., how often devices sit idle and the substitution of high cost training) than device-specific parameters (e.g., robotic exoskeleton device cost or device life). Probabilistic sensitivity analysis simultaneously considered human capital cost, device cost, and locomotor device substitution. With probabilistic sensitivity analysis, the introduction of a robotic exoskeleton only remained cost saving for one facility.

CONCLUSIONS

Providing robotic exoskeleton for over-ground training was associated with lower costs for the locomotor training of people with SCI in the base case analyses. The analysis was sensitive to parameter assumptions.

Evaluating the use of robotic and virtual reality rehabilitation technologies to improve function in stroke survivors: A narrative review

This review evaluates the effectiveness of robotic and virtual reality technologies used for neurological rehabilitation in stroke survivors. It examines each rehabilitation technology in turn before considering combinations of these technologies and the complexities of rehabilitation outcome assessment. There is high-quality evidence that upper-limb robotic rehabilitation technologies improve movement, strength and activities of daily living, whilst the evidence for robotic lower-limb rehabilitation is currently not as convincing. Virtual reality technologies also improve activities of daily living. Whilst the benefit of these technologies over dose-controlled conventional rehabilitation is likely to be small, there is a role for both technologies as part of a broader rehabilitation programme, where they may help to increase the intensity and amount of therapy delivered. Combining robotic and virtual reality technologies in a rehabilitation programme may further improve rehabilitation outcomes and we would advocate randomised controlled trials of these technologies in combination.

A Cortico- Basal Ganglia Model for choosing an optimal rehabilitation strategy in Hemiparetic Stroke

To facilitate the selection of an optimal therapy for a stroke patient with upper extremity hemiparesis, we propose a cortico-basal ganglia model capable of performing reaching tasks under normal and stroke conditions. The model contains two hemispherical systems, each organized into an outer sensory-motor cortical loop and an inner basal ganglia (BG) loop, controlling their respective hands. The model is trained to simulate two therapeutic approaches: the constraint induced movement therapy (CIMT) in which the intact is arrested, and Bimanual Reaching in which the movements of the intact arm are found to aid the affected arm. Which of these apparently mutually conflicting approaches is right for a given patient? Based on our study on the effect of lesion size on arm performance, we hypothesize that the choice of the therapy depends on the lesion size. Whereas bimanual reaching is more suitable for smaller lesion size, CIMT is preferred in case of larger lesion sizes. By virtue of the model's ability to capture the experimental results effectively, we believe that it can serve as a benchmark for the development and testing of various rehabilitation strategies for stroke.

On the edge between soft and rigid: an assistive shoulder exoskeleton with hyper-redundant kinematics

In this paper, we present a prototype of an innovative portable shoulder exoskeleton for human assistance and augmentation. The device provides torques to flexion/extension movements of the shoulder, compensating for gravitational forces, and is passively compliant along the remaining degrees of freedom letting the shoulder moving along them. The novelty of our system is a flexible link, made of a hyper-redundant passive structure, that avoids joint misalignment by adapting to the complex movements of the humerus head, similarly to a soft component. The flexible link is compliant to rotations around one axis but rigid around the other two axes, allowing transmission of flexion/extension torque but kinematically transparent along the remaining degrees of freedom. The device is light weight and allows to cover around the 82% of the shoulder flexion/extension range of motion. The exoskeleton was tested on a cohort of 5 healthy subjects, monitoring shoulder kinematics, interaction forces and acquiring the electromyography of three major muscles contributing to shoulder flexion. During both static postures and dynamic movements, assistance from the exoskeleton resulted in a significant reduction of muscular effort in the anterior (-32.2% in static, -25.3% in dynamic) and medial deltoid (56.9% in static, -49.6% in dynamic) and an average reduction of the biceps brachii.

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

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

Upper limb robotics applied to neurorehabilitation: An overview of clinical practice

BACKGROUND

During the last two decades, extensive interaction between clinicians and engineers has led to the development of systems that stimulate neural plasticity to optimize motor recovery after neurological lesions. This has resulted in the expansion of the field of robotics for rehabilitation. Studies in patients with stroke-related upper-limb paresis have shown that robotic rehabilitation can improve motor capacity. However, few other applications have been evaluated (e.g. tremor, peripheral nerve injuries or other neurological diseases).

PURPOSE

This paper presents an overview of the current use of upper limb robotic systems for neurorehabilitation, and highlights the rationale behind their use for the assessment and treatment of common neurological disorders.

CONCLUSIONS

Rehabilitation robots are little integrated in clinical practice, except after stroke. Although few studies have been carried out to evaluate their effectiveness, evidence from the neurosciences and indications from pilot studies suggests that upper limb robotic rehabilitation can be applied safely in various other neurological conditions. Rehabilitation robots provide an intensity, quality and dose of treatment that exceeds therapist-mediated rehabilitation. Moreover, the use of force fields, multi-sensory environments, feedback etc. renders such rehabilitation engaging and motivating. Future studies should evaluate the effectiveness of rehabilitation robots in neurological pathologies other than stroke.

Comparison of proximal versus distal upper-limb robotic rehabilitation on motor performance after stroke: a cluster controlled trial

This study examined the treatment efficacy of proximal-emphasized robotic rehabilitation by using the InMotion ARM (P-IMT) versus distal-emphasized robotic rehabilitation by using the InMotion WRIST (D-IMT) in patients with stroke. A total of 40 patients with stroke completed the study. They received P-IMT, D-IMT, or control treatment (CT) for 20 training sessions. Primary outcomes were the Fugl-Meyer Assessment (FMA) and Medical Research Council (MRC) scale. Secondary outcomes were the Motor Activity Log (MAL) and wrist-worn accelerometers. The differences on the distal FMA, total MRC, distal MRC, and MAL quality of movement scores among the 3 groups were statistically significant (P = 0.02 to 0.05). Post hoc comparisons revealed that the D-IMT group significantly improved more than the P-IMT group on the total MRC and distal MRC. Furthermore, the distal FMA and distal MRC improved more in the D-IMT group than in the CT group. Our findings suggest that distal upper-limb robotic rehabilitation using the InMotion WRIST system had superior effects on distal muscle strength. Further research based on a larger sample is needed to confirm long-term treatment effects of proximal versus distal upper-limb robotic rehabilitation.

Supporting Stroke Motor Recovery Through a Mobile Application: A Pilot Study

Neuroplasticity and motor learning are promoted with repetitive movement, appropriate challenge, and performance feedback. ARMStrokes, a smartphone application, incorporates these qualities to support motor recovery. Engaging exercises are easily accessible for improved compliance. In a multiple-case, mixed-methods pilot study, the potential of this technology for stroke motor recovery was examined. Exercises calibrated to the participant’s skill level targeted forearm, elbow, and shoulder motions for a 6-wk protocol. Visual, auditory, and vibration feedback promoted self-assessment. Pre- and posttest data from 6 chronic stroke survivors who used the app in different ways (i.e., to measure active or passive motion, to track endurance) demonstrated improvements in accuracy of movements, fatigue, range of motion, and performance of daily activities. Statistically significant changes were not obtained with this pilot study. Further study on the efficacy of this technology is supported.

Combined therapy using botulinum toxin A and single-joint hybrid assistive limb for upper-limb disability due to spastic hemiplegia

We investigated the combination of robot-assisted rehabilitation (RT) using a single-joint hybrid assistive limb (HAL-SJ) and botulinum toxin A (BTX-A) as therapy for paretic arm with spasticity in post-stroke patients. Participants were seven patients (4 females, 3 males; mean (±SD) age: 60.6±8.4years) who had spastic hemiplegia following chronic stroke. On the day following BTX-A injection, we started RT, which was performed for 20 sessions of 60min each over a two-week period. Clinical outcome measures, including Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), and Disability Assessment Scale (DAS), and cortical activity were evaluated at baseline, and two weeks, and four months following BTX-A injection. Cortical activity associated with elbow joint movement of the affected arm was assessed via functional near infrared spectroscopy (fNIRS). FMA, MAL, and DAS scores significantly improved at two weeks and four months (p<0.05), except DAS scores at four months (p=0.068). The fNIRS study showed that cortical activation increased in the ipsilesional primary sensorimotor area at two weeks and at the four months follow-up. Our pilot study showed that the combination of RT and BTX-A therapy was an effective approach for treating spastic hemiplegia due to stroke, and functional imaging study showed neuroplasticity induced by the treatment.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

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

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

Robotic technologies and rehabilitation: new tools for stroke patients' therapy

Introduction. The role of robotics in poststroke patients' rehabilitation has been investigated intensively. This paper presents the state-of-the-art and the possible future role of robotics in poststroke rehabilitation, for both upper and lower limbs. Materials and Methods. We performed a comprehensive search of PubMed, Cochrane, and PeDRO databases using as keywords “robot AND stroke AND rehabilitation.” Results and Discussion. In upper limb robotic rehabilitation, training seems to improve arm function in activities of daily living. In addition, electromechanical gait training after stroke seems to be effective. It is still unclear whether robot-assisted arm training may improve muscle strength, and which electromechanical gait-training device may be the most effective for walking training implementation. Conclusions. In the field of robotic technologies for stroke patients' rehabilitation we identified currently relevant growing points and areas timely for developing research. Among the growing points there is the development of new easily transportable, wearable devices that could improve rehabilitation also after discharge, in an outpatient or home-based setting. For developing research, efforts are being made to establish the ideal type of treatment, the length and amount of training protocol, and the patient's characteristics to be successfully enrolled to this treatment.

Development of a fuzzy logic based intelligent system for autonomous guidance of post-stroke rehabilitation exercise

This paper presents preliminary studies in developing a fuzzy logic based intelligent system for autonomous post-stroke upper-limb rehabilitation exercise. The intelligent system autonomously varies control parameters to generate different haptic effects on the robotic device. The robotic device is able to apply both resistive and assistive forces for guiding the patient during the exercise. The fuzzy logic based decision-making system estimates muscle fatigue of the patient using exercise performance and generates a combination of resistive and assistive forces so that the stroke survivor can exercise for longer durations with increasing control. The fuzzy logic based system is initially developed using a study with healthy subjects and preliminary results are also presented to validate the developed system with healthy subjects. The next stage of this work will collect data from stroke survivors for further development of the system.

People, sensors, decisions

The ratio of healthcare professionals to care recipients is dropping at an alarming rate, particularly for the older population. It is estimated that the number of persons with Alzheimer's disease, for example, will top 100 million worldwide by the year 2050 [Alzheimer's Disease International 2009]. It will become harder and harder to provide needed health services to this population of older adults. Further, patients are becoming more aware and involved in their own healthcare decisions. This is creating a void in which technology has an increasingly important role to play as a tool to connect providers with recipients. Examples of interactive technologies range from telecare for remote regions to computer games promoting fitness in the home. Currently, such technologies are developed for specific applications and are difficult to modify to suit individual user needs. The future potential economic and social impact of technology in the healthcare field therefore lies in our ability to make intelligent devices that are customizable by healthcare professionals and their clients, that are adaptive to users over time, and that generalize across tasks and environments.

A wide application area for technology in healthcare is for assistance and monitoring in the home. As the population ages, it becomes increasingly dependent on chronic healthcare, such as assistance for tasks of everyday life (washing, cooking, dressing), medication taking, nutrition, and fitness. This article will present a summary of work over the past decade on the development of intelligent systems that provide assistance to persons with cognitive disabilities. These systems are unique in that they are all built using a common framework, a decision-theoretic model for general-purpose assistance in the home. In this article, we will show how this type of general model can be applied to a range of assistance tasks, including prompting for activities of daily living, assistance for art therapists, and stroke rehabilitation. This model is a Partially Observable Markov Decision Process (POMDP) that can be customized by end-users, that can integrate complex sensor information, and that can adapt over time. These three characteristics of the POMDP model will allow for increasing uptake and long-term efficiency and robustness of technology for assistance.

Embracing change: practical and theoretical considerations for successful implementation of technology assisting upper limb training in stroke

Background

Rehabilitation technology for upper limb training of stroke patients may play an important role as therapy tool in future, in order to meet the increasing therapy demand. Currently, implementation of this technology in the clinic remains low. This study aimed at identifying criteria and conditions that people, involved in development of such technology, should take into account to achieve a (more) successful implementation of the technology in the clinic.

Methods

A literature search was performed in PubMed and IEEE databases, and semi-structured interviews with therapists in stroke rehabilitation were held, to identify criteria and conditions technology should meet to facilitate (implementation of) technology-assisted arm-hand skills training in rehabilitation therapy of stroke patients. In addition, an implementation strategy frequently applied in general health care was used to compose a stepwise guidance to facilitate successful implementation of this technology in therapy of stroke patients. Implementation-related criteria mentioned by therapists during the interviews were integrated in this guidance.

Results

Results indicate that, related to therapy content, technology should facilitate repetition of task-related movements, tailored to the patient and patient’s goals, in a meaningful context. Variability and increasing levels of difficulty in exercises should be on offer. Regarding hardware and software design of technology, the system should facilitate quick familiarisation and be easily adjustable to individual patients during therapy by therapists (and assistants). The system should facilitate adaptation to individual patients’ needs and their progression over time, should be adjustable as to various task-related variables, should be able to provide instructions and feedback, and should be able to document patient’s progression. The implementation process of technology in the clinic is provided as a stepwise guidance that consists of five phases therapists have to go through. The guidance includes criteria and conditions that motivate therapists, and make it possible for them, to actually use technology in their daily clinical practice.

Conclusions

The reported requirements are important as guidance for people involved in the development of rehabilitation technology for arm-hand therapy of stroke patients. The stepwise guide provides a tool for facilitating successful implementation of technology in clinical practice, thus meeting future therapy demand.

A decision-theoretic approach in the design of an adaptive upper-limb stroke rehabilitation robot

This paper presents an automated system for a rehabilitation robotic device that guides stroke patients through an upper-limb reaching task. The system uses a partially observable Markov decision process (POMDP) as its primary engine for decision-making. The POMDP allows the system to automatically modify exercise parameters to account for the specific needs and abilities of different individuals, and to use these parameters to take appropriate decisions about stroke rehabilitation exercises. The performance of the system was evaluated through various simulations and by comparing the decisions made by the system with those of a human therapist for a single patient. In general, the simulations showed promising results and the therapist thought the system decisions were believable.

Evaluation of proprioceptive sense of the elbow joint with RehabRoby

In recent years, robot-assisted rehabilitation systems have been an active research area that can quantitatively monitor and adapt to patient progress, and ensure consistency during rehabilitation. In this work, an exoskeleton type robot-assisted rehabilitation system called RehabRoby is developed. A control architecture, which contains a high level controller and a low level controller, is designed for RehabRoby. Proprioceptive sense of healthy subjects has been evaluated during the execution of a task with RehabRoby. Additionally, usability of RehabRoby has been evaluated using a questionnaire.

Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis

OBJECTIVE

To evaluate the efficacy of a gravity-supported, computer-enhanced device (Armeo® Spring) for upper limb rehabilitation in chronic stroke patients.

MATERIAL AND METHODS

We included 23 chronic hemiparetic patients (chronicity: 328 ± 90.8 days; distribution: 17 men and 6 women) aged 54.6 ± 9.5 years, who had sustained ischaemic stroke (n=12) or haemorrhagic stroke (n=11). All patients completed 36 one-hour sessions using the Armeo® Spring system. Arm movement was assessed at the beginning and end of the treatment programme and once more 4 months later. Main outcome measurements covered structure, activity, and function, as per the International Classification of Functioning, Disability and Health: Modified Ashworth Scale, Motricity Index (MI), Fugl-Meyer Assessment Scale (FM), Motor Assessment Scale (MAS), Manual Function Test (MFT), and Wolf Motor Function Test (WMFT).

RESULTS

Repeated measures ANOVA showed significant improvement (time effect) for all function scales (P<.01 for FM and MI) and activity scales (P<.01 for MAS, MFT and WMFT-ability, and P<.05 WMFT-time) without significant changes in muscle tone. The post-hoc analysis (Bonferroni) showed different evolutionary patterns for function and activity measurements, and clear benefits related to Armeo® Spring training, especially on activity scales.

CONCLUSIONS

Armeo® Spring is an effective tool for rehabilitating the affected arm in patients with hemiparesis secondary to ictus, even in the chronic stage.

Constraining upper limb synergies of hemiparetic patients using a robotic exoskeleton in the perspective of neuro-rehabilitation

The aim of this paper was to explore how an upper limb exoskeleton can be programmed to impose specific joint coordination patterns during rehabilitation. Based on rationale which emphasizes the importance of the quality of movement coordination in the motor relearning process, a robot controller was developed with the aim of reproducing the individual corrections imposed by a physical therapist on a hemiparetic patient during pointing movements. The approach exploits a description of the joint synergies using principal component analysis (PCA) on joint velocities. This mathematical tool is used both to characterize the patient's movements, with or without the assistance of a physical therapist, and to program the exoskeleton during active-assisted exercises. An original feature of this controller is that the hand trajectory is not imposed on the patient: only the coordination law is modified. Experiments with hemiparetic patients using this new active-assisted mode were conducted. Obtained results demonstrate that the desired inter-joint coordination was successfully enforced, without significantly modifying the trajectory of the end point.

Improving fine motor function after brain injury using gesture recognition biofeedback

PURPOSE

We developed a gesture recognition biofeedback (GRB) device for improving fine motor function in persons with brain injury using surface muscle pressures of the forearm to provide real-time visual biofeedback. The GRB apparatus is easy to don by moderately impaired users and does not require precise placement of sensors.

METHOD

The efficacy of GRB training with each subject was assessed by comparing its effectiveness against standard repetitive training without feedback. The outcome was measured using a nine-hole peg test (HPT) administered before and after each condition, in a cross-over study design.

RESULTS

GRB was shown to be effective for short-term improvement of fine motor function of 12 impaired participants, reducing their average time to completion of the HPT by 15.5% (S.D. 7.14%). In a subset of impaired subjects, this effect was significant in comparison to similar training without biofeedback (p < 0.05). Control subjects experienced negligible change in HPT time.

CONCLUSIONS

This pilot study of a heterogeneous group shows that GRB may offer a simple means to help impaired users re-learn specified manual tasks.

Results of clinicians using a therapeutic robotic system in an inpatient stroke rehabilitation unit

Background

Physical rehabilitation is an area where robotics could contribute significantly to improved motor return for individuals following a stroke. This paper presents the results of a preliminary randomized controlled trial (RCT) of a robot system used in the rehabilitation of the paretic arm following a stroke.

Methods

The study's objectives were to explore the efficacy of this new type of robotic therapy as compared to standard physiotherapy treatment in treating the post-stroke arm; to evaluate client satisfaction with the proposed robotic system; and to provide data for sample size calculations for a proposed larger multicenter RCT. Twenty clients admitted to an inpatient stroke rehabilitation unit were randomly allocated to one of two groups, an experimental (robotic arm therapy) group or a control group (conventional therapy). An occupational therapist blinded to patient allocation administered two reliable measures, the Chedoke Arm and Hand Activity Inventory (CAHAI-7) and the Chedoke McMaster Stroke Assessment of the Arm and Hand (CMSA) at admission and discharge. For both groups, at admission, the CMSA motor impairment stage of the affected arm was between 1 and 3.

Results

Data were compared to determine the effectiveness of robot-assisted versus conventional therapy treatments. At the functional level, both groups performed well, with improvement in scores on the CAHAI-7 showing clinical and statistical significance. The CAHAI-7 (range7-49) is a measure of motor performance using functional items. Individuals in the robotic therapy group, on average, improved by 62% (95% CI: 26% to 107%) while those in the conventional therapy group changed by 30% (95% CI: 4% to 61%). Although performance on this measure is influenced by hand recovery, our results showed that both groups had similar stages of motor impairment in the hand. Furthermore, the degree of shoulder pain, as measured by the CMSA pain inventory scale, did not worsen for either group over the course of treatment.

Conclusion

Our findings indicated that robotic arm therapy alone, without additional physical therapy interventions tailored to the paretic arm, was as effective as standard physiotherapy treatment for all responses and more effective than conventional treatment for the CMSA Arm (p = 0.04) and Hand (p = 0.04). At the functional level, both groups performed equally well.

The development of an adaptive upper-limb stroke rehabilitation robotic system

Background

Stroke is the primary cause of adult disability. To support this large population in recovery, robotic technologies are being developed to assist in the delivery of rehabilitation. This paper presents an automated system for a rehabilitation robotic device that guides stroke patients through an upper-limb reaching task. The system uses a decision theoretic model (a partially observable Markov decision process, or POMDP) as its primary engine for decision making. The POMDP allows the system to automatically modify exercise parameters to account for the specific needs and abilities of different individuals, and to use these parameters to take appropriate decisions about stroke rehabilitation exercises.

Methods

The performance of the system was evaluated by comparing the decisions made by the system with those of a human therapist. A single patient participant was paired up with a therapist participant for the duration of the study, for a total of six sessions. Each session was an hour long and occurred three times a week for two weeks. During each session, three steps were followed: (A) after the system made a decision, the therapist either agreed or disagreed with the decision made; (B) the researcher had the device execute the decision made by the therapist; (C) the patient then performed the reaching exercise. These parts were repeated in the order of A-B-C until the end of the session. Qualitative and quantitative question were asked at the end of each session and at the completion of the study for both participants.

Results

Overall, the therapist agreed with the system decisions approximately 65% of the time. In general, the therapist thought the system decisions were believable and could envision this system being used in both a clinical and home setting. The patient was satisfied with the system and would use this system as his/her primary method of rehabilitation.

Conclusions

The data collected in this study can only be used to provide insight into the performance of the system since the sample size was limited. The next stage for this project is to test the system with a larger sample size to obtain significant results.

Assessment and modulation of neural plasticity in rehabilitation with transcranial magnetic stimulation

Despite intensive efforts to improve outcomes after acquired brain injury, functional recovery is often limited. One reason for this limitation is the challenge in assessing and guiding plasticity after brain injury. In this context, transcranial magnetic stimulation (TMS), a noninvasive tool of brain stimulation, could play a major role. TMS has been shown to be a reliable tool for measuring plastic changes in the motor cortex associated with interventions in the motor system, such as motor training and motor cortex stimulation. In addition, as illustrated by the experience in promoting recovery from stroke, TMS is a promising therapeutic tool to minimize motor, speech, cognitive, and mood deficits. In this review, we will focus on stroke to discuss how TMS can provide insights into the mechanisms of neurologic recovery and how it can be used for measurement and modulation of plasticity after an acquired brain insult.

Movement therapy induced neural reorganization and motor recovery in stroke: a review

This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.

Interventions to promote upper limb recovery in stroke survivors with severe paresis: a systematic review

PURPOSE

To investigate the effect of interventions that promote upper limb (UL) recovery in stroke survivors with severe paresis.

METHODS

A systematic search of the scientific literature from January 1970 to March 2009 was conducted using CINAHL, Cochrane, PEDro, Pubmed and Web of Science. keywords used included stroke, severe, hemiplegia, UL, task-oriented, robot, non-robot and electrical stimulation. Methodological quality of the studies was assessed using the PEDro rating scale. Studies were grouped into one of three intervention categories: robotic therapy, electrical stimulation or 'other' therapy.

RESULTS

Seventeen randomised controlled trials met the inclusion criteria. A 'best evidence synthesis' indicated strong evidence that robotic therapy provides a large beneficial effect and limited evidence that electrical stimulation and 'other' interventions provide a large beneficial effect on function. There is no evidence that these interventions influence use of the arm in everyday tasks.

CONCLUSION

There are a number of newly developed interventions that enable stroke survivors with severe paresis to actively participate in task-oriented practice to promote UL recovery. While these interventions offer some promise for stroke survivors with severe paresis, ultimately, the effectiveness of these interventions will be dependent on whether they lead to restoration of function to the point at which the stroke survivor can practice everyday tasks.

The development of an upper limb stroke rehabilitation robot: identification of clinical practices and design requirements through a survey of therapists

PURPOSE. Timely and adequate rehabilitation after a stroke is crucial to maximising recovery. A way of increasing treatment access could be through robots, which would aid therapists in providing post-stroke rehabilitation. This research sought to discover the needs and preferences of therapists with respect to a robot that focuses on upper limb rehabilitation. Understanding requirements for devices could help to increase integration into clinical practice. METHODS. An international online survey was distributed through professional organisations and e-mail list services to therapists. The survey contained 85 items covering topics such as therapist background and treatment approach, rehabilitation aims and robotic rehabilitation device attributes. RESULTS. Data were analysed for 233 respondents, most of whom were physiotherapists and occupational therapists from Australia, Canada and USA. Top attributes included: facilitating a variety of arm movements, being usable while seated, giving biofeedback to clients, having virtual activities specific to daily living, being useful in-home and having resistance adjustable to client needs. In addition, the device should cost under 6000 USD. CONCLUSIONS. Findings from this survey provide guidance for technology developers regarding therapists' specifications for a robotic device for upper limb rehabilitation. In addition, findings offer a better understanding of how acceptance of such devices may be facilitated.

Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial

OBJECTIVE

To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis.

METHODS

A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline-posttreatment and at 6 months-were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9).

RESULTS

Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ± 1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps >.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P < .05).

CONCLUSION

This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.

Assessment of upper-limb sensorimotor function of subacute stroke patients using visually guided reaching

OBJECTIVE

Using robotic technology, we examined the ability of a visually guided reaching task to assess the sensorimotor function of patients with stroke.

METHODS

Ninety-one healthy participants and 52 with subacute stroke of mild to moderate severity (26 with left- and 26 with right-affected body sides) performed an unassisted reaching task using the KINARM robot. Each participant was assessed using 12 movement parameters that were grouped into 5 attributes of sensorimotor control.

RESULTS

A number of movement parameters individually identified a large number of stroke participants as being different from 95% of the controls-most notably initial direction error, which identified 81% of left-affected patients. We also found interlimb differences in performance between the arms of those with stroke compared with controls. For example, whereas only 31% of left-affected participants showed differences in reaction time with their affected arm, 54% showed abnormal interlimb differences in reaction time. Good interrater reliability (r > 0.7) was observed for 9 of the 12 movement parameters. Finally, many stroke patients deemed impaired on the reaching task had been scored 6 or less on the arm portion of the Chedoke-McMaster Stroke Assessment Scale, but some who scored a normal 7 were also deemed impaired in reaching.

CONCLUSIONS

Robotic technology using a visually guided reaching task can provide reliable information with greater sensitivity about a patient's sensorimotor impairments following stroke than a standard clinical assessment scale.

Impact of intensity of practice after stroke: Issues for consideration

PURPOSE

The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the paper raises the question of what it is that patients actually learn when they improve their functional skills. Search strategy. For this purpose articles from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE and PiCarta and references presented in relevant publications were examined.

DISCUSSION AND CONCLUSION

Although, there is strong evidence that early augmented exercise therapy time (expressed as time dedicated to practice) may enhance functional recovery, there is a discrepancy between the evidence for the benefits of intensive practice, on the one hand, and, the implementation of intensive rehabilitation treatment programmes in the current healthcare system on the other. Further emphasis should be given on a better understanding of the time-dependency of prognostic factors that determine the effectiveness of intensive practice in patients with stroke. In addition, a better understanding is needed of the neurophysiological and biomechanical mechanisms that underlie compensation-related learning of functional tasks after stroke.

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

Background

It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.

Methods

A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).

Results

One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.

Conclusion

This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

Neuromuscular electrical stimulation for motor restoration in hemiplegia

Clinical applications of neuromuscular electrical stimulation (NMES) in stroke rehabilitation provide both therapeutic and functional benefits. Therapeutic applications include upper and lower limb motor relearning and reduction of poststroke shoulder pain. There is growing evidence that NMES, especially those approaches that incorporate task-specific strategies, is effective in facilitating upper and lower limb motor relearning. There is also strong evidence that NMES reduces poststroke shoulder subluxation and pain. Functional applications include upper and lower limb neuroprostheses. Lower limb neuroprostheses in the form of peroneal nerve stimulators is effective in enhancing the gait speed of stroke survivors with foot-drop. The development of hand neuroprostheses is in its infancy and must await additional fundamental and technical advances before reaching clinical viability. The limitations of available systems and future developments are discussed.

A perspective on intelligent devices and environments in medical rehabilitation

Globally, the number of people older than 65 years is anticipated to double between 1997 and 2025, while at the same time the number of people with disabilities is growing at a similar rate, which makes technical advances and social policies critical to attain, prolong, and preserve quality of life. Recent advancements in technology, including computation, robotics, machine learning, communication, and miniaturization of sensors have been used primarily in manufacturing, military, space exploration, and entertainment. However, few efforts have been made to utilize these technologies to enhance the quality of life of people with disabilities. This article offers a perspective of future development in seven emerging areas: translation of research into clinical practice, pervasive assistive technology, cognitive assistive technologies, rehabilitation monitoring and coaching technologies, robotic assisted therapy, and personal mobility and manipulation technology.