New technologies promoting active upper limb rehabilitation after stroke: an overview and network meta-analysis

The role of robot-assisted training on rehabilitation outcomes in Parkinson's disease: a systematic review and meta-analysis

PURPOSE

The study aims to assess the efficacy of robot-assisted rehabilitation training on upper and lower limb motor function and fatigue in Parkinson's disease (PD), and to explore the best-acting robotic rehabilitation program.

METHODS

We searched studies in seven databases and the search period was from the build to 30 June 2023. Two researchers independently screened studies and assessed the quality of the studies for data extraction.

RESULTS

A total of 21 studies were included, 18 studies related to lower limbs rehabilitation and 3 studies related to upper limbs rehabilitation, involving a total of 787 participants. The results showed that robot-assisted rehabilitation significantly improved indicators of lower limb motor function UPDRS Part III (WMD = -3.58, 95% CI = -5.91 to -1.25, p = 0.003) and BBS (WMD = 4.24, 95% CI = 2.88 to 5.54, p < 0.001), as well as non-motor symptoms of fatigue (WMD = -13.39, 95% CI = -17.92 to -8.86, p < 0.001) in PD patients. At the level of upper limb function, there was no statistically significant difference in the outcome measures of PFS (WMD = -0.25, 95% CI = -4.44 to 3.93, p = 0.9) and BBT (WMD = 1.73, 95% CI = -2.85 to 6.33, p = 0.458).

CONCLUSION

Robot-assisted rehabilitation significantly improved motor function, fatigue, and balance confidence in PD patients, but current evidence doesn't show that intelligent rehabilitation systems improve upper limb function. In particular, robotics combined with virtual reality worked best.

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.

Perspectives of Decision Support System TeleRehab in the Management of Post-Stroke Telerehabilitation

Stroke is the main cause of disability among adults. Decision-making in stroke rehabilitation is increasingly complex; therefore, the use of decision support systems by healthcare providers is becoming a necessity. However, there is a significant lack of software for the management of post-stroke telerehabilitation (TR). This paper presents the results of the developed software "TeleRehab" to support the decision-making of clinicians and healthcare providers in post-stroke TR. We designed a Python-based software with a graphical user interface to manage post-stroke TR. We searched Scopus, ScienceDirect, and PubMed databases to obtain research papers with results of clinical trials for post-stroke TR and to form the knowledge base of the software. The findings show that TeleRehab suggests recommendations for TR to provide practitioners with optimal and real-time support. We observed feasible outcomes of the software based on synthetic data of patients with balance problems, spatial neglect, and upper and lower extremities dysfunctions. Also, the software demonstrated excellent usability and acceptability scores among healthcare professionals.

Stroke Survivors' Interaction With Hand Rehabilitation Devices: Observational Study

BACKGROUND

The hand is crucial for carrying out activities of daily living as well as social interaction. Functional use of the upper limb is affected in up to 55% to 75% of stroke survivors 3 to 6 months after stroke. Rehabilitation can help restore function, and several rehabilitation devices have been designed to improve hand function. However, access to these devices is compromised in people with more severe loss of function.

OBJECTIVE

In this study, we aimed to observe stroke survivors with poor hand function interacting with a range of commonly used hand rehabilitation devices.

METHODS

Participants were engaged in an 8-week rehabilitation intervention at a technology-enriched rehabilitation gym. The participants spent 50-60 minutes of the 2-hour session in the upper limb section at least twice a week. Each participant communicated their rehabilitation goals, and an Action Research Arm Test (ARAT) was used to measure and categorize hand function as poor (scores of 0-9), moderate (scores of 10-56), or good (score of 57). Participants were observed during their interactions with 3 hand-based rehabilitation devices that focused on hand rehabilitation: the GripAble, NeuroBall, and Semi-Circular Peg Board. Observations of device interactions were recorded for each session.

RESULTS

A total of 29 participants were included in this study, of whom 10 (34%) had poor hand function, 17 (59%) had moderate hand function, and 2 (7%) had good hand function. There were no differences in the age and years after stroke among participants with poor hand function and those with moderate (P=.06 and P=.09, respectively) and good (P=.37 and P=.99, respectively) hand function. Regarding the ability of the 10 participants with poor hand function to interact with the 3 hand-based rehabilitation devices, 2 (20%) participants with an ARAT score greater than 0 were able to interact with the devices, whereas the other 8 (80%) who had an ARAT score of 0 could not. Their inability to interact with these devices was clinically examined, and the reason was determined to be a result of either the presence of (1) muscle tone or stiffness or (2) muscle weakness.

CONCLUSIONS

Not all stroke survivors with impairments in their hands can make use of currently available rehabilitation technologies. Those with an ARAT score of 0 cannot actively interact with hand rehabilitation devices, as they cannot carry out the hand movement necessary for such interaction. The design of devices for hand rehabilitation should consider the accessibility needs of those with poor hand function.

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 stratified effects of repetitive transcranial magnetic stimulation in upper limb motor impairment recovery after stroke: a meta-analysis

Background

The recovery of upper extremity motor impairment after stroke remains a challenging task. The clinical effectiveness of repetitive transcranial magnetic stimulation (rTMS), which is believed to aid in the recovery process, is still uncertain.

Methods

A systematic search was conducted in Medline (Ovid), Cochrane and Embase electronic databases from March 28, 2014, to March 28, 2023. The inclusion criteria consisted of randomized controlled trials that assessed the effects of rTMS on the recovery of upper limb motor impairment among stroke patients. Various measurements, including the Fugl Meyer Assessment Upper Extremity Scale (FMA-UE), Brunnstrom recovery stage, Action Research Arm Test (ARAT), and Barthel index, were evaluated both before and after the intervention.

Results

Nineteen articles with 865 patients were included. When considering only the rTMS parameters, both inhibitory and excitatory rTMS improved FMA-UE (MD = 1.87, 95% CI = [0.88]-[2.86], p < 0.001) and Barthel index (MD = 9.73, 95% CI = [4.57]-[14.89], p < 0.001). When considering only the severity of upper limb hemiplegia, both less severe (MD = 1.56, 95% CI = [0.64]-[2.49], p < 0.001) and severe (MD = 2.05, 95% CI = [1.09]-[3.00], p < 0.001) hemiplegia benefited from rTMS based on FMA-UE. However, when considering the rTMS parameters, severity of hemiplegia and stroke stages simultaneously, inhibitory rTMS was found to be significantly effective for less severe hemiplegia in the acute and subacute phases (MD = 4.55, 95% CI = [2.49]-[6.60], p < 0.001), but not in the chronic phase based on FMA-UE. For severe hemiplegia, inhibitory rTMS was not significantly effective in the acute and subacute phases, but significantly effective in the chronic phase (MD = 2.10, 95% CI = [0.75]-[3.45], p = 0.002) based on FMA-UE. Excitatory rTMS was found to be significantly effective for less severe hemiplegia in the acute and subacute phases (MD = 1.93, 95% CI = [0.58]-[3.28], p = 0.005) based on FMA-UE. The improvements in Brunnstrom recovery stage and ARAT need further research.

Conclusion

The effectiveness of rTMS depends on its parameters, severity of hemiplegia, and stroke stages. It is important to consider all these factors together, as any single grouping method is incomplete.

Error Enhancement for Upper Limb Rehabilitation in the Chronic Phase after Stroke: A 5-Day Pre-Post Intervention Study

A large proportion of chronic stroke survivors still struggle with upper limb (UL) problems in daily activities, typically reaching tasks. During three-dimensional reaching movements, the deXtreme robot offers error enhancement forces. Error enhancement aims to improve the quality of movement. We investigated clinical and patient-reported outcomes and assessed the quality of movement before and after a 5 h error enhancement training with the deXtreme robot. This pilot study had a pre-post intervention design, recruiting 22 patients (mean age: 57 years, mean days post-stroke: 1571, male/female: 12/10) in the chronic phase post-stroke with UL motor impairments. Patients received 1 h robot treatment for five days and were assessed at baseline and after training, collecting (1) clinical, (2) patient-reported, and (3) kinematic (KINARM, BKIN Technologies Ltd., Kingston, ON, Canada) outcome measures. Our analysis revealed significant improvements (median improvement (Q1-Q3)) in (1) UL Fugl-Meyer assessment (1.0 (0.8-3.0), p < 0.001) and action research arm test (2.0 (0.8-2.0), p < 0.001); (2) motor activity log, amount of use (0.1 (0.0-0.3), p < 0.001) and quality of use (0.1 (0.1-0.5), p < 0.001) subscale; (3) KINARM-evaluated position sense (-0.45 (-0.81-0.09), p = 0.030) after training. These findings provide insight into clinical self-reported and kinematic improvements in UL functioning after five hours of error enhancement UL training.

Artificial Intelligence and Digital Divide in Physiotherapy Education

The potential of artificial intelligence (AI) in health care and education has become increasingly evident, promising to revolutionize how healthcare professionals deliver services and how learners engage with educational content. AI enhances individualized student learning experiences and transforms education delivery by adapting to emerging healthcare advancements. We emphasize the current need for more exploration of AI's applications in day-to-day education in physiotherapy schools. We conducted a PubMed search, revealing a significant gap in research on AI in physiotherapy education compared to medical and dental education. Knowledge gaps and varied perspectives among Canadian healthcare students, including physiotherapy students, highlight the need for targeted educational strategies and ethical considerations. We conclude with a call to bridge the digital divide in physiotherapy education, stressing the importance of integrating AI to empower students and foster innovation in physiotherapy education.

User Experience Evaluation of Upper Limb Rehabilitation Robots: Implications for Design Optimization: A Pilot Study

With the development of science and technology, people are trying to use robots to assist in stroke rehabilitation training. This study aims to analyze the result of the formative test to provide the orientation of upper limb rehabilitation robot design optimization. We invited 21 physical therapists (PTs) and eight occupational therapists (OTs) who had no experience operating any upper limb rehabilitation robots before, and 4 PTs and 1 OT who had experience operating upper limb rehabilitation robots. Data statistics use the Likert scale. The general group scored 3.5 for safety-related topics, while the experience group scored 4.5. In applicability-related questions, the main function score was 2.3 in the general group and 2.4 in the experience group; and the training trajectory score was 3.5 in the general group and 5.0 in the experience group. The overall ease of use score was 3.1 in the general group and 3.6 in the experience group. There was no statistical difference between the two groups. The methods to retouch the trajectory can be designed through the feedback collected in the formative test and gathering further detail in the next test. Further details about the smooth trajectory must be confirmed in the next test. The optimization of the recording process is also important to prevent users from making additional effort to know it well.

A Robot-Assisted Framework for Rehabilitation Practices: Implementation and Experimental Results

One of the most interesting characteristics of collaborative robots is their ability to be used in close cooperation scenarios. In industry, this facilitates the implementation of human-in-loop workflows. However, this feature can also be exploited in different fields, such as healthcare. In this paper, a rehabilitation framework for the upper limbs of neurological patients is presented, consisting of a collaborative robot that helps users perform three-dimensional trajectories. Such a practice is aimed at improving the coordination of patients by guiding their motions in a preferred direction. We present the mechatronic setup, along with a preliminary experimental set of results from 19 volunteers (patients and control subjects) who provided positive feedback on the training experience (52% of the subjects would return and 44% enjoyed performing the exercise). Patients were able to execute the exercise, with a maximum deviation from the trajectory of 16 mm. The muscular effort required was limited, with average maximum forces recorded at around 50 N.

Visual feedback and age affect upper limb reaching accuracy and kinematics in immersive virtual reality among healthy adults

This cross-sectional study aimed to evaluate the effect of visual feedback, age and movement repetition on the upper limb (UL) accuracy and kinematics during a reaching task in immersive virtual reality (VR). Fifty-one healthy participants were asked to perform 25 trials of a reaching task in immersive VR with and without visual feedback of their hand. They were instructed to place, as accurately and as fast as possible, a controller held in their non-dominant hand in the centre of a virtual red cube of 3 cm side length. For each trial, the end-point error (distance between the tip of the controller and the centre of the cube), a coefficient of linearity (CL), the movement time (MT), and the spectral arc length of the velocity signal (SPARC), which is a movement smoothness index, were calculated. Multivariate analyses of variance were conducted to assess the influence of visual feedback, age and trial repetition on the average end-point error, SPARC, CL and MT, and their time course throughout the 25 trials. Providing visual feedback of the hand reduced average end-point error ( P  < 0.001) and MT ( P  = 0.044), improved SPARC ( P  < 0.001) but did not affect CL ( P  = 0.07). Younger participants obtained a lower mean end-point error ( P  = 0.037), a higher SPARC ( P  = 0.021) and CL ( P  = 0.013). MT was not affected by age ( P  = 0.671). Trial repetition increased SPARC ( P  < 0.001) and CL ( P  < 0.001), and reduced MT ( P  = 0.001) but did not affect end-point error ( P  = 0.608). In conclusion, the results of this study demonstrated that providing visual feedback of the hand and being younger improves UL accuracy and movement smoothness in immersive VR. UL kinematics but not accuracy can be improved with more trial repetitions. These findings could guide the future development of protocols in clinical rehabilitation and research.

Efficacy of Robot-Assisted Training on Rehabilitation of Upper Limb Function in Patients With Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically evaluate the effect of robot-assisted training (RAT) on upper limb function recovery in patients with stroke, providing the evidence-based medical basis for the clinical application of RAT.

DATA SOURCES

We searched online electronic databases up to June 2022, including PubMed, The Cochrane Library, Scopus, Web of Science, EMBASE, WanFang Data, CNKI, and VIP full-text databases.

STUDY SELECTION

Randomized controlled trials of the effect of RAT on upper extremity functional recovery in patients with stroke.

DATA EXTRACTION

The Cochrane Collaboration Tool for Assessing the Risk of Bias was used to assess study quality and risk of bias.

DATA SYNTHESIS

Fourteen randomized controlled trials involving 1275 patients were included for review. Compared with the control group, RAT significantly improved upper limb motor function and daily living ability. The overall differences were statistically significant, Fugl-Meyer Assessment for the Upper Extremity (FMA-UE; standard mean difference=0.69; 95% confidence interval, 0.34, 1.05; P=.0001), modified Barthel Index (standard mean difference=0.95; 95% confidence interval, 0.75, 1.15; P<.00001), whereas the differences in modified Ashworth Scale, FIM, and Wolf Motor Function Test scores were not statistically significant.

SUBGROUP ANALYSIS

Compared with the control group, the differences between FMA-UE and modified Barthel Index at 4 and 12 weeks of RAT, there were statistically significant, the differences of FMA-UE and modified Ashworth Scale in patients with stroke in the acute and chronic phases were statistically significant.

CONCLUSION

The present study showed that RAT can significantly enhance the upper limb motor function and activities of daily life in patients with stroke undergoing upper limb rehabilitation.

Functional electrical stimulation therapy controlled by a P300-based brain-computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

Introduction

Up to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain-Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.

Methods

A non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl-Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann-Whitney U statistical tests (𝛼 = 0.05).

Results

After training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.

Discussion

It has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.

Conclusion

The results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

Clinical Features to Predict the Use of a sEMG Wearable Device (REMO®) for Hand Motor Training of Stroke Patients: A Cross-Sectional Cohort Study

After stroke, upper limb motor impairment is one of the most common consequences that compromises the level of the autonomy of patients. In a neurorehabilitation setting, the implementation of wearable sensors provides new possibilities for enhancing hand motor recovery. In our study, we tested an innovative wearable (REMO^®) that detected the residual surface-electromyography of forearm muscles to control a rehabilitative PC interface. The aim of this study was to define the clinical features of stroke survivors able to perform ten, five, or no hand movements for rehabilitation training. 117 stroke patients were tested: 65% of patients were able to control ten movements, 19% of patients could control nine to one movement, and 16% could control no movements. Results indicated that mild upper limb motor impairment (Fugl-Meyer Upper Extremity ≥ 18 points) predicted the control of ten movements and no flexor carpi muscle spasticity predicted the control of five movements. Finally, severe impairment of upper limb motor function (Fugl-Meyer Upper Extremity > 10 points) combined with no pain and no restrictions of upper limb joints predicted the control of at least one movement. In conclusion, the residual motor function, pain and joints restriction, and spasticity at the upper limb are the most important clinical features to use for a wearable REMO^® for hand rehabilitation training.

Quo Vadis, Amadeo Hand Robot? A Randomized Study with a Hand Recovery Predictive Model in Subacute Stroke

BACKGROUND

Early identification of hand-prognosis-factors at patient's admission could help to select optimal synergistic rehabilitation programs based on conventional (COHT) or robot-assisted (RAT) therapies.

METHODS

In this bi-phase cross-over prospective study, 58 stroke patients were enrolled in two randomized groups. Both groups received same treatments A + B (A = 36 COHT sessions for 10 weeks; B = 36 RAT sessions for 10 weeks; 45 min/session; 3 to 5 times per week). Outcome repeated measures by blinded assessors included FMUL, BBT, NHPT, Amadeo Robot (AHR) and AMPS. Statistical comparisons by Pearson's rank correlations and one-way analyses of variance (ANOVA) with Bonferroni posthoc tests, with size effects and statistic power, were reported. Multiple backward linear regression models were used to predict the variability of sensorimotor and functional outcomes.

RESULTS

Isolated COHT or RAT treatments improved hand function at 3 months. While "higher hand paresis at admission" affected to sensorimotor and functional outcomes, "laterality of injury" did not seem to affect the recovery of the hand. Kinetic-kinematic parameters of robot allowed creating a predictive model of hand recovery at 3 and 6 months from 1st session.

CONCLUSIONS

Hand impairment is an important factor in define sensorimotor and functional outcomes, but not lesion laterality, to predict hand recovery.

A Smart Glove Digital System Promotes Restoration of Upper Limb Motor Function and Enhances Cortical Hemodynamic Changes in Subacute Stroke Patients with Mild to Moderate Weakness: A Randomized Controlled Trial

This study was a randomized controlled trial to examine the effects of the RAPAEL^® Smart Glove digital training system on upper extremity function and cortical hemodynamic changes in subacute stroke patients. Of 48 patients, 20 experimental and 16 controls completed the study. In addition to conventional occupational therapy (OT), the experimental group received game-based digital hand motor training with the RAPAEL^® Smart Glove digital system, while the control group received extra OT for 30 min. The Fugl-Meyer assessment (UFMA) and Jebsen-Tayler hand function test (JTT) were assessed before (T0), immediately after (T1), and four weeks after intervention (T2). Cortical hemodynamics (oxyhemoglobin [OxyHb] concentration) were measured by functional near-infrared spectroscopy. The experimental group had significantly better improvements in UFMA (T1-T0 mean [SD]; Experimental 13.50 [7.49]; Control 8.00 [4.44]; p = 0.014) and JTT (Experimental 21.10 [20.84]; Control 5.63 [5.06]; p = 0.012). The OxyHb concentration change over the ipsilesional primary sensorimotor cortex during the affected wrist movement was greater in the experimental group (T1, Experimental 0.7943 × 10^-4 μmol/L; Control -0.3269 × 10^-4 μmol/L; p = 0.025). This study demonstrated a beneficial effect of game-based virtual reality training with the RAPAEL^® Smart Glove digital system with conventional OT on upper extremity motor function in subacute stroke patients.