The use of robots in stroke rehabilitation: A narrative review

Impedance Sliding-Mode Control Based on Stiffness Scheduling for Rehabilitation Robot Systems

Rehabilitation robots can reproduce the rehabilitation movements of therapists by designed rehabilitation robot control methods to achieve the goal of training the patients' motion abilities. This paper proposes an impedance sliding-mode control method based on stiffness-scheduled law for the rehabilitation robot, which can be applied to rehabilitation training with both active and passive modes. A free-model-based sliding-mode control strategy is developed to avoid model dependence and reduce the system uncertainty caused by limb shaking. Additionally, the stiffness scheduling rule automatically regulates the impedance parameter of the rehabilitation robot based on the force exerted by the patient on the robot such that the rehabilitation training caters to the patient's health condition. The proposed method is compared with the fixed stiffness and variable stiffness impedance methods, and the superiority of the proposed method is proved. Rehabilitation training experiments on an actual rehabilitation robot are provided to demonstrate the feasibility and stability of the proposed method.

Clinical potential and neuroplastic effect of targeted virtual reality based intervention for distal upper limb in post-stroke rehabilitation: a pilot observational study

PURPOSE

A library of Virtual Reality (VR) tasks has been developed for targeted post-stroke rehabilitation of distal upper extremities. The objective of this pilot study was to evaluate the clinical potential of the targeted VR-based therapeutic intervention in a small cohort of patients specifically with chronic stroke. Furthermore, our aim was to explore the possible neuronal reorganizations in corticospinal pathways in response to the distal upper limb targeted VR-intervention.

METHODOLOGY

Five patients with chronic stroke were enrolled in this study and were given VR-intervention of 20 sessions of 45 min each. Clinical Scales, cortical-excitability measures (using Transcranial Magnetic Stimulation): Resting Motor Threshold (RMT), and Motor Evoked Potential (MEP) amplitude, task-specific performance metrics i.e., Time taken to complete the task (TCT), smoothness of trajectory, relative % error were evaluated pre- and post-intervention to evaluate the intervention-induced improvements.

RESULTS

Pre-to post-intervention improvements were observed in Fugl-Meyer Assessment (both total and wrist/hand component), Modified Barthel Index, Stroke Impact Scale, Motor Assessment Scale, active range of motion at wrist, and task-specific outcome metrics. Pre-to post-intervention ipsilesional RMT reduced (mean ∼9%) and MEP amplitude increased (mean ∼29µV), indicating increased cortical excitability at post-intervention.

CONCLUSION

VR-training exhibited improved motor outcomes and cortical-excitability in patients with stroke. Neurophysiological changes observed in terms of improved cortical-excitability might be a consequence of plastic reorganization induced by VR-intervention.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Healthcare professionals' perspectives on development of assistive technology using the comprehensive assistive technology model

The implementation of technology in healthcare shows promising results and provides new opportunities in rehabilitation. However, the adoption of technology into daily care is largely dependent on the acceptance rate of end-users. This study aims to gather information from healthcare professionals on the development of new assistive technology that match users' needs using the Comprehensive Assistive Technology model. In total 27 healthcare professionals (12 occupational therapists, 8 physiotherapists, 3 nurses, 2 allied health directors, a physician and a speech therapist) attended one of four online focus group discussions. These focus group discussions were structured using a question guide based on three predefined scenarios. Recordings were transcribed and data was analyzed using a thematic analysis (NVivo). Major themes identified in this study were safety, price and usability. Healthcare professionals focused on both functional capabilities of the user, as well as behavioral aspects of usability and attitude toward technology. Furthermore, the need for assistive technology that were catered toward the limitations in activity and user experience, was highlighted extensively. Based on information gathered from healthcare professionals a user-centered approach in development of safe, low-cost devices that maximize both functional outcomes and user acceptance, could potentially increase the adoption of new technology in rehabilitation.

From one to many: Hypertonia in schizophrenia spectrum psychosis an integrative review and adversarial collaboration report

Different types of resistance to passive movement, i.e. hypertonia, were described in schizophrenia spectrum disorders (SSD) long before the introduction of antipsychotics. While these have been rediscovered in antipsychotic-naïve patients and their non-affected relatives, the existence of intrinsic hypertonia vs drug-induced parkinsonism (DIP) in treated SSD remains controversial. This integrative review seeks to develop a commonly accepted framework to specify the putative clinical phenomena, highlight conflicting issues and discuss ways to challenge each hypothesis and model through adversarial collaboration. The authors agreed on a common framework inspired from systems neuroscience. Specification of DIP, locomotor paratonia (LMP) and psychomotor paratonia (PMP) identified points of disagreement. Some viewed parkinsonian rigidity to be sufficient for diagnosing DIP, while others viewed DIP as a syndrome that should include bradykinesia. Sensitivity of DIP to anticholinergic drugs and the nature of LPM and PMP were the most debated issues. It was agreed that treated SSD should be investigated first. Clinical features of the phenomena at issue could be confirmed by torque, EMG and joint angle measures that could help in challenging the selectivity of DIP to anticholinergics. LMP was modeled as the release of the reticular formation from the control of the supplementary motor area (SMA), which could be challenged by the tonic vibration reflex or acoustic startle. PMP was modeled as the release of primary motor cortex from the control of the SMA and may be informed by subclinical echopraxia. If these challenges are not met, this would put new constraints on the models and have clinical and therapeutic implications.

Application of the extended technology acceptance model to explore clinician likelihood to use robotics in rehabilitation

PURPOSE

Evidence suggests that patients with upper limb impairment following a stroke do not receive recommended amounts of motor practice. Robotics provide a potential solution to address this gap, but clinical adoption is low. The aim of this study was to utilize the technology acceptance model as a framework to identify factors influencing clinician adoption of robotic devices into practice.

MATERIALS AND METHOD

Mixed methods including survey data and focus group discussions with allied health clinicians whose primary caseload was rehabilitation of the neurologically impaired upper limb. Surveys based on the technology acceptance measure were completed pre/post exposure to and use of a robotic device. Focus groups discussions based on the theory of planned behaviour were conducted at the conclusion of the study.

RESULTS

A total of 34 rehabilitation clinicians completed the surveys with pre-implementation data indicating that rehabilitation clinicians perceive robotic devices as complex to use, which influenced intention to use such devices in practice. The focus groups found that lack of experience and time to learn influenced confidence to implement robotic devices into practice.

CONCLUSION

This study found that perceived usefulness and perceived ease of use of a robotic device in clinical rehabilitation can be improved through experience, training and embedded technological support. However, training and embedded support are not routinely offered, suggesting there is a discordance between current implementation and the learning needs of rehabilitation clinicians.IMPLICATIONS FOR REHABILITATIONPatients do not receive adequate amounts of upper limb motor practice following a stroke, and although robotic devices have the potential to address this gap, clinical adoption is low.The technology acceptance model identified that clinicians perceive robotic devices to be complex to use with current implementation efforts failing to consider their training needs.Implementation adoption of robotic devices in rehabilitation should be supported with adequate training and technological support if sustainable practice change is to be achieved.

Multi-Channel FES Gait Rehabilitation Assistance System Based on Adaptive sEMG Modulation

Functional electrical stimulation (FES) can be used to stimulate the lower-limb muscles to provide walking assistance to stroke patients. However, the existing surface electromyography (sEMG)-based FES control methods mostly only consider a single muscle with a fixed stimulation intensity and frequency. This study proposes a multi-channel FES gait rehabilitation assistance system based on adaptive myoelectric modulation. The proposed system collects sEMG of the vastus lateralis muscle on the non-affected side to predict the sEMG values of four targeted lower-limb muscles on the affected side using a bidirectional long short-term memory (BILSTM) model. Next, the proposed system modulates the real-time FES output frequency for four targeted muscles based on the predicted sEMG values to provide muscle force compensation. Fifteen healthy subjects were recruited to participate in an offline model-building experiment conducted to evaluate the feasibility of the proposed BILSTM model in predicting the sEMG values. The experimental results showed that the [Formula: see text] value of the best-obtained prediction result reached 0.85 using the BILSTM model, which was significantly higher than that using traditional prediction methods. Moreover, two patients after stroke were recruited in the online assisted-walking experiment to verify the effectiveness of the proposed walking-assistance system. The experimental results showed that the activation of the target muscles of the patients was higher after FES, and the gait movement data were significantly different before and after FES. The proposed system can be effectively applied to walking assistance for stroke patients, and the experimental results can provide new ideas and methods for sEMG-controlled FES rehabilitation applications.

Lower extremity robotic exoskeleton devices for overground ambulation recovery in acquired brain injury-A review

Acquired brain injury (ABI) is a leading cause of ambulation deficits in the United States every year. ABI (stroke, traumatic brain injury and cerebral palsy) results in ambulation deficits with residual gait and balance deviations persisting even after 1 year. Current research is focused on evaluating the effect of robotic exoskeleton devices (RD) for overground gait and balance training. In order to understand the device effectiveness on neuroplasticity, it is important to understand RD effectiveness in the context of both downstream (functional, biomechanical and physiological) and upstream (cortical) metrics. The review identifies gaps in research areas and suggests recommendations for future research. We carefully delineate between the preliminary studies and randomized clinical trials in the interpretation of existing evidence. We present a comprehensive review of the clinical and pre-clinical research that evaluated therapeutic effects of RDs using various domains, diagnosis and stage of recovery.

Control strategies used in lower limb exoskeletons for gait rehabilitation after brain injury: a systematic review and analysis of clinical effectiveness

BACKGROUND

In the past decade, there has been substantial progress in the development of robotic controllers that specify how lower-limb exoskeletons should interact with brain-injured patients. However, it is still an open question which exoskeleton control strategies can more effectively stimulate motor function recovery. In this review, we aim to complement previous literature surveys on the topic of exoskeleton control for gait rehabilitation by: (1) providing an updated structured framework of current control strategies, (2) analyzing the methodology of clinical validations used in the robotic interventions, and (3) reporting the potential relation between control strategies and clinical outcomes.

METHODS

Four databases were searched using database-specific search terms from January 2000 to September 2020. We identified 1648 articles, of which 159 were included and evaluated in full-text. We included studies that clinically evaluated the effectiveness of the exoskeleton on impaired participants, and which clearly explained or referenced the implemented control strategy.

RESULTS

(1) We found that assistive control (100% of exoskeletons) that followed rule-based algorithms (72%) based on ground reaction force thresholds (63%) in conjunction with trajectory-tracking control (97%) were the most implemented control strategies. Only 14% of the exoskeletons implemented adaptive control strategies. (2) Regarding the clinical validations used in the robotic interventions, we found high variability on the experimental protocols and outcome metrics selected. (3) With high grade of evidence and a moderate number of participants (N = 19), assistive control strategies that implemented a combination of trajectory-tracking and compliant control showed the highest clinical effectiveness for acute stroke. However, they also required the longest training time. With high grade of evidence and low number of participants (N = 8), assistive control strategies that followed a threshold-based algorithm with EMG as gait detection metric and control signal provided the highest improvements with the lowest training intensities for subacute stroke. Finally, with high grade of evidence and a moderate number of participants (N = 19), assistive control strategies that implemented adaptive oscillator algorithms together with trajectory-tracking control resulted in the highest improvements with reduced training intensities for individuals with chronic stroke.

CONCLUSIONS

Despite the efforts to develop novel and more effective controllers for exoskeleton-based gait neurorehabilitation, the current level of evidence on the effectiveness of the different control strategies on clinical outcomes is still low. There is a clear lack of standardization in the experimental protocols leading to high levels of heterogeneity. Standardized comparisons among control strategies analyzing the relation between control parameters and biomechanical metrics will fill this gap to better guide future technical developments. It is still an open question whether controllers that provide an on-line adaptation of the control parameters based on key biomechanical descriptors associated to the patients' specific pathology outperform current control strategies.

Co-creation and stroke rehabilitation: a scoping review

PURPOSE

Co-creation is identified as a concept with potential to address many challenges in modern healthcare systems. Its application within stroke rehabilitation is yet to be reviewed. The purpose of this paper is to identify when and how co-creation has been used in the literature to develop services and approaches to stroke survivor care and rehabilitation.

MATERIALS AND METHODS

A scoping review was conducted guided by the framework outlined by Arksey and O'Malley. Articles were included if they involved co-creation with stroke survivors and identified co-creation as their methodology to develop post-stroke services. Quality appraisal of included articles was completed.

RESULTS

The search strategy identified 565 articles. Fourteen articles met inclusion criteria. The results demonstrate that co-creation as a methodology to develop stroke rehabilitation services is a contemporary field, producing both technology and non-technology-based interventions, predominately in the community context. Co-creation application was inconsistent, with a plethora of methodologies used, and terminology to describe co-creation varying between the studies.

CONCLUSIONS

Co-creation in stroke rehabilitation is currently in an expanding and rudimentary phase. This review identified the variability of its application, with future work needed to establish clarity and consistency in terminology and methodologies utilised to operationalise co-creation in stroke rehabilitation.Implications for rehabilitationCo-creation is a contemporary and evolving service improvement approach in stroke rehabilitation, utilised most commonly in the community context.Inconsistent terminology and diverse methodologies are utilised to enact co-creation in stroke rehabilitation.Opportunities exist to advance co-creation in the stroke rehabilitation space through developing consistency in its application, and further investigation into its use with the stroke survivor population.

The Use of Sports Rehabilitation Robotics to Assist in the Recovery of Physical Abilities in Elderly Patients with Degenerative Diseases: A Literature Review

The increase in the number of elderly patients with degenerative diseases has brought additional medical and financial pressures, which are adding to the burden on society. The development of sports rehabilitation robotics (SRR) is becoming increasingly sophisticated at the technical level of its application; however, few studies have analyzed how it works and how effective it is in aiding rehabilitation, and fewer individualized exercise rehabilitation programs have been developed for elderly patients. The purpose of this study was to analyze the working methods and the effects of different types of SRR and then to suggest the feasibility of applying SRR to enhance the physical abilities of elderly patients with degenerative diseases. The researcher's team searched 633 English-language journal articles, which had been published over the past five years, and they selected 38 of them for a narrative literature review. Our summary found the following: (1) The current types of SRR are generally classified as end-effector robots, smart walkers, intelligent robotic rollators, and exoskeleton robots-exoskeleton robots were found to be the most widely used. (2) The current working methods include assistant tools as the main intermediaries-i.e., robots assist patients to participate; patients as the main intermediaries-i.e., patients dominate the assistant tools to participate; and sensors as the intermediaries-i.e., myoelectric-driven robots promote patient participation. (3) Better recovery was perceived for elderly patients when using SRR than is generally achieved through the traditional single-movement recovery methods, especially in strength, balance, endurance, and coordination. However, there was no significant improvement in their speed or agility after using SRR.

Cortical processing during robot and functional electrical stimulation

Introduction

Like alpha rhythm, the somatosensory mu rhythm is suppressed in the presence of somatosensory inputs by implying cortical excitation. Sensorimotor rhythm (SMR) can be classified into two oscillatory frequency components: mu rhythm (8-13 Hz) and beta rhythm (14-25 Hz). The suppressed/enhanced SMR is a neural correlate of cortical activation related to efferent and afferent movement information. Therefore, it would be necessary to understand cortical information processing in diverse movement situations for clinical applications.

Methods

In this work, the EEG of 10 healthy volunteers was recorded while fingers were moved passively under different kinetic and kinematic conditions for proprioceptive stimulation. For the kinetics aspect, afferent brain activity (no simultaneous volition) was compared under two conditions of finger extension: (1) generated by an orthosis and (2) generated by the orthosis simultaneously combined and assisted with functional electrical stimulation (FES) applied at the forearm muscles related to finger extension. For the kinematic aspect, the finger extension was divided into two phases: (1) dynamic extension and (2) static extension (holding the extended position).

Results

In the kinematic aspect, both mu and beta rhythms were more suppressed during a dynamic than a static condition. However, only the mu rhythm showed a significant difference between kinetic conditions (with and without FES) affected by attention to proprioception after transitioning from dynamic to static state, but the beta rhythm was not.

Discussion

Our results indicate that mu rhythm was influenced considerably by muscle kinetics during finger movement produced by external devices, which has relevant implications for the design of neuromodulation and neurorehabilitation interventions.

Planar Model for Vibration Analysis of Cable Rehabilitation Robots

Cable robots are widely used in the field of rehabilitation. These robots differ from other cable robots because the cables are rather short and are usually equipped with magnetic hooks to improve the ease of use. The vibrations of rehabilitation robots are dominated by the effects of the hooks and payloads, whereas the cables behave as massless springs. In this paper, a 2D model of the cables of a robot that simulates both longitudinal and transverse vibrations is developed and experimentally validated. Then the model is extended to simulate the vibrations of an actual 3D robot in the symmetry planes. Finally, the calculated modal properties (natural frequencies and modes of vibration) are compared with the typical spectrum of excitation due to the cable’s motion. Only the first transverse mode can be excited during the rehabilitation exercise.

User-centered design and development of TWIN-Acta: A novel control suite of the TWIN lower limb exoskeleton for the rehabilitation of persons post-stroke

Introduction

Difficulties faced while walking are common symptoms after stroke, significantly reducing the quality of life. Walking recovery is therefore one of the main priorities of rehabilitation. Wearable powered exoskeletons have been developed to provide lower limb assistance and enable training for persons with gait impairments by using typical physiological movement patterns. Exoskeletons were originally designed for individuals without any walking capacities, such as subjects with complete spinal cord injuries. Recent systematic reviews suggested that lower limb exoskeletons could be valid tools to restore independent walking in subjects with residual motor function, such as persons post-stroke. To ensure that devices meet end-user needs, it is important to understand and incorporate their perspectives. However, only a limited number of studies have followed such an approach in the post-stroke population.

Methods

The aim of the study was to identify the end-users needs and to develop a user-centered-based control system for the TWIN lower limb exoskeleton to provide post-stroke rehabilitation. We thus describe the development and validation, by clinical experts, of TWIN-Acta: a novel control suite for TWIN, specifically designed for persons post-stroke. We detailed the conceived control strategy and developmental phases, and reported evaluation sessions performed on healthy clinical experts and people post-stroke to evaluate TWIN-Acta usability, acceptability, and barriers to usage. At each developmental stage, the clinical experts received a one-day training on the TWIN exoskeleton equipped with the TWIN-Acta control suite. Data on usability, acceptability, and limitations to system usage were collected through questionnaires and semi-structured interviews.

Results

The system received overall good usability and acceptability ratings and resulted in a well-conceived and safe approach. All experts gave excellent ratings regarding the possibility of modulating the assistance provided by the exoskeleton during the movement execution and concluded that the TWIN-Acta would be useful in gait rehabilitation for persons post-stroke. The main limit was the low level of system learnability, attributable to the short-time of usage. This issue can be minimized with prolonged training and must be taken into consideration when planning rehabilitation.

Discussion

This study showed the potential of the novel control suite TWIN-Acta for gait rehabilitation and efficacy studies are the next step in its evaluation process.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Upper limb soft robotic wearable devices: a systematic review

INTRODUCTION

Soft robotic wearable devices, referred to as exosuits, can be a valid alternative to rigid exoskeletons when it comes to daily upper limb support. Indeed, their inherent flexibility improves comfort, usability, and portability while not constraining the user's natural degrees of freedom. This review is meant to guide the reader in understanding the current approaches across all design and production steps that might be exploited when developing an upper limb robotic exosuit.

METHODS

The literature research regarding such devices was conducted in PubMed, Scopus, and Web of Science. The investigated features are the intended scenario, type of actuation, supported degrees of freedom, low-level control, high-level control with a focus on intention detection, technology readiness level, and type of experiments conducted to evaluate the device.

RESULTS

A total of 105 articles were collected, describing 69 different devices. Devices were grouped according to their actuation type. More than 80% of devices are meant either for rehabilitation, assistance, or both. The most exploited actuation types are pneumatic (52%) and DC motors with cable transmission (29%). Most devices actuate 1 (56%) or 2 (28%) degrees of freedom, and the most targeted joints are the elbow and the shoulder. Intention detection strategies are implemented in 33% of the suits and include the use of switches and buttons, IMUs, stretch and bending sensors, EMG and EEG measurements. Most devices (75%) score a technology readiness level of 4 or 5.

CONCLUSION

Although few devices can be considered ready to reach the market, exosuits show very high potential for the assistance of daily activities. Clinical trials exploiting shared evaluation metrics are needed to assess the effectiveness of upper limb exosuits on target users.

Effects of robotic rehabilitation on recovery of hand functions in acute stroke: A preliminary randomized controlled study

OBJECTIVE

The aim of this study was to investigate the effects of EMG-driven robotic rehabilitation on hand motor functions and daily living activities of patients with acute ischemic stroke.

MATERIALS & METHOD

A preliminary randomized-controlled, single-blind trial rectuited twenty-four patients with acute ischemic stroke (<1 month after cerebrovascular accident) and randomly allocated to experimental group (EG) and control group (CG). Neurophysiological rehabilitation program was performed to both EG and CG for 5 days a week and totally 15 sessions. The EG also received robotic rehabilitation with the EMG-driven exoskeleton hand robot (Hand of Hope®, Rehab-Robotics Company) 15 sessions over 3 weeks. Hand motor functions (Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT)), activities of daily living (Motor Activity Log (MAL)), force and EMG activities of extensor and flexor muscles for the cup test were evaluated before treatment (pretreatment) and after the 15th session (posttreatment).

RESULTS

Eleven patients (59.91 ± 14.20 yr) in the EG and 9 patients (70 ± 14.06 yr) in the CG completed the study. EG did not provide a significant advantage compared with the CG in FMA-UE, ARAT and MAL scores and cup-force and EMG activities (p > .05 for all).

CONCLUSION

In this preliminary study, improvement in motor functions, daily living activities and force were found in both groups. However, addition of the EMG-driven robotic treatment to the neurophysiological rehabilitation program did not provide an additional benefit to the clinical outcomes in 3 weeks in acute stroke patients.

A Therapeutic Approach Using the Combined Application of Virtual Reality with Robotics for the Treatment of Patients with Spinal Cord Injury: A Systematic Review

Spinal cord injury (SCI) has been associated with high mortality rates. Thanks to the multidisciplinary vision and approach of SCI, including the application of new technologies in the field of neurorehabilitation, people with SCI can survive and prosper after injury. The main aim of this systematic review was to analyze the effectiveness of the combined use of VR and robotics in the treatment of patients with SCI. The literature search was performed between May and July 2021 in the Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), PubMed, and Web of Science. The methodological quality of each study was assessed using the SCIRE system and the PEDro scale, whereas the risk of bias was analyzed using the Cochrane Collaboration’s tool. A total of six studies, involving 63 participants, were included in this systematic review. Relevant changes were found in the upper limbs, with improvements of shoulder and upper arm mobility, as well as the strengthening of weaker muscles. Combined rehabilitation may be a valuable approach to improve motor function in SCI patients. Nonetheless, further research is necessary, with a larger patient sample and a longer duration.

Rehabilitation robotics after stroke: a bibliometric literature review

INTRODUCTION

Stroke is the leading cause of long-term disability in developed countries. Due to population aging, the number of people requiring rehabilitation after stroke is going to rise in the coming decades. Robot-mediated neurorehabilitation has the potential to improve clinical outcomes of rehabilitation treatments. A statistical analysis of the literature aims to focus on the main trend of this topic.

AREAS COVERED

A bibliometric survey on post-stroke robotic rehabilitation was performed through a database collection of scientific publications in the field of rehabilitation robotics. By covering the last 20 years, 17429 sources were collected. Relevant patterns and statistics concerning the main research areas were analyzed. Leading journals and conferences which publish and disseminate knowledge in the field were identified. A detailed nomenclature study was carried out. The time trends of the research field were captured. Opinions and predictions of future trends that are expected to shape the near future of the field were discussed.

EXPERT OPINION

Data analysis reveals the continuous expansion of the research field over the last two decades, which is expected to rise considerably in near future. More attention will be paid to the lower limbs rehabilitation and disease/design specific applications in early-stage patients.

Evaluation of the implementation of Armeo®Spring in a specialized neurorehabilitation center

Rehabilitation of the upper extremity (UE) is an essential part of the process following an acquired brain injury, where robot technologies have the potential of making the rehabilitation more intensive and effective. However, the implementation of robot technologies in a clinical setting can be complicated and not always successful. The aim of this study was to evaluate the implementation of the robot technology Armeo®Spring (Hocoma, Volketswil, Switzerland) at a specialized neurorehabilitation center, and to propose a list of actions for further implementation of the technology.The Study, Act and Plan phases of the Plan-Do-Study-Act (PDSA) model for structuring technology implementations was applied as the methodological framework in this study. In the Study-phase, nine semi-structured interviews with therapists, using Armeo®Spring, were conducted to evaluate the current implementation. In the Act-phase, a workshop was held with 13 participants to discuss the findings of the Study-phase and to find possible solutions to the identified problems. The results were incorporated into a list of actions (Plan-phase) for further implementation of Armeo®Spring.Facilitating and inhibiting factors for the implementation of Armeo®Spring were identified. Facilitating factors were the practical "hands-on" approach during training, support from the management, support and sparring with colleagues as well as a positive work culture. The inhibiting factors were related to the retention of the therapists' acquired competencies, the identification of the type of patient that can benefit from this form of training, challenges due to the technical use of Armeo®Spring, and prioritization of the rehabilitation needs of the patients.Several solutions were proposed in the Act-phase, which subsequently resulted in eight concrete actions to facilitate the further implementation of Armeo®Spring. It is expected that these actions will contribute to the further implementation of Armeo®Spring at the neurorehabilitation center. As a first step, an Armeo®Spring group with therapists from all relevant wards was established.

Cross-Validation of Machine Learning Models for the Functional Outcome Prediction after Post-Stroke Robot-Assisted Rehabilitation

The state of the art is still lacking an extensive analysis of which clinical characteristics are leading to better outcomes after robot-assisted rehabilitation on post-stroke patients. Prognostic machine learning-based models could promote the identification of predictive factors and be exploited as Clinical Decision Support Systems (CDSS). For this reason, the aim of this work was to set the first steps toward the development of a CDSS, by the development of machine learning models for the functional outcome prediction of post-stroke patients after upper-limb robotic rehabilitation. Four different regression algorithms were trained and cross-validated using a nested 5×10-fold cross-validation. The performances of each model on the test set were provided through the Median Average Error (MAE) and interquartile range. Additionally, interpretability analyses were performed, to evaluate the contribution of the features to the prediction. The results on the two best performing models showed a MAE of 13.6 [13.4] and 13.3 [14.8] on the Modified Barthel Index score (MBI). The interpretability analyses highlighted the Fugl-Meyer Assessment, MBI, and age as the most relevant features for the prediction of the outcome. This work showed promising results in terms of outcome prognosis after robot-assisted treatment. Further research should be planned for the development, validation and translation into clinical practice of CDSS in rehabilitation. Clinical relevance- This work establishes the premises for the development of data-driven tools able to support the clinical decision for the selection and optimisation of the robotic rehabilitation treatment.

Upper-Limb Robot-Assisted Therapy Based on Visual Error Augmentation in Virtual Reality for Motor Recovery and Kinematics after Chronic Hemiparetic Stroke: A Feasibility Study

The purpose of this study was to investigate the effect of upper-limb robot-assisted therapy based on visual error augmentation in virtual reality (UL-RAT-VEAVR) for motor recovery and kinematics after chronic hemiparetic stroke. This study applied a single-group pre- and post-intervention study design. A total of 27 stroke survivors (20 males and 7 females; mean age 54.51 years, mean onset duration 12.7 months) volunteered to participate in this study. UL-RAT-VEAVR was performed three times a week for four weeks, amounting to a total of twelve sessions, in which an end-effector-based robotic arm was used with a visual display environment in virtual reality. Each subject performed a total of 480 point-to-point movements toward 3 direction targets (medial, ipsilateral, and contralateral side) in the visual display environment system while holding the handle of the end-effector-based robotic arm. The visual error (distance to the targets on the monitor) in virtual reality was increased by 5% every week based on the subject’s maximum point-to-point reaching trajectory. Upper-limb motor recovery was measured in all subjects using the Fugl−Meyer Assessment (FMA) upper-limb subscale, the Box and Block Test (BBT), and the Action Research Arm Test (ARAT), before and after training. In addition, a kinematic assessment was also performed before and after training and consisted of time, speed, distance, and curvilinear ratio for point-to-point movement. There were significant improvements in both upper-limb motor function and kinematics after 4 weeks of UL-RAT-VEAVR (p < 0.05). Our results showed that the UL-RAT-VEAVR may have the potential to be used as one of the upper-limb rehabilitation strategies in chronic stroke survivors. Future studies should investigate the clinical effects of the error-augmentation paradigm using an RCT design.

Effect of upper extremity load on pelvic movements during wheeled upright walker use

[Purpose] This study aimed to elucidate the effects of upper extremity loading on pelvic movements during wheeled upright walker use. [Participants and Methods] Thirteen healthy male adults participated in this intervention study. Participants walked under five conditions with targeted loads on their upper extremities of 0%, 10%, 20%, 30%, and 40% of their body weights using a wheeled upright walker with armrests. Measured items included gait velocity and stride length; the angle of the maximum trunk anterior tilt; the range of motion of the trunk and pelvis in the movements of obliquity, tilt, and rotation; and the amplitude of the center of mass in the vertical and lateral directions captured and calculated using a three-dimensional motion analysis system. [Results] Increasing the load on the upper extremities did not shorten the stride or restrict pelvic movement during gait using upright walker use. The range of pelvic rotation with walker use increased versus that of the standard gait. [Conclusion] The pelvis showed quantitative movements during gait using the wheeled upright walker with armrests. These results could be helpful in the development of robotic assistive devices.

Development and Clinical Evaluation of a Novel Foot Stretching Robot that Simultaneously Stretches Plantar Fascia and Achilles Tendon for Treatment of Plantar Fasciitis

OBJECTIVE

This paper presents the development and clinical evaluation of a foot stretching robot that simultaneously stretches the plantar fascia and Achilles tendon for the treatment of plantar fasciitis. The therapeutic effectiveness of the robot and feasibility of using metatarsophalangeal joint stiffness as an indicator of recovery were identified through the clinical evaluations.

METHODS

The robot implements an effective foot stretching protocol through a novel mechanism design that simultaneously stretches the plantar fascia and Achilles tendon using a single motor. Thirty patients with plantar fasciitis and fifteen healthy participants volunteered in the cross-sectional clinical evaluation, and nine patients from the patients group participated in the one-month clinical trial. Four main outcomes (Foot Function Index, Visual Analogue Scale-Foot and Ankle, plantar fascia thickness, and metatarsophalangeal joint stiffness) were used for the clinical evaluations.

RESULTS

In the cross-sectional clinical evaluation, the symptomatic feet of patients showed moderate negative correlation between normalized metatarsophalangeal joint stiffness and plantar fascia thickness with statistical significance. In the one-month clinical trial, all the main outcomes showed significant improvement after using the developed robot. Comparing our results with previous studies also indicated a therapeutic superiority of our robot for treating plantar fasciitis.

CONCLUSION

Our foot stretching robot had significant therapeutic effect on plantar fasciitis, and normalized metatarsophalangeal joint stiffness measured by our robot could be used as a monitoring indicator for recovery from plantar fasciitis.

SIGNIFICANCE

This study contributed to practical issues related to treatment of plantar fasciitis, and our results could be applied to effective treatment of plantar fasciitis and progressive monitoring of recovery.

Optimization of machine learning method combined with brain-computer interface rehabilitation system

[Purpose] Stroke patients are unable to move on their own and must be rehabilitated to allow the nervous system to trigger and restore its function. Traditional practice is to use electrode caps to extract brain wave features and combine them with assistive devices. However, there are problems that the electrode cap is not easy to wear, and the potential recognition is not good, and different extraction methods will affect the accuracy of the Brain-Computer Interfaces (BCI), which still has room for improvement. [Participants and Methods] The brainwave headphones used in this experiment do not must a conductive gel to get a good EEG for neural induction and drive the upper limb rehabilitation robot. Next, 8 stroke patients and 200 normal participants were invited for a 4-week rehabilitation training. The effectiveness of the training was determined using Fast Fourier Transform (FFT), Magnitude squared coherence (MSC) feature extraction methods, and five machine learning techniques that induced flicker frequencies. [Results] The results show that the optimal steady-state visual evoked flicker frequency is 6 Hz, and the identification rate of FFT is about 5.2% higher than that of the MSC method. Using an optimized model for different feature extraction methods can improve the recognition rate by 1.3%–9.1%. [Conclusion] The images based on Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS) index improvement, and functional Magnetic Resonance Imaging (fMRI) show that the sensory region of brain movement has become a concentrated activation phenomenon. Besides strengthening the feature extraction method also lets the elbow has an obvious recovery effect.

Implementing Robotic-Assisted Gait Training in Acute Inpatient Stroke Rehabilitation: A Quality Improvement Initiative

Background

The recovery of independent walking is one of the major goals of stroke rehabilitation; however, due to the current acute inpatient rehabilitation care paradigm, the intensity of walking practice provided has been far below that recommended for motor recovery to occur. A quality improvement initiative was implemented to encourage the physical therapist (PT) to incorporate various robotic gait training devices as part of the standard allotted PT sessions to improve the intensity of gait training.

Materials and Methods

After 6 months, a retrospective review was performed to assess the feasibility of the robotic-assisted gait training (RAGT) intervention in limited-ambulatory stroke patients and determine preliminary efficacy of the RAGT program by analyzing Functional Index Measure (FIM) motor gain and accelerometer-based daily step counts in patients who received the RAGT versus a group treated with conventional therapy.

Results

About 30% of limited-ambulatory patients admitted to the stroke rehabilitation unit received consistent integrated RAGT without safety concerns. Compared to those who received conventional treatment, these patients showed greater mean FIM motor gain (32.30 versus 17.88) at discharge (P < 0.005) and higher number of step counts in PT sessions (P < 0.005). Age, gender, or admission FIM motor were not associated with FIM motor gain.

Conclusions

Across a 6-month initial implementation period, RAGT was feasible and was associated with higher repetition of walking practice and also with improved FIM motor scores in limited-ambulatory individuals in an acute inpatient stroke rehabilitation program. However, the frequency of RAGT and the percentage of patients participating need to further improve. Some strategies to address these concerns were identified.

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.

A day in the life: a qualitative study of clinical decision-making and uptake of neurorehabilitation technology

BACKGROUND

Neurorehabilitation engineering faces numerous challenges to translating new technologies, but it is unclear which of these challenges are most limiting. Our aim is to improve understanding of rehabilitation therapists' real-time decision-making processes on the use of rehabilitation technology (RT) in clinical treatment.

METHODS

We used a phenomenological qualitative approach, in which three OTs and two PTs employed at a major, technology-encouraging rehabilitation hospital wrote vignettes from a written prompt describing their RT use decisions during treatment sessions with nine patients (4 with stroke, 2 traumatic brain injury, 1 spinal cord injury, 1 with multiple sclerosis). We then coded the vignettes using deductive qualitative analysis from 17 constructs derived from the RT literature and the Consolidated Framework for Implementation Research (CFIR). Data were synthesized using summative content analysis.

RESULTS

Of the constructs recorded, the five most prominent are from CFIR determinants of: (i) relative advantage, (ii) personal attributes of the patients, (iii) clinician knowledge and beliefs of the device/intervention, (iv) complexity of the devices including time and setup, and (v) organizational readiness to implement. Therapists characterized candidate RT as having a relative disadvantage compared to conventional treatment due to lack of relevance to functional training. RT design also often failed to consider the multi-faceted personal attributes of the patients, including diagnoses, goals, and physical and cognitive limitations. Clinicians' comfort with RT was increased by their previous training but was decreased by the perceived complexity of RT. Finally, therapists have limited time to gather, setup, and use RT.

CONCLUSIONS

Despite decades of design work aimed at creating clinically useful RT, many lack compatibility with clinical translation needs in inpatient neurologic rehabilitation. New RT continue to impede the immediacy, versatility, and functionality of hands-on therapy mediated treatment with simple everyday objects.

How to Improve the Management of Acute Ischemic Stroke by Modern Technologies, Artificial Intelligence, and New Treatment Methods

Stroke remains one of the leading causes of death and disability in Europe. The European Stroke Action Plan (ESAP) defines four main targets for the years 2018 to 2030. The COVID-19 pandemic forced the use of innovative technologies and created pressure to improve internet networks. Moreover, 5G internet network will be helpful for the transfer and collecting of extremely big databases. Nowadays, the speed of internet connection is a limiting factor for robotic systems, which can be controlled and commanded potentially from various places in the world. Innovative technologies can be implemented for acute stroke patient management soon. Artificial intelligence (AI) and robotics are used increasingly often without the exception of medicine. Their implementation can be achieved in every level of stroke care. In this article, all steps of stroke health care processes are discussed in terms of how to improve them (including prehospital diagnosis, consultation, transfer of the patient, diagnosis, techniques of the treatment as well as rehabilitation and usage of AI). New ethical problems have also been discovered. Everything must be aligned to the concept of “time is brain”.

The effect of Electromyography (EMG)-driven Robotic Treatment on the recovery of the hand Nine years after stroke

OBJECTIVE

To investigate the effect of electromyography (EMG)-driven robotic therapy on the recovery of the hand in a stroke case lasting 9 years.

CASE

An 18-year-old patient with hemiparesis due to the ischemic lesion was admitted to our clinic with hand impairment. Fifteen sessions (5 weeks x 3 times) of robotic rehabilitation were applied with the Hand of Hope. Average EMG (mV) of flexor digitorum superficialis (FDS) muscle, average force (N) and the rate of force development (RFD)(N/s) were also assessed before and after the treatment following the 5th and 10th sessions and at the end of treatment. Also, Fugl-Meyer Assessment of Upper Extremity Scale (FMU-UE), Motor Activity Log (MAL), Canadian Occupational Performance Score (COPM) and Visual Analog Scale (VAS) were used for assessment before and after the treatment.

RESULTS

The average EMG measured from FDS increased from 0.093-0.133 mV. The average force and average RFD increased from 45.6-97.7 and from 135.6-172.6 respectively. While affected and/or unaffected side force ratio increased dramatically from 54%-82%, the FMA-UE score increased from 56-59. The MAL quality of use score increased from 3.93-4.13. Performance and satisfaction scores of COPM changed from 5.25-7.25 and 4.5-8.25 respectively. VAS score for fatigue changed from 6 to 4.

DISCUSSION

The improvement achieved 9 years later with 15 sessions of rehabilitation suggests that improvement may be possible for chronic stroke patients.

Baduanjin Qigong Improves Balance, Leg Strength, and Mobility in Individuals With Chronic Stroke: A Randomized Controlled Study

BACKGROUND

Effective and sustainable exercise training methods for improving balance poststroke are needed.

OBJECTIVE

To evaluate the effect of Baduanjin Qigong for improving balance after stroke.

METHODS

This was a single-blinded randomized controlled study in which only the assessor was blinded. Fifty-eight people with chronic stroke (mean age: 62.5 ± 11.8 years) were randomly assigned to the experimental (n = 29) or control group (n = 29). The experimental group underwent 8 weeks of supervised Baduanjin training (3 sessions per week). This was followed by home-based practice of the same exercises 3 days a week for another 8 weeks. The control group underwent 2 sessions of supervised conventional fitness training in the first week, followed by home-based exercise practice 3 days a week until the end of week 16. All outcomes were measured at baseline, week 8, and week 16.

RESULTS

Significantly greater improvements in the Mini-Balance Evaluation Systems Test (Mini-BESTest), composite equilibrium score (Sensory Organization Test), 5 Times Sit to Stand, and Timed Up and Go test were detected at week 8 in the experimental group than in the control group (P < .017). Further improvement in the Mini-BESTest was observed from week 8 to 16 in the experimental group (P < .001). Other outcomes (Limit of Stability, Fall-Efficacy Scale, Modified Barthel Index, Stroke-Specific Quality of Life) showed no significant results.

CONCLUSION

Baduanjin is effective in improving balance, leg strength, and mobility and is a safe and sustainable form of home-based exercise for people with chronic stroke.

Brain-Computer Interfaces in Neurorecovery and Neurorehabilitation

Recent advances in brain-computer interface technology to restore and rehabilitate neurologic function aim to enable persons with disabling neurologic conditions to communicate, interact with the environment, and achieve other key activities of daily living and personal goals. Here we evaluate the principles, benefits, challenges, and future directions of brain-computer interfaces in the context of neurorehabilitation. We then explore the clinical translation of these technologies and propose an approach to facilitate implementation of brain-computer interfaces for persons with neurologic disease.

Converging Robotic Technologies in Targeted Neural Rehabilitation: A Review of Emerging Solutions and Challenges

Recent advances in the field of neural rehabilitation, facilitated through technological innovation and improved neurophysiological knowledge of impaired motor control, have opened up new research directions. Such advances increase the relevance of existing interventions, as well as allow novel methodologies and technological synergies. New approaches attempt to partially overcome long-term disability caused by spinal cord injury, using either invasive bridging technologies or noninvasive human-machine interfaces. Muscular dystrophies benefit from electromyography and novel sensors that shed light on underlying neuromotor mechanisms in people with Duchenne. Novel wearable robotics devices are being tailored to specific patient populations, such as traumatic brain injury, stroke, and amputated individuals. In addition, developments in robot-assisted rehabilitation may enhance motor learning and generate movement repetitions by decoding the brain activity of patients during therapy. This is further facilitated by artificial intelligence algorithms coupled with faster electronics. The practical impact of integrating such technologies with neural rehabilitation treatment can be substantial. They can potentially empower nontechnically trained individuals-namely, family members and professional carers-to alter the programming of neural rehabilitation robotic setups, to actively get involved and intervene promptly at the point of care. This narrative review considers existing and emerging neural rehabilitation technologies through the perspective of replacing or restoring functions, enhancing, or improving natural neural output, as well as promoting or recruiting dormant neuroplasticity. Upon conclusion, we discuss the future directions for neural rehabilitation research, diagnosis, and treatment based on the discussed technologies and their major roadblocks. This future may eventually become possible through technological evolution and convergence of mutually beneficial technologies to create hybrid solutions.

Providing unloading by exoskeleton improves shoulder flexion performance after stroke

Robotic devices can be engaged actively or passively to unload arm weight or impose additional loading. The conditions of variable loading and unloading offer an opportunity to investigate motor performance of the arm affected by a stroke. The objective of this study was to investigate the interactive effects of the proximal arm impairment and passive weight compensation on shoulder flexion performance in the sagittal plane after stroke. Twenty-eight participants (age 57 ± 10 years, 21/28 ≤ 6 weeks post-stroke) played a shoulder flexion game under five standardized weight compensation configurations provided by the Armeo^®Spring exoskeleton. Percent of targets acquired and root mean square error were calculated to derive three behavioral and three kinematic outcomes: total score/overall error (loading/unloading conditions and five configurations combined), loading and unloading score/error (five configurations combined), and weight compensation configuration score/error for each setting separately. The total score was positively related and the overall error was negatively related to proximal arm impairment (Fugl-Meyer upper extremity movement subscale, maximum 30, FM30). The unloading score (80 ± 27%) and error (5 ± 4°) were significantly better than the loading score (45 ± 38%, p < 0.01) and error (14± 9°, p < 0.01) with improvements most pronounced in the mid-range of FM30 (4-15 points). The configuration scores/error gradually improved with each increment in unloading for the mid-range FM30 participants, while only error improved in those with low FM30. In conclusion, shoulder flexion performance depends on proximal arm impairment, but it is also influenced by the degree of unloading/loading provided, particularly among individuals with moderate paresis after stroke.

The Effects of Unilateral Versus Bilateral Motor Training on Upper Limb Function in Adults with Chronic Stroke: A Systematic Review

OBJECTIVES

Rehabilitation goals for chronic stroke patients are largely focused around regaining functional ability and independence, with particular focus on upper limb motor function. Unilateral and Bilateral motor training may help achieve this. Our objective was to evaluate and compare the effects of unilateral and bilateral motor training on upper limb motor function in chronic stroke patients.

MATERIALS AND METHODS

A comprehensive literature search was conducted until June 2020 through several electronic databases (CENTRAL, Medline, CINAHL, EBSCO, AMED and PEDro) to identify relevant studies. Studies that used the Fugl Meyer Assessment (FMA) as a minimum, to assess upper limb motor function following unilateral versus bilateral training in chronic stroke patients, qualified for inclusion within the review. Randomised controlled trial (RCT), cohort study and cross-sectional study designs were considered. The Cochrane risk of bias tool was used to assess Randomised Controlled Trials (RCTs). The findings were qualitatively synthesised.

RESULTS

From a total of 838 studies identified, 7 RCTs were included in this review. All except one of the studies included reported an unclear risk of bias, with one low risk of bias reported. Overall, the studies reported that unilateral and bilateral training improved upper limb function in chronic stroke patients. Improvements between interventions were equivocal. Bilateral upper limb training however may be more efficacious for increasing upper limb strength and quality of movement, with unilateral training more beneficial for recovering functional ability for activities of daily living.

CONCLUSION

While the findings of the included studies support the use of unilateral and bilateral motor training post chronic stroke, the seven studies that were included methodologically all presented with limitations, hence strong conclusions cannot be drawn and further research is warranted.

The realization of robotic neurorehabilitation in clinical: use of computational intelligence and future prospects analysis

Introduction: Although there is a need for rehabilitation treatment with the increase in the aging population, the shortage of skilled physicians frustrates this necessity. Robotic technology has been advocated as one of the most viable methods with the potential to replace humans in providing physical rehabilitation of patients with neurological impairment. However, because the pioneering robot devices suffer several reservations such as safety and comfort concerns in clinical practice, there is an urgent need to provide upgraded replacements. The rapid development of intelligent computing has attracted the attention of researchers concerning the utilization of computational intelligence algorithms for robots in rehabilitation. Areas covered: This article reviews the state of the art and advances of robotic neurorehabilitation with computational intelligence. We classified advances into two categories: mechanical structures and control methods. Prospective outlooks of rehabilitation robots also have been discussed. Expert opinion: The aggravation of global aging has promoted the application of robotic technology in neurorehabilitation. However, this approach is not mature enough to guarantee the safety of patients. Our critical review summarizes multiple computation algorithms which have been proved to be valuable for better robotic use in clinical settings and guide the possible future advances in this industry.

Dexteria app. therapy versus conventional hand therapy in stroke

Purpose

Hand impairment post-stroke is a very common and important rehabilitation goal for functional independence. Advanced therapy options such as an app. therapy provides repetitive training, which may be beneficial for improving fine motor function. This study aims to evaluate the effect of app-based therapy compared to conventional hand therapy in improving dexterity in individuals with stroke.

Methodology

In total, 39 individuals within the first year of stroke with Brunnstrom stage of hand recovery IV to VI were randomly divided into three groups. All three groups received 60 min of therapy for 21 sessions over a period of 30 days. Group A received conventional hand therapy; Group B received app. therapy, while Group C received conventional therapy along with the app. therapy. All participants were assessed on the Nine-Hole Peg Test and Jebsen–Taylor Hand Function Test at the beginning and after completion of 21 sessions of intervention. Kruskal–Wallis (H) test and Wilcoxon test were used for statistical analysis.

Results

All three groups improved on hand function post-treatment. However, Group C demonstrated significant improvement with 16%–58% increase in hand function performance on outcome measures (p < 0.05).

Findings

Findings of the present study demonstrate improvement in dexterity with the app. therapy and combination therapy, in comparison to conventional therapy alone in individuals with stroke.

Originality

This experimental study focuses the first time on a structured protocol using an enabling technology adjunct to conventional physical therapy to improve hand function in individuals with stroke, which opens up the further scope in Neurorehabilitation.

Peer review

The peer review history for this article is available at: https://publons.com/publon/10.1108/ILT-04-2020-0144/

A comparison of the effects and usability of two exoskeletal robots with and without robotic actuation for upper extremity rehabilitation among patients with stroke: a single-blinded randomised controlled pilot study

Background

Robotic rehabilitation of stroke survivors with upper extremity dysfunction may yield different outcomes depending on the robot type. Considering that excessive dependence on assistive force by robotic actuators may interfere with the patient’s active learning and participation, we hypothesised that the use of an active-assistive robot with robotic actuators does not lead to a more meaningful difference with respect to upper extremity rehabilitation than the use of a passive robot without robotic actuators. Accordingly, we aimed to evaluate the differences in the clinical and kinematic outcomes between active-assistive and passive robotic rehabilitation among stroke survivors.

Methods

In this single-blinded randomised controlled pilot trial, we assigned 20 stroke survivors with upper extremity dysfunction (Medical Research Council scale score, 3 or 4) to the active-assistive robotic intervention (ACT) and passive robotic intervention (PSV) groups in a 1:1 ratio and administered 20 sessions of 30-min robotic intervention (5 days/week, 4 weeks). The primary (Wolf Motor Function Test [WMFT]-score and -time: measures activity), and secondary (Fugl-Meyer Assessment [FMA] and Stroke Impact Scale [SIS] scores: measure impairment and participation, respectively; kinematic outcomes) outcome measures were determined at baseline, after 2 and 4 weeks of the intervention, and 4 weeks after the end of the intervention. Furthermore, we evaluated the usability of the robots through interviews with patients, therapists, and physiatrists.

Results

In both the groups, the WMFT-score and -time improved over the course of the intervention. Time had a significant effect on the WMFT-score and -time, FMA-UE, FMA-prox, and SIS-strength; group × time interaction had a significant effect on SIS-function and SIS-social participation (all, p < 0.05). The PSV group showed better improvement in participation and smoothness than the ACT group. In contrast, the ACT group exhibited better improvement in mean speed.

Conclusions

There were no differences between the two groups regarding the impairment and activity domains. However, the PSV robots were more beneficial than ACT robots regarding participation and smoothness. Considering the high cost and complexity of ACT robots, PSV robots might be more suitable for rehabilitation in stroke survivors capable of voluntary movement.

Trial registration The trial was registered retrospectively on 14 March 2018 at ClinicalTrials.gov (NCT03465267).

Influence on the user's emotional state of the graphic complexity level in virtual therapies based on a robot-assisted neuro-rehabilitation platform

BACKGROUND

In recent years, a remarkable trend in neurorehabilitation is the combination of conventional methods and emerging technologies, such as robotic platforms with virtual reality (VR), Serious Games (SG) and other types of sophisticated graphic interfaces. The aim of the present study is to evaluate the influence on the user's mental workload of the degree of graphic detail present in this kind of environments, comparing the experience of subjects working with two graphical environments with the same physical load but radically different graphic detail levels.

METHODS

The same therapy is performed by 52 healthy subjects in two totally different graphic environments, one rich in details and visual stimuli, and its schematic version focusing just in the target graphic elements. Autonomic Nervous System (ANS) activity, related to emotional state, is analyzed through the capture and processing of associated physiological signals. The SAM test is used to assess the subjective perception of the participants in order to establish a relationship with the calculated physiological parameters.

RESULTS

Indexes calculated from the ANS physiological signals show significant differences between the basal state and those corresponding to the performance of the therapies but do not allow discriminating between the effects of performing a therapy based on an environment rich in stimuli and an austere one. In the case of subjective perceptions, based on the results of the SAM test, the subjects perceive significant differences between the basal stage and the therapies, and also between each of the two graphic environments.

CONCLUSIONS

Users reflected that a graphic environment rich in detail was more pleasant and attractive than a schematic one. However, this is not reflected in values obtained from their physiological activity, which suggests that more research is needed about the online inference of the emotional state of the subject from the record of his physiological activity.

Combination of Exoskeletal Upper Limb Robot and Occupational Therapy Improve Activities of Daily Living Function in Acute Stroke Patients

PURPOSE

Previous studies have suggested that upper limb rehabilitation using therapeutic robots improves motor function of stroke patients. However, the effect of upper limb robotic rehabilitation on improving functioning in activities of daily living (ADL) remains unclear. The present study aimed to determine whether upper limb rehabilitation using single joint Hybrid Assistive Limb (HAL-SJ) affects ADL function and the use of a hemiparetic arm in ADLs of acute stroke patients.

MATERIALS AND METHODS

Twelve acute stroke patients participated in the study and were randomly divided into group A or group B. The patients in group A followed an A-B-A-B design and those in group B followed a B-A-B-A design. The patients received combination HAL-SJ and occupational therapy during A and conventional occupational therapy during B.

RESULTS

Upper limb motor function and ADLs, in particular, dressing the upper body, were improved during combination HAL-SJ and occupational therapy. Interestingly, the use of a hemiparetic arm in daily life evaluated using the motor activity log was also significantly improved during A in group A.

CONCLUSIONS

Combination HAL-SJ and occupational therapy affects ADL function and real use of a hemiparetic arm in the daily life of acute stroke patients.