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Effects of robot-assisted upper limb rehabilitation in stroke patients: a systematic review with meta-analysis
Abstract
Technology-supported training is emerging as a solution to support therapists in their efforts providing high-intensity, repetitive, and task-specific treatment, in order to enhance the recovery process. The aim of this review is to assess the effectiveness of different robotic devices (end-effector and exoskeleton robots) in comparison with any other type of intervention. Furthermore, we aim to assess whether or not better improvements are obtained in the sub-acute phase after stroke onset than in the chronic phase. A research was conducted in the electronic bibliographic databases Cochrane, MEDLINE, and EMBASE. A total of 17 studies were included: 14 randomized controlled trials, 2 systematic reviews, and one meta-analysis. Fugl-Meyer and modified Ashworth scale were selected to measure primary outcomes, i.e., motor function and muscle tone. Functional independence measure and motor activity log were selected to measure secondary outcomes, i.e., activities of daily living. In comparison with conventional therapy, the robot-assisted rehabilitation is more effective in improving upper limb motor function recovery, especially in chronic stroke patients. No significant improvements are observed in the reduction of muscle tone or daily living activities. The present systematic review shows that the use of robotic devices can positively affect the recovery of arm function in patients with stroke.
... The main goal in stroke rehabilitation is the restoration of motor skills by undergoing repetitive, high-intensity exercises and using programmed activities that allow stroke patients to regain motor and functional abilities (Yakub, 2014), the use of Robot Assistive Therapy (RAT) or therapy with robotics into technology. which holds promise for the rehabilitation of patients with motor impairment caused by stroke (Bertani et al., 2017). Rehabilitation robots are designed to adapt to the patient's functional level and several types of robots can be used for stroke rehabilitation including assisting ADL (Activity Daily Living) and functional abilities and rehabilitation robots can also facilitate clinical assessments of improving hand functional abilities (Dehem et al., 2019). ...
... It can cause unilateral or bilateral upper extremity dysfunction from the early stages of the disease and causing muscle weakness, spasticity, loss of coordination and sensory disturbances of the upper limbs (Maris et al., 2018), besides In addition, stroke also causes weakness, impairment and limitations of motor, sensory, perceptual functions (Franck et al., 2017). Robotic therapy is a promising technology for the rehabilitation of patients with motor disorders caused by stroke (Bertani et al., 2017). ...
... Robotic therapy is a promising technology for the rehabilitation of patients with motor disorders caused by stroke (Bertani et al., 2017). Compared to conventional therapists robotic therapy requires several rehabilitation training sessions, resulting in impractical and unaffordable therapy for many patients. ...
Background: Stroke is a neurological deficit disease caused by bleeding or blockage of blood vessels in the brain which can cause disability or death. Vascular injuries cause various neurological disorders, motor disorders and functional disorders of the hands which are very necessary to carry out daily activities. Robot Assistive Therapy as a breakthrough in stroke rehabilitation technology can be used as an alternative therapy method for post-stroke rehabilitation. This study aims to determine the effectiveness of the use of robotic assistive therapy and conventional therapy on the functional abilities of stroke patients' hands.
Subjects and Method: This study used a systematic review and meta-analysis design using the PRISMA flowchart guidelines and the PICO model (Population = Stroke patients. Intervention = Robot Assistive Therapy. Comparison = Conventional therapy. Outcome = Hand functional ability). The article search process was carried out using databases from PubMed, Science Direct, AJOT, Springer Link, and Google Scholar. The keywords used are “Robot Assistive Therapy” AND “stroke” AND “hand function” AND “randomized controlled trial” AND “Fugl Meyer Assessment”. The inclusion criteria in this study were full-text articles using the Randomized Controlled Trial (RCT) design from 2012 to 2022. The corresponding articles were then critically reviewed and analyzed using RevMan 5.3 software.
Results: A meta-analysis was conducted on 9 randomized controlled trials (RCTs) from Belgium, Italy, Japan, Germany, Lithuania and Switzerland with a total sample of 537 stroke patients. The results of the meta-analysis showed that there was no difference in effectiveness between the use of robot assistive therapy and conventional therapy in improving the functional abilities of stroke patients' hands (SMD= -0.02; 95% CI= -0.42 to 0.38; p= 0.930).
Conclusion: There is no difference in effectiveness between the use of assistive therapy robots and conventional therapy in improving the functional abilities of stroke patients' hands.
Keywords: robot assistive therapy, stroke, hand functional abilities, meta-analysis
Correspondence: Haris Sutopo, Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir Sutami 36A, Surakarta 57126, Jawa Tengah, Indonesia. Email: hartop4wd@gmail.com. Telepon: +628155010610.
... 16,17 Robotic arms have been used to improve upper limb function in post-stroke patients, and their efficacy has been demonstrated in several studies. [18][19][20][21] Studies have demonstrated that robotic arms can help acute post-stroke patients improve their upper limbs, particularly their shoulders and elbows. 20,21 However, this kind of device has also been shown to be ineffective in improving upper limb function during either the acute or chronic phases of stroke. ...
... 20,21 However, this kind of device has also been shown to be ineffective in improving upper limb function during either the acute or chronic phases of stroke. 18,19 These inconsistent findings may lead to erroneous conclusions about the benefits of robotic arms and affect their therapeutic use for this population. ...
... lished, but few have focused on upper limb function. 18,24 The results of these studies contrast with our findings regarding the effect of robotic arm use on upper limb function. A review by Mehrholz (2020) showed no significantly improved hand or arm function. ...
Several studies have reported the effects of robotic arms on improving upper limb function in patients with stroke. However, previous studies have reported inconsistent findings that may lead to incorrect applications of robotic arm use. Six databases were searched for relevant randomized controlled trials. Meta-analyses were performed for upper limb performance measures, including subgroup analysis of pooled upper limb rehabilitation data such as stroke stage and intervention delivery dose. Furthermore, the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2) and sensitivity analysis were used to assess methodology and determine publication bias. The final analysis included 18 studies. Robotic arms improved upper limb and hand function in patients with stroke. Subgroup analysis revealed that robotic arm interventions lasting 30-60 min per session significantly improved upper limb function. However, no significant improvement was observed in shoulder and elbow or wrist and hand movements. This review may help develop applicable rehabilitation robots and collaboration between clinicians.
... Despite the continuing debate around the effectiveness of upper limb robot-assisted therapy (Chien et al., 2020;Rodgers et al., 2019), this treatment appears as an appropriate treatment dose to be administered in terms of the quantity of movements performed and the intensity of the exercises. Although many randomised studies and systematic reviews have been conducted on robot-assisted therapy (Bertani et al., 2017;Chien et al., 2020;K. Lo et al., 2017;Mehrholz et al., 2020;Zhang et al., 2017), an issue often raised is the heterogeneity of practices and poorly described interventions (Burgar et al., 2011). ...
... Indeed, this therapy is considered safe in subacute and chronic stroke patients, i.e. not deleterious to muscle tone and shoulder pain (Mehrholz et al., 2020). However, its effects on the reduction of spasticity remain controversial (Bertani et al., 2017;Veerbeek et al., 2017). ...
... The results appear to differ according to the phase of stroke. A Cochrane review in 2015 found improvements of activities of daily living in patients with acute and subacute stroke but not in the chronic phase (Mehrholz et al., 2015) while three recent systematic reviews found that robotassisted therapy was more effective than standard care in the chronic phase (Bertani et al., 2017;Wu et al., 2021;Zhang et al., 2017). ...
Background:
Rehabilitation of stroke-related upper limb paresis is a major public health issue.
Objective:
Robotic systems have been developed to facilitate neurorehabilitation by providing key elements required to stimulate brain plasticity and motor recovery, namely repetitive, intensive, adaptative training with feedback. Although the positive effect of robot-assisted therapy on motor impairments has been well demonstrated, the effect on functional capacity is less certain.
Method:
This narrative review outlines the principles of robot-assisted therapy for the rehabilitation of post-stroke upper limb paresisRESULTS:A paradigm is proposed to promote not only recovery of impairment but also function.
Conclusion:
Further studies that would integrate some principles of the paradigm described in this paper are needed.
... [4] Robot-assisted rehabilitation can provide better task-oriented, repetitive, and high-intensity training compared to that seen in conventional therapist-assisted training. [5] Rehabilitation robot types include end-effector type and exoskeletal type. Previous studies showed that therapeutic rehabilitation with an exoskeletal robot improved the patient's upper limb motor function and daily activity function. ...
... [6,7] A systematic review with meta-analysis concluded that exoskeletal robots had significantly favorable outcomes on poststroke upper arm motor function compared to end-effector robots. [5] Veerbeek et al [8] reported that shoulder/elbow robotics improved motor function and muscle strength significantly Medicine in stroke patients. On the other hand, elbow/wrist robotics improved only motor control. ...
Background:
Upper limb robotic rehabilitation can be beneficial to the patients when applied appropriately. HEXO-UR30A is a novel exoskeletal type upper limb rehabilitation robot that provides continuous passive motion to the shoulder joint.
Objective:
The purpose of this study is to evaluate the effectiveness of HEXO-UR30A on the patient's functional change, spasticity, and range of motion (ROM).
Methods:
We included stroke patients with upper limb hemiparesis of age > 19 years with spasticity grading of modified Ashworth scale < 3 and Brunnstrom recovery stage ≥ 4. The efficacy of the robot was investigated based on a rehabilitation program for 3 weeks. Patient's functions were compared before vs after treatment and between the HEXO group vs control. We conducted the Fugl-Meyer Assessment of the Upper Extremity, modified Barthel index, modified Ashworth scale, ROM, and Motricity Index upper limb. Patients' satisfaction was evaluated using a questionnaire after every 10 sessions of training.
Results:
In the HEXO group, the Fugl-Meyer assessment for shoulder improved significantly (P value = .006*) compared with the control group (P value = .075). Both groups showed significant improvement (P value < .05) in Motricity Index upper limb after treatment. There were some improvements in the passive and active ROM. Patients in the HEXO group reported high satisfaction with upper limb rehabilitation.
Conclusion:
These results show that HEXO-UR30A can improve functional ability in chronic stroke patients. Moreover, the high satisfaction in patients might promote active involvement in upper limb rehabilitation.
... Recent advances in imaging examinations, such as functional magnetic resonance imaging and near-infrared spectroscopy, have shown that brain plasticity or reorganization can be expected after stroke. Recently, robotic rehabilitation has emerged as a training method to improve patients' limb dysfunction post-stroke [5,6]. The hybrid assistive limb (HAL) is an exoskeletal robot that controls and assists movements based on bioelectrical activity generated through voluntary movements. ...
... We set up the single-joint HAL in accordance with previous studies [5,6]. In brief, the proximal section of the HAL was fixed to a tripod using an attachment, and the distal section was fitted to the patient's upper arm with a belt for the elbow joint, which was attached to the HAL (Figure 1a). ...
Upper extremity dysfunction after stroke affects quality of life. Focusing on the shoulder joint, we investigated the safety and effectiveness of rehabilitation using a shoulder joint hybrid assistive limb (HAL). Eight patients with chronic stroke and upper extremity functional disability were enrolled and used a shoulder joint HAL, which assisted shoulder movement based on the user’s intention, through myoelectric activation of the shoulder flexor. Ten training sessions of 30–40 min each were performed to assist voluntary movement of upper limb elevation on the affected side through triggering the deltoid muscle. All patients completed the interventions without shoulder pain. Surface electromyography evaluation indicated post-intervention improvement in coordinated movement of the affected upper extremity. Significant improvements in voluntary and passive shoulder joint range of motion were obtained after the intervention, suggesting improvement in shoulder muscle strength. A significant decrease in the modified Ashworth scale and improvements in functional scores in the upper limb were also observed. Along with safe use for our study patients, the shoulder HAL provided appropriate motor learning benefits. Improvements in shoulder joint function and whole upper limb function were observed, suggesting that HAL could be an optimal treatment method.
... Moreover, the potential treatment effects of robotic training protocols on paretic arm recovery were controversial. Several meta-analysis studies argued that functional improvements in the upper extremities post-stroke (e.g., motor functions, muscle tone, and activities of daily living) were comparable between robotic training protocols and dose-matched conventional rehabilitation programs [27,34,[73][74][75]. Despite some meta-analytic findings that reported significant improvements in motor control and strength of the paretic arms, the magnitude of motor recovery evidence was relatively small (e.g., two points of FMA arm score and Hedges' g = 0.25) [34,76] and insignificant in the random-effects model [75]. ...
... Several meta-analysis studies argued that functional improvements in the upper extremities post-stroke (e.g., motor functions, muscle tone, and activities of daily living) were comparable between robotic training protocols and dose-matched conventional rehabilitation programs [27,34,[73][74][75]. Despite some meta-analytic findings that reported significant improvements in motor control and strength of the paretic arms, the magnitude of motor recovery evidence was relatively small (e.g., two points of FMA arm score and Hedges' g = 0.25) [34,76] and insignificant in the random-effects model [75]. Some studies suggested that quantifying kinematic and kinetic outcome measures may effectively detect changes in upper limb functions and motor learning after robotic training protocols for certain patients with stroke [34,77]. ...
Two popular chronic stroke rehabilitation protocols are robotic-assisted movements and transcranial direct current stimulation (tDCS). Separately, both protocols have produced encouraging motor recovery improvements. An intriguing question remains: what happens to motor recovery when both protocols are administered together? Do the two protocols together produce additive dual effects? This systematic review and meta-analysis investigated the dual effect of combining robotic training and tDCS. We investigated the potential effects of tDCS protocols in addition to robotic-training programs on motor recovery of the upper and lower extremities post-stroke. A systematic literature search identified 20 qualified studies that used robotic training combined with tDCS protocols for upper limb (i.e., 15 studies) and lower limb (i.e., 5 studies) post-stroke rehabilitation. Individuals in the subacute and chronic stages of recovery were investigated. The 20 included studies compared additive effects of the combined protocols with robotic training sham control groups. Further, we estimated short-term and long-term treatment effects of the combined protocols. The random-effects model meta-analyses failed to find any significant short-term and long-term motor improvements in the upper extremities after the combined treatments. However, robotic-assisted movements combined with tDCS protocols revealed significant moderate transient and sustained improvements in functions of the lower limbs post-stroke. These meta-analytic findings suggest clinical implications concerning coupled top-down and bottom-up training protocols (i.e., robotic training and tDCS combined), which will allow us to make progress toward post-stroke motor recovery.
... These include early reperfusion therapies (i.e., intravenous thrombolysis and mechanical thrombectomy) aimed at limiting damage and preventing further cell death to contain lesion size and disability [1]. Furthermore, traditional (neurofacilitation or functional retraining through either shaping or task practice) and advanced rehabilitation protocols, including pharmacological manipulation to increase sprouting and anatomical plasticity, non-invasive brain stimulation (NIBS) to modulate the activity of targeted brain areas, and robot-aided rehabilitation (RAR) to perform an intensive, repetitive, assisted-as-needed, and task-oriented motor practice, are available in any phase of the post-stroke recovery process [2][3][4][5][6][7][8][9]. These rehabilitation strategies aim to increase the adaptive plasticity processes (mainly experience-dependent plasticity mechanisms) that develop in lesional and perilesional tissues [10][11][12]. ...
... To date, NIBS and RAR represent two cornerstones of the modern post-stroke rehabilitation era. Both strategies have been employed singularly concerning post-stroke rehabilitation with valuable positive results [2][3][4][5][6][7][8][9]. Both strategies aim at potentiating neuroplasticity mechanisms supporting functional recovery via bottom-up (RAR) and top- ...
Robot-aided rehabilitation (RAR) and non-invasive brain stimulation (NIBS) are the two main interventions for post-stroke rehabilitation. The efficacy of both approaches in combination has not been well established yet. The importance of coupling these interventions, which both enhance brain plasticity to promote recovery, lies in augmenting the rehabilitation potential to constrain the limitation in daily living activities and the quality of life following stroke. This review aimed to evaluate the evidence of NIBS coupled with RAR in improving rehabilitation outcomes of upper limb and gait motor impairment in adult individuals with stroke. We included 18 clinical trials in this review. All studies were highly heterogeneous concerning the technical characteristics of robotic devices and NIBS protocols. However, the studies reported a global improvement in body structure and function and activity limitation for the upper limb, which were non-significant between the active and control groups. Concerning gait training protocols, the active group outperformed the control group in improving walking capacity and recovery. According to this review, NIBS and RAR in combination are promising but not yet largely recommendable as a systematic approach for stroke rehabilitation as there is not enough data about this. Therefore, more homogenous clinical trials are required, pointing out the best characteristics of the combined therapeutic protocols.
... Based on learnings from neuroplasticity, task-oriented rehabilitation training is effective, and the higher the intensity, the better the activities of daily life [6,7]. For this reason, upper-limb robotic rehabilitation has attracted attention because it is a safe and efficient way to perform repetitive training while performing taskoriented rehabilitation after a stroke [8]. Upper-extremity rehabilitation treatment using a robot is more effective in improving motor function than traditional upper-extremity rehabilitation treatment in patients with chronic stroke [9]. ...
This study aimed to determine whether the treatment effect differs for patients with stroke who perform robot-assisted upper-extremity rehabilitation by themselves compared to those whose rehabilitation is actively assisted by a therapist. Stroke patients with hemiplegia were randomly divided into two groups and received robot-assisted upper-limb rehabilitation for four weeks. In the experimental group, a therapist actively intervened in the treatment, while in the control group, the therapist only observed. After four weeks of rehabilitation, the manual muscle strength, Brunnstrom stage, Fugl-Meyer assessment of the upper-extremity (FMA-UE), box and block test, and functional independence measure (FIM) showed significant improvement in both groups compared to that before treatment; however, no interval change in spasticity was noted. The post-treatment values showed that the FMA-UE and box and block tests were significantly improved in the experimental group compared to those in the control group. Comparing the changes in the pre- and post-treatment values, the FMA-UE, box and block test, and FIM of the experimental group were significantly improved compared to those in the control group. Our results suggest that active intervention by therapists during robot-assisted upper-limb rehabilitation positively impacts upper-extremity function outcomes in patients with stroke.
... Technological devices, such as robots, are able to deliver repetitive, high-intensity, standardized movement [57], a task that is difficult to achieve through manual therapy. Our analysis demonstrated that there is a sufficient magnitude [58] of WISCI-II with ES (Effect Size) = 0.23 (ES > 0.2) for robotic rehabilitation methods. ...
Gait recovery is a fundamental goal in patients with spinal cord injury to attain greater autonomy and quality of life. Robotics is becoming a valid tool in improving motor, balance, and gait function in this patient population. Moreover, other innovative approaches are leading to promising results. The aim of this study was to investigate new rehabilitative methods for gait recovery in people who have suffered spinal cord injuries. A systematic review of the last 10 years of the literature was performed in three databases (PubMed, PEDro, andCochrane). We followed this PICO of the review: P: adults with non-progressive spinal cord injury; I: new rehabilitative methods; C: new methods vs. conventional methods; and O: improvement of gait parameters. When feasible, a comparison through ES forest plots was performed. A total of 18 RCTs of the 599 results obtained were included. The studies investigated robotic rehabilitation (n = 10), intermittent hypoxia (N = 3) and external stimulation (N = 5). Six studies of the first group (robotic rehabilitation) were compared using a forest plot for 10MWT, LEMS, WISCI-II, and SCIM-3. The other clinical trials were analyzed through a narrative review of the results. We found weak evidence for the claim that robotic devices lead to better outcomes in gait independence compared to conventional rehabilitation methods. External stimulation and intermittent hypoxia seem to improve gait parameters associated with other rehabilitation methods. Research investigating the role of innovative technologies in improving gait and balance is needed since walking ability is a fundamental issue in patients with SCI.
... Their independent daily living activities are affected, limiting patients' return to family and society, bringing psychological and economic burdens to patients and their families, and causing a certain degree of social burden. At present, the rehabilitation of upper limb function is one of the difficulties in rehabilitation patients with stroke (Bertani et al., 2017). Rehabilitation methods such as exercise therapy and occupational therapy can restore the motor function of the upper limbs. ...
Background:
Stroke is a disease with a high fatality rate worldwide and a major cause of long-term disability. In the rehabilitation of limb motor function after stroke, the rehabilitation of upper limb function takes a long time and the recovery progress is slow, which seriously affects the patients' self-care ability in daily life. Repeated transcranial magnetic stimulation (rTMS) has been increasingly used to improve limb dysfunction in patients with stroke. However, a standardized reference for selecting a magnetic stimulation regimen is not available. Whether to increase the inhibition of the contralateral hemispheric motor cortex remains controversial. This study has evaluated the effects of different rTMS stimulation programs on upper limb function and corresponding brain functional network characteristics of patients with stroke and sought a new objective standard based on changes in brain network parameters to guide accurate rTMS stimulation programs.
Method:
Thirty-six patients with stroke were selected and divided into control group and treatment group by number table method, with 18 patients in each group, and 3 patients in the control group were turned out and lost due to changes in disease condition. The treatment group was divided into two groups. TMS1 group was given 1 Hz magnetic stimulation in the M1 region of the contralesional hemisphere +10 Hz magnetic stimulation in the M1 region of the affected hemisphere, and the TMS2 group was given 10 Hz magnetic stimulation in the M1 region of the affected hemisphere. The control group was given false stimulation. The treatment course was once a day for 5 days a week for 4 weeks. The Fugl-Meyer Assessment for upper extremity (FMA-UE) sand near-infrared brain function were collected before treatment, 2 weeks after treatment, and 4 weeks after treatment, and the brain function network was constructed. Changes in brain oxygenated hemoglobin concentration and brain network parameters were analyzed with the recovery of motor function (i.e., increased FMA score). Meanwhile, according to the average increment of brain network parameters, the rTMS stimulation group was divided into two groups with good efficacy and poor efficacy. Network parameters of the two groups before and after rTMS treatment were analyzed statistically.
Results:
(1) Before treatment, there was no statistical difference in Fugl-Meyer score between the control group and the magnetic stimulation group (p = 0.178).Compared with before treatment, Fugl-Meyer scores of 2 and 4 weeks after treatment were significantly increased in both groups (p <0.001), and FMA scores of 4 weeks after treatment were significantly improved compared with 2 weeks after treatment (p < 0.001). FMA scores increased faster in the magnetic stimulation group at 2 and 4 weeks compared with the control group at the same time point (p <0.001).TMS1 and TMS2 were compared at the same time point, FMA score in TMS2 group increased more significantly after 4 weeks of treatment (p = 0.010). (2) Before treatment, HbO2 content in healthy sensory motor cortex (SMC) area of magnetic stimulation group and control group was higher than that in other region of interest (ROI) area, but there was no significant difference in ROI between the two groups. After 4 weeks of treatment, the HbO2 content in the healthy SMC area was significantly decreased (p < 0.001), while the HbO2 content in the affected SMC area was significantly increased, and the change was more significant in the magnetic stimulation group (p < 0.001). (3) In-depth study found that with the recovery of motor function (FMA upper limb score increase ≥4 points) after magnetic stimulation intervention, brain network parameters were significantly improved. The mean increment of network parameters in TMS1 group and TMS2 group was significantly different (χ 2 = 5.844, p = 0.016). TMS2 group was more advantageous than TMS1 group in improving the mean increment of brain network parameters.
Conclusion:
(1) The rTMS treatment is beneficial to the recovery of upper limb motor function in stroke patients, and can significantly improve the intensity of brain network connection and reduce the island area. The island area refers to an isolated activated brain area that cannot transmit excitation to other related brain areas. (2) When the node degree of M1_Healthy region less than 0.52, it is suggested to perform promotion therapy only in the affected hemisphere. While the node degree greater than 0.52, and much larger than that in the M1_affected region. it is suggested that both inhibition in the contralesional hemisphere and high-frequency excitatory magnetic stimulation in the affected hemisphere can be performed. (3) In different brain functional network connection states, corresponding adjustment should be made to the treatment plan of rTMS to achieve optimal therapeutic effect and precise rehabilitation treatment.
... Research on the design and development of health technologies has been conducted for decades to promote a holistic approach to sustainable healthcare. 1,2 Currently, health technologies are found in various designs and used for diverse purposes, including self-care support, 3,4 organizational dashboards for performance status, 5 robots for rehabilitation, 6 and self-monitoring. [7][8][9] However, implementing health technologies in clinical practice is difficult and not easily translated into sustained practice. ...
Objective
The successful development and implementation of sustainable healthcare technologies require an understanding of the clinical setting and its potential challenges from a user perspective. Previous studies have uncovered a gap between what emergency departments deliver and the needs and preferences of patients and family members. This study investigated whether a user-driven approach and participatory design could provide a technical solution to bridge the identified gap.
Methods
We conducted four workshops, and five one-to-one workshops with patients, family members, healthcare professionals, and information technology specialists to codesign a prototype. Revisions of the prototype were made until an acceptable solution was agreed upon and tested by the participants. The data were analyzed following iterative processes (plan → act → observe → reflect).
Results
The participants emphasized the importance of a person-centered approach focusing on improved information. An already implemented system for clinicians’ use only was redesigned into a unique patient module that provides a process line displaying continually updated informative features, including (1) person-centered activities, (2) general information videos, (3) a notepad, (4) estimated waiting time, and (5) the nurse and physician responsible for care and treatment.
Conclusion
Participatory design is a usable approach to designing an information system for use in the emergency department. The process yielded insight into the complexity of translating ideas into technologies that can actually be implemented in clinical practice, and the user perspectives revealed the key to identifying these complex aspects. The iterations with the participants enabled us to redesign an existing technology.
... There are millions of individuals in the world who currently experience various movement-related disabilities [1] frequently as a result of sensory impairments, traumatic brain injuries (TBI), and musculoskeletal and neurological disorders [2,3]. Multiple review articles and meta-analyses have considered the benefits of rehabilitation and medical robotics [4][5][6][7][8][9][10] and many researchers have argued that robotic rehabilitation devices (RRDs) that emphasize intense [11], highly repetitive [12,13], and task-oriented [14] movements allows for assisting rehabilitation training and recovering the functions of patient's limbs [15][16][17][18]. ...
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.
... The internal sensors of the Cobot can be also exploited to return objective data to evaluate the progress of the patient's mobility, which itself can change the interaction by altering the control parameters of robot motion [17]. Consequently, the monitored interaction between the Cobot and the patient's limb improves the efficiency of the therapeutic action [1,13]. Through tailored end-effectors attached to Cobot extremal flange and programmed paths, a large variety of exercises can be designed for the therapist to choose from. ...
... The internal sensors of the Cobot can be also exploited to return objective data to evaluate the progress of the patient's mobility, which itself can change the interaction by altering the control parameters of robot motion [17]. Consequently, the monitored interaction between the Cobot and the patient's limb improves the efficiency of the therapeutic action [1,13]. Through tailored end-effectors attached to Cobot extremal flange and programmed paths, a large variety of exercises can be designed for the therapist to choose from. ...
... Other systematic reviews [27,28] reiterate that robotic rehabilitation by means of different devices significantly improves functionality in patients with neurological injuries when compared to conventional treatment. This is supposedly due to the mechanism of neural plasticity since new neural connections are favored when high-intensity, repetitive training occurs. ...
Objective:
To systematically review the effects of robotic rehabilitation with the Erigo® device on patients with neurological injury on safety, spasticity, muscle strength, functionality, gait/balance, and changes in the level of consciousness.
Methods:
MEDLINE, SciELO, EMBASE, The Cochrane Library - CENTRAL and PEDro databases were consulted without the restriction of date and language. Randomized controlled trials that evaluated the robotic rehabilitation and compared it to conventional or placebo therapy, isolated or in association with other therapy, were selected. Studies in which the treatment time was less than 10 sessions were excluded. The risk of bias was assessed with the use of the RoB 2.0 tool.
Results:
Nine studies were included, totaling 347 patients. The robotic rehabilitation performed by the Erigo® device proved to be safe for neurological patients. The meta-analysis showed an improvement for spasticity (MD = 0.29; 95% CI = -0.49 to -0.08; I2 = 0%), but there was no significant increase in muscle strength in patients with stroke (MD = 0.25; CI 95% = -0.22 to -0,71; I2 = 0%). Erigo® showed inconclusive effects on functionality, gait/balance and level of consciousness in patients with severe acquired brain injury and vegetative or minimally conscious state. All studies present some concerns for the risk of bias.
Conclusion:
Erigo® as a robotic rehabilitation strategy is safe for patients with acquired brain injury and appears to reduce spasticity in patients with stroke. The effects on muscle strength, functionality, gait and balance and level of consciousness remain uncertain and the methodological quality of the clinical trials included in this review is limited.
... Rehabilitation robots in the medical field are a successful example of human-robot interaction. Since rehabilitation robots can provide practical rehabilitation training, they can meet the shortage of rehabilitation resources while satisfying patients' rehabilitation training [8]. In addition, rehabilitation robots can improve the actual movement of human-robot interactions and provide behavioral predictions. ...
The maturity of human-computer interaction technology has made it possible to use surface electromyographic signals (sEMG) to control exoskeleton robots and intelligent prostheses. However, the available upper limb rehabilitation robots controlled by sEMG have the shortcoming of inflexible joints. This paper proposes a method based on a temporal convolutional network (TCN) to predict upper limb joint angles by sEMG. The raw TCN depth was expanded to extract the temporal features and save the original information. The timing sequence characteristics of the muscle blocks that dominate the upper limb movement are not apparent, leading to low accuracy of the joint angle estimation. Therefore, this study squeeze-and-excitation networks (SE-Net) to improve the network model of the TCN. Finally, seven movements of the human upper limb were selected for ten human subjects, recording elbow angle (EA), shoulder vertical angle (SVA), and shoulder horizontal angle (SHA) values during their movements. The designed experiment compared the proposed SE-TCN model with the backpropagation (BP) and long short-term memory (LSTM) networks. The proposed SE-TCN systematically outperformed the BP network and LSTM model by the mean RMSE values: by 25.0 and 36.8% for EA, by 38.6 and 43.6% for SHA, and by 45.6 and 49.5% for SVA, respectively. Consequently, its R² values exceeded those of BP and LSTM by 13.6 and 39.20% for EA, 19.01 and 31.72% for SHA, and 29.22 and 31.89% for SVA, respectively. This indicates that the proposed SE-TCN model has good accuracy and can be used to estimate the angles of upper limb rehabilitation robots in the future.
... One method of increasing access to rehabilitation is to create inexpensive, portable, wearable robotic systems that individuals can use at home and outside of the clinic to complete physiotherapy exercises. Review papers have found that robotic therapy can provide the same benefits as conventional physiotherapy, and that upper limb functions improved when robotic therapy was completed in addition to conventional therapy, especially with chronic stroke patients (4,5). Robotic therapy has many advantages such as progress tracking, real-time feedback, and reducing therapist workloads. ...
Twisted coiled actuators (TCAs) are promising artificial muscles for wearable soft robotic devices due to their biomimetic properties, inherent compliance, and slim profile. These artificial muscles are created by super-coiling nylon thread and are thermally actuated. Unfortunately, their slow natural cooling rate limits their feasibility when used in wearable devices for upper limb rehabilitation. Thus, a novel cooling apparatus for TCAs was specifically designed for implementation in soft robotic devices. The cooling apparatus consists of a flexible fabric channel made from nylon pack cloth. The fabric channel is lightweight and could be sewn onto other garments for assembly into a soft robotic device. The TCA is placed in the channel, and a miniature air pump is used to blow air through it to enable active cooling. The impact of channel size on TCA performance was assessed by testing nine fabric channel sizes—combinations of three widths (6, 8, and 10 mm) and three heights (4, 6, and 8 mm). Overall, the performance of the TCA improved as the channel dimensions increased, with the combination of a 10 mm width and an 8 mm height resulting in the best balance between cooling time, heating time, and stroke. This channel was utilized in a follow-up experiment to determine the impact of the cooling apparatus on TCA performance. In comparison to passive cooling without a channel, the channel and miniature air pump reduced the TCA cooling time by 42% ( 21.71 ± 1.24 s to 12.54 ± 2.31 s, p < 0.001 ). Unfortunately, there was also a 9% increase in the heating time ( 3.46 ± 0.71 s to 3.76 ± 0.71 s, p < 0.001 ) and a 28% decrease in the stroke ( 5.40 ± 0.44 mm to 3.89 ± 0.77 mm, p < 0.001 ). This work demonstrates that fabric cooling channels are a viable option for cooling thermally actuated artificial muscles within a soft wearable device. Future work can continue to improve the channel design by experimenting with other configurations and materials.
... For instance, classical randomized clinical trials studying the value of robot-assisted upper limb rehabilitation in stroke patients, which at least partially have shown positive effects on motor impairment, employed a much larger number of training sessions. For instance, the number of sessions listed in the meta-analysis of Bertani and colleagues ranged from 15 to 36 sessions [28]. However, it is important to mention that, when we additionally examined training-related effects on fine-grained isolated performance metrics, the analyses indicated that there was an overall "training-independent" improvement in the accuracy (deviance) from day one to day two, but no improvement in speed and jerk. ...
Task-specific training constitutes a core element for evidence-based rehabilitation strategies targeted at improving upper extremity activity after stroke. Its combination with additional treatment strategies and neurotechnology-based solutions could further improve patients' outcomes. Here, we studied the effect of gamified robot-assisted upper limb motor training on motor performance, skill learning, and transfer with respect to a non-gamified control condition with a group of chronic stroke survivors. The results suggest that a gamified training strategy results in more controlled motor performance during the training phase, which is characterized by a higher accuracy (lower deviance), higher smoothness (lower jerk), but slower speed. The responder analyses indicated that mildly impaired patients benefited most from the gamification approach. In conclusion, gamified robot-assisted motor training, which is personalized to the individual capabilities of a patient, constitutes a promising investigational strategy for further improving motor performance after a stroke.
... Robots, in combination with exergames, can provide high-dose and high-intensity training with precise feedback on movement accuracy and induce motor learning in children diagnosed with cerebral palsy (CP; Bertani et al., 2017;Chen et al., 2018;Gilliaux et al., 2015). Motivation can also be enhanced by basing an intervention on the child's personal goals and needs. ...
Importance: Children with hemiparesis experience limitations in activities of daily living (ADLs) as a result of upper limb impairments. To address these limitations, we developed a group-based Personalized Upper Limb Intensive Therapy (PULIT) program combining modified constraint-induced movement therapy, bimanual intensive therapy, and exergame-based robotics.
Objective: To determine the effectiveness of PULIT in helping children with upper limb impairments achieve individually set goals and enable transfer of the attained motor skills into ADLs.
Design: Retrospective analysis.
Setting: Day camp at a pediatric rehabilitation clinic in Switzerland.
Participants: Twenty-three children with upper limb impairment (unilateral cerebral palsy, n = 16; acquired brain injury, n = 7); 13 boys and 10 girls (M age = 7 yr, 8 mo, SD = 2 yr, 1 mo; Manual Ability Classification System Level I–IV).
Intervention: Thirty hours of PULIT over the course of 8 days.
Outcomes and Measures: Goal attainment scaling (GAS) was assessed on the first and last day of intervention. The Canadian Occupational Performance Measure (COPM) and dexterity tests, such as the Box and Block Test (BBT), were administered 3 wk before and 3 wk after the intervention.
Results: Total goal achievement was 85.7%. GAS, parent- and child-rated COPM Performance and Satisfaction, and the BBT of the affected and dominant upper limb improved significantly.
Conclusions and Relevance: PULIT effectively increases children’s dexterity of the impaired and dominant upper limb, improves ADL performance, and achieves individual goals. This retrospective analysis could serve as a basis for a future randomized trial.
What This Article Adds: This article informs occupational therapy practitioners about a therapy program that includes conventional and rehabilitation technology interventions and enables children with hemiparesis of the upper limb to improve relevant ADL tasks in 8 days’ time.
... Research on neurological rehabilitation suggests that repetitive motor activity has positive effects with respect to improving movement coordination and avoiding muscle atrophy, and the therapeutic effect is mainly determined by the intention, task-oriented quality and sustainability of rehabilitation training. Robotic systems have a natural advantage in rehabilitation over traditional rehabilitation treatments (Bertani et al., 2017). Robot-assisted therapy can deliver long-endurance, repetitive and sustainable therapeutic training using programmable control strategies (Milot et al., 2013). ...
Robot-assisted rehabilitation has proven to be
effective for improving the motor performance of patients with neuromuscular
injuries. The effectiveness of robot-assisted training directly depends on
the control strategy applied in the therapy training. This paper presents an
end-effector upper-limb rehabilitation robot for the functional recovery
training of disabled patients. A force-field-based rehabilitation
control strategy is then developed to induce active patient participation
during training tasks. The proposed control strategy divides the
3D space around the rehabilitation training path into
a human-dominated area and a robot-dominated area. It encodes the space around the
training path and endows the corresponding normal and tangential force; the
tangential component assists with movement along the target path, and the normal
component pushes the patient's hand towards the target path using a
real-time adjustable controller. Compared with a common force-field
controller, the human–robot interaction in this strategy is easy and can be quickly
adjusted by changing the force field's range or the variation characteristics
of two forces, and the intervention in two directions can change
continuously and smoothly despite the patient's hand crossing the two areas. Visual
guidance based on the Unity-3D environment is introduced to provide visual
training instructions. Finally, the feasibility of the proposed control
scheme is validated via training experiments using five healthy subjects.
... Robotic assistance is considered advantageous because it (1) allows the challenge level of the task to be adjusted to better suit the needs and abilities of the user, and (2) allows users to move through a larger range of motion-thereby providing a large afferent response that is time correlated with the user's efferent motor intent. Evidence from systematic reviews and meta-analyses support the use of robotic-based training for sensorimotor rehabilitation of stroke survivors and people with spinal cord injury and multiple sclerosis [36,66,[68][69][70][71]. Research on robot-assisted movement therapy has rapidly increased in recent years, as the potential for robotic therapy after a neurological insult remains enormous [67]. ...
Arm and hand motor impairments are frequent after a neurological injury. Motor rehabilitation can improve hand and arm function in many cases, but in the current healthcare climate, the time and resources devoted to physical and occupational therapy after injury are inadequate. This represents an opportunity for technology to be introduced that can complement rehabilitation practices, provide motivating task training and allow remote supervision of exercise training performed in the home. Over the last decades, many research groups have been developing robotic devices for exercise therapy, as well as other methods such as electrical stimulation of muscles or vagus nerve stimulation. Robotic devices tend to be expensive and recent studies have raised some doubt as to whether assistance to movements is always preferable as it can reduce salience and engagement. This chapter reviews the evidence for spontaneous recovery, the means and mechanisms of conventional rehabilitation interventions, the advent of affordable passive devices and other treatment modalities that can be used in combination with passive devices. It is argued that task practice on passive devices, in some cases remotely supervised over the internet or augmented with functional electrical stimulation (FES), is now an affordable and important modality of occupational and physical therapy. Passive devices offer numerous opportunities in the field of neurological rehabilitation to support arm and hand motor recovery.
... In general, according to rehabilitation robot structures, they split into two groups: end-effectors and exoskeletons [3]. End-effectors are characterized by their function to assist limbs with rehabilitation processes, which require trajectories with different shapes and sizes [4]. This kind of robot applies its movable handle to drive the patient's limb [5]. ...
A novel cable driven parallel robot is introduced to assist upper limb in rehabilitation treatments in this paper, which has a lightweight structure. This robot is characterized by a novel and flexible end-effector that is easy to change assembly for different therapies. And it is designed for desktop usage, so its size is not too large. After presenting the structure, the kinematic model is presented for optimal design. Then, the minimal singular value is considered as the velocity transmission index. For upper limb rehabilitation, a new optimal design problem with the transmission index and the robot size is formulated. Last, the optimization presents a design with satisfying performances in velocity transmission capability and robot size.
... When calculating the necessary robot control torques, many assist-as-needed controllers are complex enough to account for dynamic contributions from the subject's arm, but none to date account for patient-specific neural control deficits or desired neural control changes. Compared to patients receiving conventional therapy, those receiving upper extremity robotic therapy do not generally exhibit larger improvements in their ability to perform activities of daily living [10,11]. While the reasons for this lack of effectiveness remain unclear, the uniqueness of each patient's neural control deficits and the generic nature of existing rehabilitation robot control methods are likely contributing factors [12][13][14]. ...
Rehabilitation robot efficacy for restoring upper extremity function post-stroke could potentially be improved if robot control algorithms accounted for patient-specific neural control deficiencies. As a first step toward the development of such control algorithms using model-based methods, this study provides general guidelines for creating and simulating closed chain arm-robot models in the OpenSim environment, along with a specific example involving a three-dimensional arm moving within a two degree-of-freedom upper extremity rehabilitation robot. The closed chain arm-robot model developed in OpenSim was evaluated using experimental robot motion and torque data collected from a single healthy subject under four conditions: 1) active robot alone, 2) active robot with passive arm, 3) passive robot with active arm, and 4) active robot with active arm. Computational verification of the combined model was performed for all four conditions, whereas experimental validation was performed for only the first two conditions since torque measurements were not available for the arm. For the four verification problems, forward dynamic simulations reproduced experimentally measured robot joint angles with average root-mean-square (RMS) errors of less than 0.3 degrees and correlation coefficients of 1.00. For the two validation problems, inverse dynamic simulations reproduced experimentally measured robot motor torques with average RMS errors less than or equal to 0.5 Nm and correlation coefficients between 0.92 and 0.99. If patient-specific muscle–tendon and neural control models can be successfully added in the future, the coupled arm-robot OpenSim model may provide a useful testbed for designing patient-specific robot control algorithms that facilitate recovery of upper extremity function post-stroke.
... ere are more and more people in the world suffering from spinal cord injuries (SCIs), with approximately 60% with cervical SCIs leading to tetraplegia [1], which can create severe arm disabilities, resulting in an inability to complete activities of daily living (ADLs) [2]. In addition, stroke is becoming the leading cause of permanent disabilities worldwide, with over 15 million new cases each year and 50 million stroke survivors [3]; more than two-third of all patients affected by stroke have impaired upper limb motor function and have difficulty in independently performing ADLs [4]. Evidence has suggested that upper limb motor skills can be improved by following rehabilitation interventions [5], which attracts more and more scholars engaged in upper limb rehabilitation robot (ULRR) research [6,7], for the ULRRs have the potential to provide intensive rehabilitation consistently for a longer duration [8] irrespective of the skills and fatigue level of the therapist. ...
End-effector type upper limb rehabilitation robots (ULRRs) are connected to patients at one distal point, making them have simple structures and less complex control algorithms, and they can avoid abnormal motion and posture of the target anatomical joints and specific muscles. Given that the end-effector type ULRR focuses more on the rehabilitation of the combined motion of upper limb chain, assisting the patient to perform collaborative tasks, and its intervention has some advantages than the exoskeleton type ULRR, we developed a novel three-degree-of-freedom (DOF) end-effector type ULRR. The advantage of the mechanical design is that the designed end-effector type ULRR can achieve three DOFs by using a four-bar mechanism and a lifting mechanism; we also developed the patient-specific exercises including patient-passive exercise and patient-cooperative exercise, and the advantage of the developed patient-cooperative exercise is that we simplified the human-robot coupling system model into a single spring system instead of the mass-spring-damp system, which efficiently improved the response speed of the control system. In terms of the organization structure of the work, we introduced the end-effector type ULRR’s mechanical design, control system, inverse solution of positions, patient-passive exercise based on the inverse solution of positions and the linear position interpolation of servo drives, and patient-cooperative exercise based on the spring model, in sequence. Experiments with three healthy subjects have been conducted, with results showing good trajectory tracking performance in patient-passive exercise and showing effective, flexible, and good real-time interactive performance in patient-cooperative exercise.
... Robot-assisted upper-limb training has proven beneficial in improving motor performance in stroke patients [6]. Behavioral recovery is also accompanied by vascular remodeling and blood flow restoration in peri-infarct cortices [7]. ...
Functional near-infrared spectroscopy (fNIRS) enables characterizing neural activation in rehabilitation training due to its noninvasive, less physical restriction, and no electromagnetic disturbance. Previous studies have proved the reliability of fNIRS responses in non-motor (e.g., visual stimuli) and fine-motor (e.g., finger tapping) tasks. However, it is still unknown whether fNIRS responses remain reliable in gross-motor tasks, such as upper-limb training, which is the prerequisite for interpretation of rehabilitation training-related changes. In this study, we aimed to investigate the within-session reliability of fNIRS responses in robot-assisted upper-limb training. Ten healthy participants were recruited to conduct elbow extension-flexion in three robot-assisted modes (Passive, Active1, and Active2). fNIRS data of three identical runs were used to assess the within-session reliability in terms of the coefficient of determination (R 2), degree of spatial overlap (R overlap), and intraclass correlation (ICC) of fNIRS temporal features. The obtained results revealed fair-to-good spatial reliability at the subject-level (0.46 < R 2 < 0.72; 0.63 < R overlap < 0.80) and good-to-excellent temporal reliability of Slope, Max/Min, and Mean of fNIRS responses (0.64 < ICC < 0.88), based on the criteria proposed by Cicchetti and Sparrow. We also found that the within-session reliability was positively correlated with the intensity of training mode (Passive < Active1 < Active2), especially for the spatial reliability. Overall, our findings suggested that fNIRS is a reliable tool for measuring neural activity in robot-assisted upper-limb training. On the basis of these findings, practical guidance was provided for future fNIRS-based neurorehabilitation research.
... Many types of upper limb robotic device or rehabilitators for stroke rehabilitation have been developed to assist physiotherapists during rehabilitation program. The systematic reviews on the effects of robotic rehabilitator within the stroke population have been increased in recent years [11][12][13][14][15]. These robotic rehabilitators provide precise measurement of the sensory motor performance of the patient, which can positively influence the rehabilitation result [11]. ...
Stroke patients with upper limb disability restricted to carry out their activities of daily living. The patient needs a motivation to recover from a stroke and the patient also needs to go through a rehabilitation process at the same time. The conventional rehabilitation process scoring systems are always subjective, lack reliability and relies heavily on the ability of the trained physiotherapist that providing only rough estimates on motor function. On the other hand, robot-based assessments are objective, repeatable, and could potentially reduce the assessment time. Therefore, a simple non-motorized device was developed as a tool to objectively assess hand function of stroke patients. This study was carried out to investigate the suitability of using thedeveloped device with stroke patient populations and to evaluate the performance of clinical scores prediction of the stroke patients. A total of five patients with upper limb disability following stroke consented to take part in this study. Twelve predictive variables were investigated, relating to the total movement time, velocity, strategy, accuracy, and smoothness from three robotic assessment modules which are Draw I, Draw Diamond and Draw Circle. The hardware for measuring elbow angle hasbeen developed to measurethe shoulder movement performedby patient during the assessment process. In addition to that, the shoulder movement calculation method has been proposed and validated.The findings indicatethat the performance of prediction for all assessment modules hasbeen increased after implementing the shoulder movement calculation. It is recommended this calculation method to be used in conjunction with kinematic variables to carry out the data acquisition process in the future for improvement of effectiveness and accuracy of the robotic assessment.
... There do, however, continue to be various challenges for both people with stroke and health care professionals working in stroke rehabilitation, and these are heightened by access issues in regional and rural areas [16,37,38]. Specific to health services, challenges include delivering services that are both efficient and effective, maintaining the currency of practice with the rapid emergence and diversification of rehabilitation technologies and design paradigms, the availability of specialists skills/knowledge/services, the access to staff training to advance staff capabilities, and managing the socio-political factors that influence technology supply and practice [34] (p.668). ...
Rehabilitation technologies are rapidly evolving, presenting promising interventions for people with neurological impairments. Access to technology, however, is greater in metropolitan than rural areas. Applying a capabilities approach to this access issue foregrounds healthcare recipients’ rights and personhood within the discourse on resource allocation. Within this context, this study aimed to investigate the economic viability of robotics-based therapy (RBT) in rural Victoria, Australia. A regional health network developed a model of care to provide equitable access to RBT following stroke. This explorative economic evaluation examined both the clinical and economic impact of RBT program implementation across six program iterations compared to 1:1 out-patient rehabilitation. While clinical outcomes were equivalent, the per patient RBT cost ranged from AUD 2681 (Program 1) to AUD 1957 (Program 6), while the per patient cost of usual care 1:1 out-patient rehabilitation, was AUD 2584. Excluding Program 1, the health service cost of usual care 1:1 out-patient rehabilitation was consistently higher, indicating that an established RBT program may be cost-effective, specifically providing less cost for the same effect. This research demonstrates the economic feasibility of delivering RBT in a regional public health stroke service. More broadly, it provided a reduction in the capability gap between rural and metropolitan stroke survivors by tackling an access disadvantage.
... Such devices are usually wearable, more comfortable and less bulky than rigid exoskeleton type devices. That makes them very suited for use in everyday environments, to assist with daily tasks (14). The Carbonhand (Bioservo Technologies AG; Kista, Sweden) is such a wearable, soft-robotic glove, which supports the grip of its user by assisting finger flexion. ...
In an ongoing study, an assistive wearable soft-robotic glove is tested at home for 6 weeks by subjects with decreased handgrip strength, due to different hand injuries or diseases, to assess whether use of this assistive grip-supporting glove will result in improved hand strength/ function. An interim analysis of the available dataset of 46 participants showed that (unsupported) grip strength and hand function improved after using the soft-robotic glove as assistive aid during activities of daily living (ADLs) during 6 weeks at home. After glove use is ended, this is maintained for at least 4 weeks. Considering that in the current situation the analysis is underpowered, these interim results are promising for finding a clinical (therapeutic) effect of using a soft-robotic glove as assistance during ADLs. If this is the case, this might open up entirely new opportunities for extending rehabilitation into people's homes, while also providing them with assistance to directly support performance of daily activities. Such a combination is becoming available with the development of mature and user-friendly wearable soft-robotic devices. This would enable very high doses of training throughout the day, in the most functional, task-specific way possible, and possibly prevention of learned non-use.
... Among them, hemiparesis is one of the most important symptoms and can lead to impaired activities of daily living (ADL) and a lower quality of life [2,3]. Recently, some novel rehabilitative interventions for hemiparesis after stroke were developed [4][5][6][7]. However, in the process of rehabilitation after stroke, it is still necessary to predict functional outcomes in order to set feasible goals and devise plans for daily living in the chronic phase [8,9]. ...
Background:
Recently, it was reported that the extent of cortico-cortical functional connections can be estimated by the correlation coefficient based on electroencephalography (EEG) monitoring. We aimed to investigate whether the EEG correlation coefficient change with motor task activation can predict the functional outcomes of hemiparetic stroke patients.
Methods:
Sixteen post-stroke hemiparetic patients admitted to our rehabilitation ward were studied. On admission, EEG recording to calculate the correlation coefficient was performed at rest and during motor task activation. For the analysis of the EEG data, the program software FOCUS (NIHON KOHDEN, Japan) was used. The motor function of paretic limbs was evaluated with the Fugl-Meyer Assessment (FMA) on admission and 4 weeks after admission.
Results:
Significant increases in the correlation coefficient with motor task activation were noted in C3-F3 or C4-F4, C3-F7 or C4-F8, and F3-F7 or F4-F8 of the lesional hemisphere. Among them, the rate of the correlation coefficient change in F3-F7 or F4-F8 in the lesional hemisphere was significantly correlated with the rate of the upper-limb FMA score change.
Conclusion:
The extent of the EEG correlation coefficient change with motor task activation in F3-F7 or F4-F8 of the lesional hemisphere may help predict the motor functional outcomes of hemiparetic upper limbs after stroke.
... In the current literature, many researchers are investigating the effects of different devices and robots used in upper limb rehabilitation [39,40]. Technology-supported rehabilitation was previously encountered in neurological pathologies, but due to the effects on reducing motor impairments and improving upper limb function, this therapeutical method is also highly recommended in orthopaedic disorders [41,42]. ...
Background and Objectives: Shoulder disorders are associated with pain, restricted range of motion and muscular strength, moderate disability and diminished proprioception. This study aimed to compare the effectiveness of an innovative technology-supported and a classical therapist-based proprioceptive training program in addition to conventional physiotherapy, on joint position sense (JPS), pain and function, in individuals with different musculoskeletal shoulder disorders, such as rotator cuff tear, subacromial impingement syndrome and superior labrum anterior and posterior tear. The innovative element of the proprioceptive training programme consists of the use of the Kinesimeter, a device created for both training and assessing shoulder JPS. Materials and Methods: The shoulder JPS test and the DASH outcome questionnaire were applied to fifty-five individuals (28 females, 27 males, mean age 56.31 ± 6.75), divided into three groups: 17 in the conventional physiotherapy group (control group); 19 in the conventional physiotherapy + classical proprioceptive training program group (CPT group); and 19 in the conventional physiotherapy + innovative proprioceptive training program group (KPT group). Assessments were performed before and after a four-week rehabilitation program, with five physiotherapy sessions per week. Results: When baseline and post-intervention results were compared, the value of the shoulder JPS and DASH outcome questionnaire improved significantly for the KPT and CPT groups (all p < 0.001). Both KPT and CPT groups showed statistically significant improvements in JPS, pain and function, compared to the control group which received no proprioceptive training (all p < 0.05). However, the KPT group showed no significant benefits compared to the CPT group. Conclusions: Our findings indicate that using the Kinesimeter device as a novel, innovative proprioceptive training tool has similar effects as the classical proprioceptive training programs among individuals with different non-operated musculoskeletal shoulder disorders such as: rotator cuff tear, subacromial impingement syndrome, and superior labrum anterior and posterior tear.
... análise de subgrupo os resultados devam ser interpretados com cautela, porque a qualidade da evidência foi de baixa a muito baixa e houve variação entre os ensaios quanto à duração e quantidade de treinamento, tipo de tratamento e diferenças nas características dos pacientes, dificultando a comparação e interpretação adequada dos efeitos relatados.Bertani et al. (2017), descobriram que em indivíduos pós-AVE crônico, a terapia robótica é mais eficaz na redução do comprometimento motor do que a terapia convencional, mas não em indivíduos pós-AVE agudo. Uma possível razão apontada porZhang et al (2017) é o fato de que pacientes em estágio crônico conseguem tolerar melhor tratamentos intensivos do que os ...
Indivíduos pós-acidente vascular encefálico (AVE) apresentam limitações motoras no membro superior que interferem na capacidade de realizar de forma independente as atividades de vida diária, comprometendo a funcionalidade, afetando a participação social e qualidade de vida. Alternativas inovadoras de reabilitação consistem na Terapia Assistida por Robô (RT) e nos Sistemas Robóticos Híbridos de Reabilitação (SRHR), abordagem que combina a prática muscular repetitiva fornecida pela terapia robótica com a ativação muscular proporcionada pela Estimulação Elétrica Funcional (FES). Apesar dos benefícios comprovados dessas tecnologias, observa-se ainda uma falta de adesão e implementação limitada na prática clínica. Isso porque a maioria dos dispositivos híbridos estão apenas nos estágios iniciais de desenvolvimento e os equipamentos robóticos hoje disponíveis, apresentam diversas desvantagens relacionadas à dificuldade de controle, pouca funcionalidade, estética e custo elevado, comprometendo seus resultados e aplicabilidade. O objetivo deste estudo foi desenvolver um sistema robótico híbrido para uso em pessoas com comprometimento motor de membro superior decorrente de AVE com vantagens em relação aos disponíveis atualmente. Os diferenciais competitivos dizem respeito a sua estética, estrutura, sistema de acionamento e de controle, portabilidade e concomitância de articulação. Foi realizado um estudo exploratório em duas etapas. A primeira etapa consistiu no desenvolvimento do protótipo de órtese robótica e validação do funcionamento da parte biomecânica por meio de estudo piloto com quatro participantes. A segunda etapa consistiu no aprimoramento da estrutura e sistema de controle, acrescentando a FES ao acionamento, transformando-o em um sistema robótico híbrido. Foi realizado um estudo piloto multicêntrico com 10 participantes a fim de identificar as necessidades e preferências dos usuários de forma a aumentar a aceitação e implementação dessa tecnologia. Foi verificado correto funcionamento do dispositivo por meio de testes padronizados de bancada, resultando na aquisição de um novo e promissor equipamento para reabilitação de membro superior, capaz de auxiliar na recuperação das habilidades funcionais de pessoas com perda da função motora de membro superior.
... [6] These reduced upper limb functions restrict the activities of daily living of the patient, reduce their productivity, make social integration difficult, and cause an economic burden. [7] Stroke causes motor disorders such as spasticity, which is caused by an imbalance of brain activity. Spasticity is high resistance to passive muscle stretching influenced by velocity. ...
Background:
Impaired motor function and upper extremity spasticity are common concerns in patients after stroke. It is essential to plan therapeutic techniques to recover from the stroke. The objective of this study was to investigate the effects of myofascial release with the tennis ball on spasticity and motor functions of the upper extremity in patients with chronic stroke.
Methods:
Twenty-two chronic stroke patients (male-16, female-6) were selected to conduct this study. Two groups were formed: the control group (n=11) which included conventional physiotherapy only and the experimental group (n=11) which included conventional physiotherapy along with tennis ball myofascial release - in both groups interventions were performed for 6 sessions (35 minutes/session) per week for a total of 4 weeks. The conventional physiotherapy program consisted of active and passive ROM exercises, positional stretch exercises, resistance strength training, postural control exercises, and exercises to improve lower limb functions. All patients were evaluated with a modified Ashworth scale for spasticity of upper limb muscles (biceps brachii, pronator teres, and the long finger flexors) and a Fugl-Meyer assessment scale for upper limb motor functions before and after 4 weeks. Nonparametric (Mann-Whitney U test and Wilcoxon signed-rank test) tests were used to analyze data statistically. This study has been registered on clinicaltrial.gov (ID: NCT05242679).
Results:
A significant improvement (P < .05) was observed in the spasticity of all 3 muscles in both groups. For upper limb motor functions, significant improvement (P < .05) was observed in the experimental group only. When both groups were compared, greater improvement (P < .05) was observed in the experimental group in comparison to the control group for both spasticity of muscles and upper limb motor functions.
Conclusion:
Myofascial release performed with a tennis ball in conjunction with conventional physiotherapy has more beneficial effects on spasticity and motor functions of the upper extremity in patients with chronic stroke compared to conventional therapy alone.
... With the development of technology and the increasing emphasis on post-stroke rehabilitation, rehabilitation robots are used in the rehabilitation of hemiplegia patients (Cao et al., 2021;Cui et al., 2016;Jakob et al., 2018;Molteni et al., 2018;Shi et al., 2019). Upper limb rehabilitation robots can effectively improve the efficiency of rehabilitation training and save manpower loss in the treatment process (Liu et al., 2018;Bertani et al., 2017;Brahmi et al., 2018;Büsching et al., 2018). In order to raise the effect of the upper limb robot rehabilitation training, there are many control methods on the active training mode of rehabilitation robots in order to monitor the motion intention of patients. ...
Active participation in training is very important for improving the rehabilitation effect for patients with upper limb dysfunction. However, traditional upper limb rehabilitation robots cannot drive the patients' arms by following their varying motion intents during active training. This control strategy can weaken the patients' active participation. This paper proposes a novel center-driven upper limb rehabilitation robot and an electromyogram (EMG)-based motion compensation control method for the upper limb rehabilitation robot in active training in order to improve the patients' active participation. In addition, the trajectory planning equations for the proposed robot manipulator are analyzed and built in order to provide the reference trajectory in active training. In the end, two experiments are carried out to verify the proposed control method. The EMG compensation experiments show that the maximum error between the theoretical and experimental motor rotating speeds is no more than 1.3 %. The active training control experiment results show that the proposed robot can implement the reference trajectory in real time. The control method can implement the positive relationship between the rotating speed and the intensity of EMG emerging during upper limb training. It shows that the proposed rehabilitation robot can provide auxiliary force according to the patients' motion intents. The proposed rehabilitation robot can guide the patients in implementing the reference task in active training.
... Although a better therapeutic effect of robot-assisted therapy (RAT) on motor and activity function has been reported [7,[10][11][12][13], disparate effects and heterogeneities between trials were found depending on the phase of poststroke [14], the amount of training [15], the control system of the robots (e.g., patient-passive control robots versus patient-active control robots) [16] and the targeted joints of robots (e.g., proximal upper limb versus distal approach) [17], several meta-analyses have discussed the influence of stage of stroke [18][19][20][21][22] and the targeted joints of robots [20,22,23] on benefits of RAT on motor control and activity function, but few study focused on the level of impairment of patients, and the parameters of RAT such as amount of training time and the control system of the robots, thus we performed comprehensive analysis to discuss those factors to try to determine the optimal treatment parameters. ...
Objective:
To investigate the effect of robot-assisted therapy (RAT) on upper limb motor control and activity function in poststroke patients compared with that of non-robotic therapy.
Methods:
We searched PubMed, EMBASE, Cochrane Library, Google Scholar and Scopus. Randomized controlled trials published from 2010 to nowadays comparing the effect of RAT and control treatment on upper limb function of poststroke patients aged 18 or older were included. Researchers extracted all relevant data from the included studies, assessed the heterogeneity with inconsistency statistics (I2 statistics), evaluated the risk of bias of individual studies and performed data analysis.
Result:
Forty-six studies were included. Meta-analysis showed that the outcome of the Fugl-Meyer Upper Extremity assessment (FM-UE) (SMD = 0.20, P = 0.001) and activity function post intervention was significantly higher (SMD = 0.32, P < 0.001) in the RAT group than in the control group. Differences in outcomes of the FM-UE and activity function between the RAT group and control group were observed at the end of treatment and were not found at the follow-up. Additionally, the outcomes of the FM-UE (SMD = 0.15, P = 0.005) and activity function (SMD = 0.32, P = 0.002) were significantly different between the RAT and control groups only with a total training time of more than 15 h. Moreover, the differences in outcomes of FM-UE and activity post intervention were not significant when the arm robots were applied to patients with severe impairments (FM-UE: SMD = 0.14, P = 0.08; activity: SMD = 0.21, P = 0.06) or when patients were provided with patient-passive training (FM-UE: SMD = - 0.09, P = 0.85; activity: SMD = 0.70, P = 0.16).
Conclusion:
RAT has the significant immediate benefits for motor control and activity function of hemiparetic upper limb in patients after stroke compared with controls, but there is no evidence to support its long-term additional benefits. The superiority of RAT in improving motor control and activity function is limited by the amount of training time and the patients' active participation.
... The use of robot-assisted therapy, in particular for upper limb, is an emerging field of research and could help therapists to provide high-intensity, repetitive, and task-specific treatments based on neuro-plasticity theories. Evidence from a meta-analysis of 14 randomised controlled trials suggests that robot-assisted rehabilitation was more effective in improving motor function recovery, particularly in chronic strokes 283 . A large RCT has recently found that although robot assisted training did improve upper limb impairment this did not translate into improvement in arm function 284 . ...
Background: Stroke is a leading cause of death and disability in the UK with around 90,000 new stroke patients each year. The NHS England (NHSE) Long Term Plan is committed to saving 150,000 lives from cardiovascular disease over the next 10 years and improving the quality of care available for patients who have a stroke.
Methods: This overview was commissioned by NHSE to summarise what we currently know and don’t know across the breadth of the care pathway. We conducted a series of evidence reviews to inform NHSE and its providers (commissioners, primary and secondary care teams, networks) of what needs to be achieved to deliver world class services equitably across England. Here, we present a concise summary of this work.
Results: Our report summarised the findings of 539 research articles, which we organised into ten sections relating to different stages of the stroke care pathway, from prevention in the community, to acute pre-hospital and hospital care, and on to rehabilitation and longer-term care in the community. Priorities include better prevention (with 90% of stroke attributable to modifiable risk factors), and improving awareness to maximise the chances that people experiencing an ischaemic stroke will reach hospital in time to be eligible for acute treatments. We describe the effects of reorganising hospital care into a smaller number of 'hyperacute' centres, and early supported discharge. In the longer term after stroke, the needs of stroke survivors and their families are not being met, but we found little evidence about what works to improve the situation.
Conclusions: We present in this ‘concise’ version, an overview of the evidence to support the delivery of world class stroke care in England. We conclude with an overview of gaps in the evidence base for each area, set out as research questions to be prioritised and addressed.
... Our hybrid regimens are unique in using bilateral robotic practice as a priming technique to augment bilateral task practice with and without mirror visual feedback. The anticipated benefits of robot-assisted bilateral movement priming in stroke rehabilitation may be associated with balanced excitability between the ipsilesional and contralesional hemispheres [35], positive reorganization in the motor cortex [36,37], and improvements in later voluntary and complicated task performance [38]. The context-related and goal-directed practice in our treatment protocol may assist the patients to transfer therapeutic gains in clinics to their real-life environment and generalize motor improvements to performance of daily activities [21]. ...
Background
Combining robotic therapy (RT) with task-oriented therapy is an emerging strategy to facilitate motor relearning in stroke rehabilitation. This study protocol will compare novel rehabilitation regimens that use bilateral RT as a priming technique to augment two task-oriented therapies: mirror therapy (MT) and bilateral arm training (BAT) with a control intervention: RT combined with impairment-oriented training (IOT).
Methods
This single-blind, randomized, comparative efficacy study will involve 96 participants with chronic stroke. Participants will be randomized into bilateral RT+MT, bilateral RT+BAT, and bilateral RT+IOT groups and receive 18 intervention sessions (90 min/day, 3 d/week for 6 weeks). The outcomes will include the Fugl-Meyer Assessment, Stroke Impact Scale version 3.0, Medical Research Council scale, Revised Nottingham Sensory Assessment, ABILHAND Questionnaire, and accelerometer and will be assessed at baseline, after treatment, and at the 3-month follow-up. Analysis of covariance and the chi-square automatic interaction detector method will be used to examine the comparative efficacy and predictors of outcome, respectively, after bilateral RT+MT, bilateral RT+BAT, and bilateral RT+IOT.
Discussion
The findings are expected to contribute to the research and development of robotic devices, to update the evidence-based protocols in postacute stroke care programs, and to investigate the use of accelerometers for monitoring activity level in real-life situations, which may in turn promote home-based practice by the patients and their caregivers. Directions for further studies and empirical implications for clinical practice will be further discussed in upper-extremity rehabilitation after stroke.
Trial registration
This trial was registered December 12, 2018, at www.clinicaltrials.gov ( NCT03773653 ).
... The peculiarity of BCI is that it allows for functional efferentafferent contingency, immediate feedback and reinforcement even without any movement capacity (19)(20)(21). Albeit promising, BCI as a therapy for upper-limb rehabilitation is still at its infancy and most of the randomized clinical trials (RCTs) are heterogeneous in terms of brain-directed machines used, movements performed, intervention duration and targeted population (13,(22)(23)(24)(25). These variabilities are not specific to BCI therapies, but have also been reported in other stroke-related upper-limb rehabilitation treatments (13,26). ...
Effective, patient-tailored rehabilitation to restore upper-limb motor function in severely impaired stroke patients is still missing. If suitably combined and administered in a personalized fashion, neurotechnologies offer a large potential to assist rehabilitative therapies to enhance individual treatment effects. AVANCER (clinicaltrials.gov NCT04448483) is a two-center proof-of-concept trial with an individual based cumulative longitudinal intervention design aiming at reducing upper-limb motor impairment in severely affected stroke patients with the help of multiple neurotechnologies. AVANCER will determine feasibility, safety, and effectivity of this innovative intervention. Thirty chronic stroke patients with a Fugl-Meyer assessment of the upper limb (FM-UE) <20 will be recruited at two centers. All patients will undergo the cumulative personalized intervention within two phases: the first uses an EEG-based brain-computer interface to trigger a variety of patient-tailored movements supported by multi-channel functional electrical stimulation in combination with a hand exoskeleton. This phase will be continued until patients do not improve anymore according to a quantitative threshold based on the FM-UE. The second interventional phase will add non-invasive brain stimulation by means of anodal transcranial direct current stimulation to the motor cortex to the initial approach. Each phase will last for a minimum of 11 sessions. Clinical and multimodal assessments are longitudinally acquired, before the first interventional phase, at the switch to the second interventional phase and at the end of the second interventional phase. The primary outcome measure is the 66-point FM-UE, a significant improvement of at least four points is hypothesized and considered clinically relevant. Several clinical and system neuroscience secondary outcome measures are additionally evaluated. AVANCER aims to provide evidence for a safe, effective, personalized, adjuvant treatment for patients with severe upper-extremity impairment for whom to date there is no efficient treatment available.
... In the meantime, several studies have been carried out in the post-stroke rehabilitation field [19][20][21]. About 80% of people with acute stroke have upper limb motor impairment, and of those with reduced arm function early after stroke, 50% still have problems after 4 years [22]. ...
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.
BACKGROUND
To date, there have been no published studies evaluating the cost-effectiveness of robot-assisted gait training (RAGT) in adolescent and adult patients with cerebral palsy (CP). The study´s aim was to analyse the cost-effectiveness of RAGT versus conventional kinesiotherapy (CON) from the health care provider’s perspective.
METHODS
We expressed the cost-effectiveness of RAGT in the Lokomat® system after analysing the costs and effects of RAGT and conventional therapy through the Incremental Cost-Effectiveness Ratio (ICER) based on a bicentric randomised controlled study, in which we demonstrated that the intensive RAGT regimen is more effective than conventional therapy in terms of improvements in gross motor functions in adolescent and adult patients with bilateral spastic CP.
RESULTS
According to the calculated ICER ratio for Lokomat®, an additional improvement per unit of effect (1% in GMFM), compared to conventional therapy, results in an average cost increase of EUR70.38 per patient in a therapeutic block consisting of 20 TUs (Therapeutic Units).
CONCLUSION
However, from the comprehensive analysis of the results and evaluation of the long-term effects, it follows that RAGT applied in adolescent and adult patients with bilateral spastic CP is not only more effective in terms of evaluation of monitored clinical parameters, but in the long term it is also more cost-effective compared to conventional therapy.
Robot-assisted rehabilitation therapy has been proven to effectively improve upper-limb motor function in stroke patients. However, most current rehabilitation robotic controllers will provide too much assistance force and focus only on the patient's position tracking performance while ignoring the patient's interactive force situation, resulting in the inability to accurately assess the patient's true motor intention and difficulty stimulating the patient's initiative, thus negatively affecting the patient's rehabilitation outcome. Therefore, this paper proposes a fuzzy adaptive passive (FAP) control strategy based on subjects' task performance and impulse. To ensure the safety of subjects, a passive controller based on the potential field is designed to guide and assist patients in their movements, and the stability of the controller is demonstrated in a passive formalism. Then, using the subject's task performance and impulse as evaluation indicators, fuzzy logic rules were designed and used as an evaluation algorithm to quantitively assess the subject's motor ability and to adaptively modify the stiffness coefficient of the potential field and thus change the magnitude of the assistance force to stimulate the subject's initiative. Through experiments, this control strategy has been shown to not only improve the subject's initiative during the training process and ensure their safety during training but also enhance the subject's motor learning ability.
Wearable robotics, also called exoskeletons, have been engineered for human-centered assistance for decades. They provide assistive technologies for maintaining and improving patients’ natural capabilities towards self-independence and also enable new therapy solutions for rehabilitation towards pervasive health. Upper limb exoskeletons can significantly enhance human manipulation with environments, which is crucial to patients’ independence, self-esteem, and quality of life. For long-term use in both in-hospital and at-home settings, there are still needs for new technologies with high comfort, biocompatibility, and operability. The recent progress in soft robotics has initiated soft exoskeletons (also called exosuits), which are based on controllable and compliant materials and structures. Remarkable literature reviews have been performed for rigid exoskeletons ranging from robot design to different practical applications. Due to the emerging state, few have been focused on soft upper limb exoskeletons. This paper aims to provide a systematic review of the recent progress in wearable upper limb robotics including both rigid and soft exoskeletons with a focus on their designs and applications in various pervasive healthcare settings. The technical needs for wearable robots are carefully reviewed and the assistance and rehabilitation that can be enhanced by wearable robotics are particularly discussed. The knowledge from rigid wearable robots may provide practical experience and inspire new ideas for soft exoskeleton designs. We also discuss the challenges and opportunities of wearable assistive robotics for pervasive health.
In this paper, the problem of robotic rehabilitation of upper limbs is addressed by focusing attention on the control of a standard collaborative robot for those training activities that can be performed with the aid of an end-effector type system. In particular, a novel admittance control, that constrains the motion of the robot along a prescribed path without imposing a specific time law along it, has been devised. The proposed approach exploits the features of the arc-length parameterization of a generic curve to obtain a simple control formulation able to guide the patient in both a passive or an active way, with the possibility of supporting the execution of the task with an additional force or opposing the motion with a braking force. Being the method independent from the particular curve considered for the constraint specification, it allows an intuitive definition of the task to be performed via Programming by Demonstration. Experimental results show the effectiveness of the proposed approach.KeywordsAdmittance controlGuidance virtual fixturesHuman-robot interactionRehabilitation
Introduction:
The effect of early initiation of gait training using hybrid assistive limb (HAL) remains unclear. This observational study aimed to investigate whether early initiation of gait training using HAL improves functional outcomes in patients with stroke.
Methods:
We retrospectively analyzed patients with acute stroke admitted to our facility. HAL was used for exoskeletal robotic gait training. Study participants were median split into an early group and a late group based on the days from stroke onset to initiation of gait training using HAL. The functional outcomes, defined by the Brunnstrom recovery stage (BRS), modified Rankin Scale (mRS), and Functional Independence Measure (FIM) at discharge, were compared using propensity score-matched analysis.
Results:
We performed a propensity score-matched analysis in 63 patients with stroke (31 from the early group and 32 from the late group), and 17 pairs were matched. There were no significant differences in discharge in the BRS of the upper limb and finger in the post-matched cohort. On the other hand, the BRS of the lower limb in the early group was significantly higher than that in the late group. In addition, the mRS, but not FIM scores, was significantly better in the early group than that in the late group.
Conclusions:
In conclusion, early initiation of gait training using HAL might improve the motor function of the paralyzed lower limb and disability in patients with stroke.
This chapter describes the development of mechanically assistive devices to enhance upper-extremity movement training after neurologic injury. We use the term “mechanically assistive devices” to refer to non-powered devices that incorporate springs, guides, pulleys, ramps, and/or levers to assist a patient in moving his or her weakened arm primarily by reducing the effect of gravity. As a case study of this approach, we first describe the development of the T-WREX exoskeletal training device, which was then commercialized and further tested as ArmeoSpring. Next, we provide a summary of clinical evidence for the effectiveness of mechanically assistive devices. We discuss why training with mechanically assistive devices reduces arm impairment, highlighting motivational, strengthening, and proprioceptive effects. We conclude by describing our recent efforts to democratize mechanically assistive devices for arm training by incorporating them directly onto wheelchairs as armrests.
Robot-assisted haptic training has the potential to facilitate motor learning and neurorehabilitation for a diverse number of motor tasks, ranging from manipulating objects with unknown dynamics to relearning walking using robotic exoskeletons. In this chapter, we provide an overview of current haptic methods evaluated in motor (re)learning studies with the goal to discuss implications for the design of rehabilitation technology. We highlight the challenge point framework as a unifying view on how to guide the design of haptic training paradigms, based on the initial skill level of the learner and the characteristics of the task to be learned. Future work on robot-aided haptic training strategies should focus on adaptive training algorithms, providing more naturalistic congruent multisensory feedback that resembles out-of-the-lab training, and conduct long-term studies to assess the efficacy of haptic training on learning not only the trained task but importantly, on skill transfer to real tasks.
In this paper, to address motor dysfunction caused by factors such as stroke or traffic accidents, a kind of upper limb rehabilitation robot is designed for rehabilitation training. The rehabilitation robot is driven by series elastic actuator (SEA) to make the upper limb rehabilitation robot have flexible output. Flexible output can improve the compliance and safety between the patient and the rehabilitation robot, but impedance control method is needed to ensure the compliance of human–robot interaction. In order to solve the human–robot interaction problem of SEA–based upper limb rehabilitation robot, the dynamic model and an impedance control are established for the SEA–based upper limb rehabilitation robot. The impedance control method of upper limb rehabilitation robot based on terminal position is designed in detail. Aiming at the designed impedance control method, a numerical simulation model is established for the upper limb rehabilitation robot, and the accuracy of the model is verified by the simulation of the upper limb rehabilitation robot. The numerical results show that the impedance controller can meet the needs of the rehabilitation training of the upper limb rehabilitation robot, which improves the coordination of human–robot interaction in the rehabilitation process.
Objective:
Robot-assisted neuro-rehabilitation therapy plays a central role in upper extremity recovery of stroke. Even though, the efficacy of robotic training on upper extremity is not yet well defined and scant attention has been devoted to its potential effect on lower extremity. In this paper, the aim was to compare efficacy on upper and lower extremities between robot-assisted training (RAT) and therapist-mediated enhanced upper extremity therapy (EUET).
Methods:
A randomized clinical trial involving 172 stroke survivors was conducted in China. All participants received either RAT or EUET for 3 weeks. The Fugl-Meyer assessment upper extremity subscale (FMA-UE), Fugl-Meyer assessment lower extremity subscale (FMA-LE), and Modified Barthel Index (MBI) were administered at baseline, mid-treatment (one week after treatment start), and posttreatment. Results: Participants in RAT group showed a significant improvement in hemiplegia extremity, which was non-inferior to EUET group in FMA-UE (p<0.05), while suggesting greater motor recovery of lower extremity in FMA-LE (p<0.05) compared with EUET group. A marked increase in MBI was observed within groups, however, no significant difference was detected between groups.
Conclusion:
RAT is non-inferior in reducing impairment of upper extremity and appears to be superior in that of lower extremity compared with EUET for stroke survivors.
Stroke instigates regenerative responses that reorganize connectivity patterns among surviving neurons. The new connectivity patterns can be suboptimal for behavioral function. This review summarizes current knowledge on post-stroke motor system reorganization and emerging strategies for shaping it with manipulations of behavior and cortical activity to improve functional outcome.
©2015 Int. Union Physiol. Sci./Am. Physiol. Soc.
Background and purpose:
There is little evidence available on the use of robot-assisted therapy in subacute stroke patients. A randomized controlled trial was carried out to evaluate the short-time efficacy of intensive robot-assisted therapy compared to usual physical therapy performed in the early phase after stroke onset.
Methods:
Fifty-three subacute stroke patients at their first-ever stroke were enrolled 30 ± 7 days after the acute event and randomized into two groups, both exposed to standard therapy. Additional 30 sessions of robot-assisted therapy were provided to the Experimental Group. Additional 30 sessions of usual therapy were provided to the Control Group.
The following impairment evaluations were performed at the beginning (T0), after 15 sessions (T1), and at the end of the treatment (T2): Fugl-Meyer Assessment Scale (FM), Modified Ashworth Scale-Shoulder (MAS-S), Modified Ashworth Scale-Elbow (MAS-E), Total Passive Range of Motion-Shoulder/Elbow (pROM), and Motricity Index (MI).
Results:
Evidence of significant improvements in MAS-S (p = 0.004), MAS-E (p = 0.018) and pROM (p < 0.0001) was found in the Experimental Group. Significant improvement was demonstrated in both Experimental and Control Group in FM (EG: p < 0.0001, CG: p < 0.0001) and MI (EG: p < 0.0001, CG: p < 0.0001), with an higher improvement in the Experimental Group.
Conclusions:
Robot-assisted upper limb rehabilitation treatment can contribute to increasing motor recovery in subacute stroke patients. Focusing on the early phase of stroke recovery has a high potential impact in clinical practice.
To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients.
Prospective, randomized, controlled trial. Setting: Stroke units in three medical centres. Subjects: Twenty patients post stroke for a mean of 22 months. Intervention: Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90-105 minutes each day, 5 days per week, for four weeks.
Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire.
The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43).
Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.
Robot-assisted therapy (RT) is a current promising intervention in stroke rehabilitation, but more research is warranted for examining its efficacy and the dose-benefit relation. The authors investigated the effects of higher intensity versus lower intensity RT on movements of forearm pronation-supination and wrist flexion-extension relative to conventional rehabilitation (CR) in patients poststroke for a mean of 21 months.
In this pilot study, 18 patients with initial mean Fugl-Meyer Assessment (FMA) of 37 to 44 for the upper extremity were randomized to higher intensity RT, lower intensity RT, or CR intervention for 4 weeks. The dose of the higher intensity RT was twice the number of repetitions in the lower intensity RT. Outcome measures at pretreatment and posttreatment were administered to patients to evaluate beneficial and adverse effects of interventions. Primary outcomes were the FMA and Medical Research Council scale.
There were significant differences in motor function (P = .04) and daily performance (P = .03) among the 3 groups. The higher intensity RT group showed better improvement in motor function, muscle strength, performance of daily activities, and bimanual ability than the other 2 groups. The intensive RT intervention did not induce higher levels of an oxidative DNA biomarker.
Higher intensity of RT that assists forearm and wrist movements may lead to greater improvement in motor ability and functional performance in stroke patients. A sample size of only 20 to 25 in each arm of a larger randomized controlled trial is needed to confirm the findings for similar subjects.
Effective rehabilitative therapies are needed for patients with long-term deficits after stroke.
In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks.
At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported.
In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)
Reductions in blood flow to the brain of sufficient duration and extent lead to stroke, which results in damage to neuronal networks and the impairment of sensation, movement or cognition. Evidence from animal models suggests that a time-limited window of neuroplasticity opens following a stroke, during which the greatest gains in recovery occur. Plasticity mechanisms include activity-dependent rewiring and synapse strengthening. The challenge for improving stroke recovery is to understand how to optimally engage and modify surviving neuronal networks, to provide new response strategies that compensate for tissue lost to injury.
The aims of this study were to review robot-assisted motor and functional rehabilitation of the upper limb in patients with stroke and to outline possible clinical applications of robotics in neuro-rehabilitation.
Available active systems, with actuators driving the paretic arm, were sub-classified by scientific rationale and mechatronic structure as exoskeletons or operational-type machines (manipulators). Applicative studies were compared for indication of efficacy.
Clinical and biomechanical evidence available to date suggests substantial efficacy of robot--assisted neuro-rehabilitation in the recovery of the paretic arm after stroke, enabling longer dedicated training sessions with no additional work for the therapist. Further investigation of large samples of patients is required to define the relationship between disability and residual function, to provide shared criteria of evaluation of disability/outcome and protocols of rehabilitation, and to identify the expected future role and application of robotics in neuro-rehabilitation.
We undertook this investigation to determine the interrater reliability of manual tests of elbow flexor muscle spasticity graded on a modified Ashworth scale. We each independently graded the elbow flexor muscle spasticity of 30 patients with intracranial lesions. We agreed on 86.7% of our ratings. The Kendall's tau correlation between our grades was .847 (p less than .001). Thus, the relationship between the raters' judgments was significant and the reliability was good. Although the results were limited to the elbow flexor muscle group, we believe them to be positive enough to encourage further trials of the modified Ashworth scale for grading spasticity.
Stroke is the most disabling chronic condition, newly affecting 35000 persons in Canada each year. Because of declining fatality, a growing number of persons will have to cope with stroke-related disability. The purpose of this paper is to describe the disabilities experienced by persons with stroke during the first year and explore the evolution of impairment, disability, handicap and health-related quality of life.
The data for this paper come from a series of longitudinal and cross-sectional studies, collectively known as the McGill Stroke Rehabilitation Research Program.
Within the first week post-stroke, getting out of bed and walking over a short distance, even with assistance, was a strong predictor of discharge home. Most of the improvement in measures of impairment and disability occurred during the first month and, by 3 months, there was still considerable room for improvement in all measures: 85% of persons were still impaired on gait speed, 78% had not reached age-specific norms for upper extremity function, 68% still demonstrated slow physical mobility, 37% needed some assistance with basic activities of daily living and 29% were still impaired on balance. By 1 year, 73% of persons scored the maximum for basic activities of daily living but 51 and 67% of persons reported their physical health and mental health to be lower than expected. Among a hardy group of stroke survivors, still living in the community 1 year post-stroke, the most striking area of difficulty was endurance, as measured by the 6 minute walk test. Those subjects well enough to complete this task (50% of sample) were able to walk, on average, only 250 metres, equivalent to 40% of their predicted ability. This series of snapshots taken at different points in time suggests that much of the improvement in impairment and disability occurs during the first month and then reaches a plateau. Handicap and quality of life continue to be issues later. Rehabilitation strategies need to consider the multifaceted nature of disablement, which in itself changes with time post-stroke.
To examine whether robotic therapy can reduce motor impairment and enhance recovery of the hemiparetic arm in persons with chronic stroke.
Pre-posttest design.
Rehabilitation hospital, outpatient care.
Volunteer sample of 20 persons diagnosed with a single, unilateral stroke within the past 1 to 5 years, with persistent hemiparesis.
Robotic therapy was provided 3 times weekly for 6 weeks. Subjects able to reach robot targets were randomly assigned to sensorimotor or progressive-resistive robotic therapy groups. Robotic therapy consisted of goal-directed, planar reaching tasks to exercise the hemiparetic shoulder and elbow.
The Modified Ashworth Scale, Fugl-Meyer test of upper-extremity function, Motor Status Scale (MSS) score, and Medical Research Council motor power score.
Evaluations by a single blinded therapist revealed statistically significant gains from admission to discharge (P<.05) on the Fugl-Meyer test, MSS score, and motor power score. Secondary analyses revealed group differences: the progressive-resistive therapy group experienced nonspecific improvements on wrist and hand MSS scores that were not observed in the sensorimotor group.
Robotic therapy may complement other treatment approaches by reducing motor impairment in persons with moderate to severe chronic impairments.
The Motor Activity Log (MAL) is a semistructured interview for hemiparetic stroke patients to assess the use of their paretic arm and hand (amount of use [AOU]) and quality of movement [QOM]) during activities of daily living. Scores range from 0 to 5. The following clinimetric properties of the MAL were quantified: internal consistency (Cronbach alpha), test-retest agreement (Bland and Altman method), cross-sectional construct validity (correlation between AOU and QOM and with the Action Research Arm [ARA] test), longitudinal construct validity (correlation of change on the MAL during the intervention with a global change rating [GCR] and with change on the ARA), and responsiveness (effect size).
Two baseline measurements 2 weeks apart and 1 follow-up measurement immediately after 2 weeks of intensive exercise therapy either with or without immobilization of the unimpaired arm (forced use) were performed in 56 chronic stroke patients.
Internal consistency was high (AOU: alpha=0.88; QOM: alpha=0.91). The limits of agreement were -0.70 to 0.85 and -0.61 to 0.71 for AOU and QOM, respectively. The correlation with the ARA score (Spearman rho) was 0.63 (AOU and QOM). However, the improvement on the MAL during the intervention was only weakly related to the GCR and to the improvement on the ARA, Spearman rho was between 0.16 and 0.22. The responsiveness ratio was 1.9 (AOU) and 2.0 (QOM).
The MAL is internally consistent and relatively stable in chronic stroke patients not undergoing an intervention. The cross-sectional construct validity of the MAL is reasonable, but the results raise doubt about its longitudinal construct validity.
To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.
MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).
In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% Cl 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% Cl 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% Cl 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% Cl 0.29-1.10) and 1.09 (95% Cl 0.56-1.61), aerobics (SES 0.39; 95% Cl 0.05-0.74), external auditory rhythms during gait (SES 0.91; 95% Cl 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% Cl 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema.
This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.
To compare a computerized arm trainer (AT), allowing repetitive practice of passive and active bilateral forearm and wrist movement cycle, and electromyography-initiated electrical stimulation (ES) of the paretic wrist extensor in severely affected subacute stroke patients.
A total of 44 patients, 4 to 8 weeks after stroke causing severe arm paresis (Fugl-Meyer Motor Score [FM, 0 to 66] <18), were randomly assigned to either AT or ES. All patients practiced 20 minutes every workday for 6 weeks. AT patients performed 800 repetitions per session with the robot and ES patients performed 60 to 80 wrist extensions per session. The primary outcome measure was the blindly assessed FM (0 to 66), and the secondary measures were the upper limb muscle power (Medical Research Council [MRC] sum, 0 to 45) and muscle tone (Ashworth score sum, 0 to 25), assessed at the beginning and end of treatment and at 3-month follow-up.
The AT group had a higher Barthel Index score at baseline, but the groups were otherwise homogenous. As expected, FM and MRC sum scores improved overtime in both groups but significantly more in the robot AT group. The initial Barthel Index score had no influence. In the robot AT group, FM score was 15 points higher at study end and 13 points higher at 3-month follow-up than the control ES group. MRC sum score was 15 points higher at study end and at 3-month follow-up compared with the control ES group. Muscle tone remained unchanged, and no side effects occurred.
The computerized active arm training produced a superior improvement in upper limb motor control and power compared with ES in severely affected stroke patients. This is probably attributable to the greater number of repetitions and the bilateral approach.
This study presents results from a randomized controlled clinical trial of the Mirror Image Movement Enabler (MIME) robotic device for shoulder and elbow neurorehabilitation in subacute stroke patients, including data on the use of its bilateral training mode. MIME incorporates a PUMA 560 robot (Staubli Unimation Inc, Duncan, South Carolina) that applies forces to the paretic limb during unilateral and bilateral movements in three dimensions. Robot-assisted treatment (bilateral, unilateral, and combined bilateral and unilateral) was compared with conventional therapy. Similar to a previous study in chronic stroke, combined unilateral and bilateral robotic training had advantages compared with conventional therapy, producing larger improvements on a motor impairment scale and a measure of abnormal synergies. However, gains in all treatment groups were equivalent at the 6-month follow-up. Combined unilateral and bilateral training yielded functional gains that were similar to the gains from equivalent doses of unilateral-only robotic training, although the combined group had more hypertonia and less movement out of synergy at baseline. Robot-assisted treatment gains exceeded those expected from spontaneous recovery. These results are discussed in light of the need for further device development and continued clinical trials.
Thousands of systematic reviews have been conducted in all areas of health care. However, the methodological quality of these reviews is variable and should routinely be appraised. AMSTAR is a measurement tool to assess systematic reviews.
AMSTAR was used to appraise 42 reviews focusing on therapies to treat gastro-esophageal reflux disease, peptic ulcer disease, and other acid-related diseases. Two assessors applied the AMSTAR to each review. Two other assessors, plus a clinician and/or methodologist applied a global assessment to each review independently.
The sample of 42 reviews covered a wide range of methodological quality. The overall scores on AMSTAR ranged from 0 to 10 (out of a maximum of 11) with a mean of 4.6 (95% CI: 3.7 to 5.6) and median 4.0 (range 2.0 to 6.0). The inter-observer agreement of the individual items ranged from moderate to almost perfect agreement. Nine items scored a kappa of >0.75 (95% CI: 0.55 to 0.96). The reliability of the total AMSTAR score was excellent: kappa 0.84 (95% CI: 0.67 to 1.00) and Pearson's R 0.96 (95% CI: 0.92 to 0.98). The overall scores for the global assessment ranged from 2 to 7 (out of a maximum score of 7) with a mean of 4.43 (95% CI: 3.6 to 5.3) and median 4.0 (range 2.25 to 5.75). The agreement was lower with a kappa of 0.63 (95% CI: 0.40 to 0.88). Construct validity was shown by AMSTAR convergence with the results of the global assessment: Pearson's R 0.72 (95% CI: 0.53 to 0.84). For the AMSTAR total score, the limits of agreement were -0.19+/-1.38. This translates to a minimum detectable difference between reviews of 0.64 'AMSTAR points'. Further validation of AMSTAR is needed to assess its validity, reliability and perceived utility by appraisers and end users of reviews across a broader range of systematic reviews.
Investigators have demonstrated that a variety of intensive movement training protocols for persistent upper limb paralysis in patients with chronic stroke (6 months or more after stroke) improve motor outcome. This randomized controlled study determined in patients with upper limb motor impairment after chronic stroke whether movement therapy delivered by a robot or by a therapist using an intensive training protocol was superior. Robotic training (n = 11) and an intensive movement protocol (n = 10) improved the impairment measures of motor outcome significantly and comparably; there were no significant changes in disability measures. Motor gains were maintained at the 3-month evaluation after training. These data contribute to the growing awareness that persistent impairments in those with chronic stroke may not reflect exhausted capacity for improvement. These new protocols, rendered by either therapist or robot, can be standardized, tested, and replicated, and potentially will contribute to rational activity-based programs.
Background:
The Armeo Power® is a rehabilitation exoskeleton that allows early treatment of motor disabilities providing intelligent arm support in a large 3D workspace to perform intensive, repetitive and goal oriented exercises. This device could efficiently induce new connections and plasticity phenomena potentiation. Therefore, the knowledge of the potential brain plasticity reservoir following brain damage constitutes a prerequisite for an optimal rehabilitation strategy.
Objective:
To identify potential neurophysiological markers predicting the responsiveness of stroke patients to upper limb robotic treatment.
Design:
Prospective, cohort study.
Setting:
Behavioral and Robotic Neurorehabilitation Laboratory of IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy PATIENTS: We enrolled thirty-five stroke patients suffering with unilateral hemiplegia following a first-ever ischemic supra-tentorial stroke, at least 2 months before their enrolment.
Methods or interventions:
All patients underwent forty 1h Armeo Power® training sessions (i.e. five times a week for 8 weeks).
Main outcome measurements:
We assessed the spasticity and the motor function of upper limb by means of Modified Ashwort scale and Fugl-Meyer assessment, respectively. Moreover, we evaluated the cortical excitability and plasticity potential of the bilateral primary motor areas in response to repetitive paired associative stimulation paradigm using the transcranial magnetic stimulation, and Armeo Power® kinematic parameters.
Results:
The patients showing significant repetitive paired associative stimulation after-effects at baseline, exhibited an evident increase of cortical plasticity in the affected hemisphere (motor evoked potential amplitude increase p=.03), a decrease of inter-hemispheric inhibition (affected hemisphere cortical silent period duration decrease, p=.01; unaffected hemisphere cortical silent period duration increase, p=.004; repetitive paired associative stimulation aftereffect increase, p=.008). Such findings were paralleled by clinical (Fugl-Meyer, p=.04) and Armeo Power® kinematic (elbow flexion/extension, p=.02; shoulder range of movement p=.002) improvements.
Conclusions:
Our data suggest that the Armeo Power® practice may improve upper limb motor function recovery predicted by reshaping of cortical and trans-callosal plasticity, according to the baseline cortical excitability.
Understanding poststroke upper limb impairment is essential to planning therapeutic efforts to restore function. However, determining which upper limb impairment to treat and how is complex because the impairments are not static and multiple impairments may be present simultaneously. How impairments contribute to upper limb dysfunction may be understood by examining them from the perspective of their functional consequences. There are 3 main functional consequences of impairments on upper limb function: (1) learned nonuse, (2) learned bad use, and (3) forgetting as determined by behavioral analysis of tasks. The impairments that contribute to each of these functional limitations are described.
Although gait abnormality is one of the most disabling events following stroke, cognitive, and psychological impairments can be devastating. The Lokomat is a robotic that has been used widely for gait rehabilitation in several movement disorders, especially in the acute and subacute phases. The aim of this study was to evaluate the effectiveness of gait robotic rehabilitation in patients affected by chronic stroke. Psychological impact was also taken into consideration. Thirty patients (13 women and 17 men) affected by chronic stroke entered the study. All participants underwent neurological examination with respect to ambulation, Ashworth, Functional Independence Measure, and Tinetti scales to assess their physical status, and Hamilton Rating Scale for Depression, Psychological General Well-being Index, and Coping Orientation to Problem Experienced to evaluate the Lokomat-related psychological impact before and after either a conventional treatment or the robotic training. During each rehabilitation period (separated by a no-treatment period), patients underwent a total of 40 1 h training sessions (i.e. five times a week for 8 weeks). After the conventional treatment, the patients did not achieve a significant improvement in the functional status, except balance (P<0.001) and walking ability (P<0.01), as per the Tinetti scale. Indeed, after the robotic rehabilitation, significant improvements were detected in almost all the motor and psychological scales that we investigated, particularly for Psychological General Well-being Index and Coping Orientation to Problem Experienced. Manual and robotic-assisted body weight-supported treadmill training optimizes the sensory inputs relevant to step training, repeated practice, as well as neuroplasticity. Several controlled trials have shown a superior effect of Lokomat treatment in stroke patients' walking ability and velocity in particular. Therefore, our preliminary results proved that active robotic training not only facilitates gait and physical function but also the psychological status, even in patients affected by chronic stroke.
Cerebral ischemia triggers a cascade of cellular processes, which induce neuroprotection, inflammation, apoptosis and regeneration. At the neural network level, lesions concomitantly induce cerebral plasticity. Yet, many stroke survivors are left with a permanent motor deficit, and only little is known about the neurobiological factors that determine functional outcome after stroke. Transcranial magnetic stimulation (TMS) and magnetic resonance imaging (MRI) are non-invasive approaches that allow insights into the functional (re-) organization of the cortical motor system. We here combined neuronavigated TMS, MRI and analyses of connectivity to investigate to which degree recovery of hand function depends on corticospinal tract (CST) damage and biomarkers of cerebral plasticity like cortical excitability and motor network effective connectivity. As expected, individual motor performance of 12 stroke patients with persistent motor deficits was found to depend upon the degree of CST damage but also motor cortex excitability and interhemispheric connectivity. In addition, the data revealed a strong correlation between reduced ipsilesional motor cortex excitability and reduced interhemispheric inhibition in severely impaired patients. Interindividual differences in ipsilesional motor cortex excitability were stronger related to the motor deficit than abnormal interhemispheric connectivity or CST damage. Multivariate linear regression analysis combining the three factors accounted for more than 80 % of the variance in functional impairment. The inter-relation of cortical excitability and reduced interhemispheric inhibition provides direct multi-modal evidence for the disinhibition theory of the contralesional hemisphere following stroke. Finally, our data reveal a key mechanism (i.e., the excitability-related reduction in interhemispheric inhibition) accounting for the rehabilitative potential of novel therapeutic approaches which aim at modulating cortical excitability in stroke patients.
Arm hemiparesis secondary to stroke is common and disabling. We aimed to assess whether robotic training of an affected arm with ARMin-an exoskeleton robot that allows task-specific training in three dimensions-reduces motor impairment more effectively than does conventional therapy.
In a prospective, multicentre, parallel-group randomised trial, we enrolled patients who had had motor impairment for more than 6 months and moderate-to-severe arm paresis after a cerebrovascular accident who met our eligibility criteria from four centres in Switzerland. Eligible patients were randomly assigned (1:1) to receive robotic or conventional therapy using a centre-stratified randomisation procedure. For both groups, therapy was given for at least 45 min three times a week for 8 weeks (total 24 sessions). The primary outcome was change in score on the arm (upper extremity) section of the Fugl-Meyer assessment (FMA-UE). Assessors tested patients immediately before therapy, after 4 weeks of therapy, at the end of therapy, and 16 weeks and 34 weeks after start of therapy. Assessors were masked to treatment allocation, but patients, therapists, and data analysts were unmasked. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT00719433.
Between May 4, 2009, and Sept 3, 2012, 143 individuals were tested for eligibility, of whom 77 were eligible and agreed to participate. 38 patients assigned to robotic therapy and 35 assigned to conventional therapy were included in analyses. Patients assigned to robotic therapy had significantly greater improvements in motor function in the affected arm over the course of the study as measured by FMA-UE than did those assigned to conventional therapy (F=4·1, p=0·041; mean difference in score 0·78 points, 95% CI 0·03-1·53). No serious adverse events related to the study occurred.
Neurorehabilitation therapy including task-oriented training with an exoskeleton robot can enhance improvement of motor function in a chronically impaired paretic arm after stroke more effectively than conventional therapy. However, the absolute difference between effects of robotic and conventional therapy in our study was small and of weak significance, which leaves the clinical relevance in question.
Swiss National Science Foundation and Bangerter-Rhyner Stiftung.
. Individuals with chronic stroke often have long-lasting upper extremity impairments that impede function during activities of daily living. Rehabilitation robotics have shown promise in improving arm function, but current systems do not allow realistic training of activities of daily living. We have incorporated the ARMin III and HandSOME device into a novel robotic therapy modality that provides functional training of reach and grasp tasks.
. To compare the effects of equal doses of robotic and conventional therapy in individuals with chronic stroke.
. Subjects were randomized to 12 hours of robotic or conventional therapy and then crossed over to the other therapy type after a 1-month washout period. Twelve moderate to severely impaired individuals with chronic stroke were enrolled, and 10 completed the study.
. Across the 3-month study period, subjects showed significant improvements in the Fugl-Meyer (P = .013) and Box and Blocks tests (P = .028). The robotic intervention produced significantly greater improvements in the Action Research Arm Test than conventional therapy (P = .033). Gains in the Box and Blocks test from conventional therapy were larger than from robotic therapy in subjects who received conventional therapy after robotic therapy (P = .044).
. Data suggest that robotic therapy can elicit improvements in arm function that are distinct from conventional therapy and supplements conventional methods to improve outcomes. Results from this pilot study should be confirmed in a larger study.
Current health services are struggling to provide optimal rehabilitation therapy to victims of stroke. This has motivated researchers to explore the use of robotic devices to provide rehabilitation therapy for strokepatients. This paper reviews the recent progress of upper limb exoskeleton robots for rehabilitation treatment of patients with neuromuscular disorders. Firstly, a brief introduction to rehabilitation robots will be given along with examples of existing commercial devices. The advancements in upper limb exoskeleton technology and the fundamental challenges in developing these devices are described. Potential areas for future research are discussed.
This randomized, controlled, multisite Department of Veterans Affairs clinical trial assessed robot-assisted (RA) upper-limb therapy with the Mirror Image Movement Enabler (MIME) in the acute stroke rehabilitation setting. Hemiparetic subjects (n = 54) received RA therapy using MIME for either up to 15 hours (low-dose) or 30 hours (high-dose) or received up to 15 hours of additional conventional therapy in addition to usual care (control). The primary outcome measure was the Fugl-Meyer Assessment (FMA). The secondary outcome measures were the Functional Independence Measure (FIM), Wolf Motor Function Test, Motor Power, and Ashworth scores at intake, discharge, and 6-month follow-up. Mean duration of study treatment was 8.6, 15.8, and 9.4 hours for the low-dose, high-dose, and control groups, respectively. Gains in the primary outcome measure were not significantly different between groups at follow-up. Significant correlations were found at discharge between FMA gains and the dose and intensity of RA. Intensity also correlated with FMA gain at 6 months. The high-dose group had greater FIM gains than controls at discharge and greater tone but no difference in FIM changes compared with low-dose subjects at 6 months. As used during acute rehabilitation, motor-control changes at follow-up were no less with MIME than with additional conventional therapy. Intensity of training with MIME was positively correlated with motor-control gains.
The successful motor rehabilitation of stroke patients requires early intensive and task-specific therapy. A recent Cochrane Review, although based on a limited number of randomized controlled trials (RCTs), showed that early robotic training of the upper limb (i.e., during acute or subacute phase) can enhance motor learning and improve functional abilities more than chronic-phase training. In this article, a new subacute-phase RCT with the Neuro-Rehabilitation-roBot (NeReBot) is presented. While in our first study we used the NeReBot in addition to conventional therapy, in this new trial we used the same device in substitution of standard proximal upper-limb rehabilitation. With this protocol, robot patients achieved similar reductions in motor impairment and enhancements in paretic upper-limb function to those gained by patients in a control group. By analyzing these results and those of previous studies, we hypothesize a new robotic protocol for acute and subacute stroke patients based on both treatment modalities (in addition and in substitution).
Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetit