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

Effectiveness of modified constraint-induced movement therapy on upper limb function of stroke survivors in inpatient hospital settings: a systematic review and meta-analysis

PURPOSE

To synthesise evidence on the effectiveness of modified constraint-induced movement therapy on upper limb function in stroke survivors within inpatient hospital settings.

METHODS

A systematic review was pre-registered in PROSPERO (CRD42023421715b) and searched six databases (EMBASE, AMED, MEDLINE, CINAHL, Cochrane Library, OTseeker) up to November 2024.

Articles included adults with stroke undergoing modified constraint-induced movement therapy in inpatient hospital settings. Article quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Homogenous data was synthesised in a meta-analysis and assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Remaining data was synthesised descriptively.

RESULTS

Ten randomised controlled trials (364 participants) were included. Four (191 participants) were analysed in a meta-analysis, showing modified constraint-induced movement therapy improved upper limb function (standardised mean difference (SMD) 0.94, 95% confidence interval (CI) 0.40 to 1.48), based on low-quality evidence. Five articles included follow-up, with two (90 participants) reporting sustained improvements. Five articles assessed activities of daily living, with two (136 participants) reporting positive effects.

CONCLUSION

Modified constraint-induced movement therapy improves upper limb function in the acute and sub-acute stages of stroke recovery within inpatient hospital settings. Sustainability of improvements and the impact on activities of daily living remains uncertain.

Effects of Robot-Assisted Therapy for Upper Limb Rehabilitation After Stroke: An Umbrella Review of Systematic Reviews

BACKGROUND

Robotic rehabilitation, which provides a high-intensity, high-frequency therapy to improve neuroplasticity, is gaining traction. However, its effectiveness for upper extremity stroke rehabilitation remains uncertain. This study comprehensively reviewed meta-analyses on the effectiveness of upper extremity robot-assisted therapy in patients with stroke.

METHODS

We combined results from 396 randomized controlled trials (RCTs) in 16 meta-analyses and conducted a new meta-analysis using nonoverlapping RCTs and 6 additional RCTs published after 2024. Duplicate studies were removed, all data were from RCTs, and a random-effects model resolved heterogeneity. Effects were analyzed by comparing robot-assisted therapy with conventional therapy at the same dose and as an add-on to conventional therapy.

RESULTS

Compared with conventional therapy, the effect of robot-assisted therapy on the Fugl-Meyer assessment was summarized as a significant standardized mean difference (SMD) of 0.29 (95% CI, 0.14-0.44; number of individual RCTs reanalyzed, 100 RCTs), and the additional effect of robot-assisted therapy was an SMD of 0.42 (95% CI, 0.23-0.61; 16 RCTs). However, these Fugl-Meyer assessment improvements did not meet the minimum clinically important difference thresholds identified in previous studies: 12.4 for subacute and 3.5 for chronic stroke. For activities of daily living, only the additional effect was significant by SMD of 0.35 (95% CI, 0.17-0.54; 26 RCTs), muscle strength was significant by SMD of 0.46 (95% CI, 0.22-0.70; 31 RCTs), and spasticity was not significant by SMD of -0.25 (95% CI, -0.55 to 0.06; 25 RCTs).

CONCLUSIONS

Robot-assisted therapy shows statistically significant improvements in motor recovery as measured by the Fugl-Meyer assessment in patients with stroke, both at the same dose and as an add-on to conventional therapy; however, these improvements do not meet the minimum clinically important difference. These benefits are consistent across different stages of stroke recovery, different types of robotic devices, duration of intervention, and training sites. However, the heterogeneity of included studies in patient population, stroke severity, intervention protocol, and robot type limits generalizability. High-quality trials are needed to better define the value of robot-assisted therapy across various devices and strategies.

A robotic rehabilitation intervention in a home setting during the Covid-19 outbreak: a feasibility pilot study in patients with stroke

BACKGROUND

Telerehabilitation allows patients to engage in therapy away from healthcare facilities, often in the comfort of their homes. Studies have suggested that it can effectively improve motor and cognitive function. However, its applicability may be limited to patients with severe impairments who require physical assistance. The proposed study aims to evaluate the feasibility and effects of a home-based rehabilitation program for post-stroke patients, based on the use of a planar robot, able to overcome the limitations posed by the COVID-19 pandemic.

METHODS

We enrolled 20 patients with stroke (11 men, aged 66.1 ± 9.2 years). Patients underwent 20 one-hour robotic upper limb rehabilitation sessions, consisting of the execution of planar point-to-point reaching exercises, using a robotic device in their own home, with the remote supervision of a physical therapist. We assessed the feasibility of this intervention by examining adverse events, patient satisfaction (measured on a Likert scale), usability (using the System Usability Scale, SUS), acceptability (evaluated through the Technology Acceptance Model questionnaire, TAM+), and pain onset (measured with the Numeric Rating Scale). To gauge the clinical effects of the treatment, we analyzed changes in the motor and sensory components of the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) before and after the intervention.

RESULTS

The approach was safe, as we did not observe any adverse events, and patients did not experience an increase in pain levels. Patients expressed their appreciation for the treatment, providing an average Likert scale score of 8 out of 10. The usability of the treatment received high marks, with an average SUS score of 78 ± 12. Similarly, the treatment acceptability was favorable, with all examined domains scoring above 4, indicating a positive attitude towards the proposed solution. Moreover, we observed a statistically significant improvement in the motor part of the FMA-UE (p < 0.001).

CONCLUSION

Our results demonstrate the feasibility, safety, and effectiveness of employing a rehabilitation robot for upper limb rehabilitation in post-stroke patients within a home-based environment. These findings mark a significant step in advancing innovative and easily accessible rehabilitation options for stroke survivors, ensuring uninterrupted care and creating new opportunities to enhance their functional abilities.

TRIAL REGISTRATION

clinicaltrial.gov (NCT05250934).

Closed-loop rehabilitation of upper-limb dyskinesia after stroke: from natural motion to neuronal microfluidics

This review proposes an innovative closed-loop rehabilitation strategy that integrates multiple subdomains of stroke science to address the global challenge of upper-limb dyskinesia post-stroke. Despite advancements in neural remodeling and rehabilitation research, the compartmentalization of subdomains has limited the effectiveness of current rehabilitation strategies. Our approach unites key areas-including the post-stroke brain, upper-limb rehabilitation robotics, motion sensing, metrics, neural microfluidics, and neuroelectronics-into a cohesive framework designed to enhance upper-limb motion rehabilitation outcomes. By leveraging cutting-edge technologies such as lightweight rehabilitation robotics, advanced motion sensing, and neural microfluidic models, this strategy enables real-time monitoring, adaptive interventions, and personalized rehabilitation plans. Furthermore, we explore the potential of closed-loop systems to drive neural plasticity and functional recovery, offering a transformative perspective on stroke rehabilitation. Finally, we discuss future directions, emphasizing the integration of emerging technologies and interdisciplinary collaboration to advance the field. This review highlights the promise of closed-loop strategies in achieving unprecedented integration of subdomains and improving post-stroke upper-limb rehabilitation outcomes.

Rehabilitation with and Without Robot and Allied Digital Technologies (RADTs) in Stroke Patients: A Study Protocol for a Multicentre Randomised Controlled Trial on the Effectiveness, Acceptability, Usability, and Economic-Organisational Sustainability of RADTs from Subacute to Chronic Phase (STROKEFIT4)

Background: Rehabilitation after stroke often employs Robots and Allied Digital Technologies (RADTs). However, evidence of their effectiveness remains inconclusive due to study heterogeneity and limited sample sizes. Methods: This is a protocol of a pragmatic multicentre, multimodal, randomised, controlled, parallel-group (1:1) interventional study with blinded assessors aimed at assessing the effectiveness and sustainability of RADT-mediated rehabilitation compared to traditional rehabilitation. The trial will recruit 596 adult subacute post-stroke patients. Participants will be randomised into either the experimental group (using RADTs and two therapists supervising four to six patients) or the control group (individual traditional rehabilitation). Patients in both groups will undergo a comprehensive rehabilitation treatment, targeting (a) upper limb sensorimotor abilities; (b) lower limb sensorimotor abilities and gait; (c) balance; and (d) cognitive abilities. Patients will undergo 25 sessions, each lasting 45 min, with a frequency of 5 (inpatients) or 3 (outpatients) times a week. The primary endpoint is the non-inferiority of RADTs in the recovery of the activities of daily living (ADL) using the modified Barthel Index. If non-inferiority is established, the study will evaluate the superiority. Secondary endpoints will analyse the improvements in the aforementioned domains, as well as changes in neural plasticity and biochemical aspects. Upper limb dexterity and gait recovery rates during treatment will be monitored. The study will also evaluate ADL and quality of life during a six-month follow-up period. Acceptability and usability of integrated RADTs-based rehabilitation for patients, families, and healthcare providers, along with economic and organisational sustainability for patients, payers, and society, will also be assessed. Conclusions: This study aims to establish stronger evidence on the effectiveness of RADTs in post-stroke patients. Trial registration number: NCT06547827.

The use of robotic upper limb therapy in routine clinical practice for stroke survivors: Insights from Australian therapists

INTRODUCTION

There is a limited understanding of therapist acceptance and use of robot-assisted upper limb therapy (RT-ULT) in routine practice. The aim of this study was to explore the factors that influence Australian therapist acceptance and use of RT-ULT.

METHODS

Two discipline-specific focus groups were conducted involving occupational therapists (n = 5) and physiotherapists (n = 4) who had used RT-ULT. Focus group questions were developed, and transcriptions analysed using the Theoretical Domains Framework (TDF). Additionally, participants scored the overall usability of the RT-ULT device with the System Usability Scale (SUS).

CONSUMER AND COMMUNITY INVOLVEMENT

There was no direct involvement from consumers or community in this study.

FINDINGS

Nine of the 14 domains of the TDF were covered in depth by participants during the focus groups: environmental context and resources, beliefs about consequences, knowledge, skills, decision-making, reinforcement, social influences, social/professional role and identity (single domain), and beliefs about capabilities. Physiotherapists recorded higher scores of the device on the SUS than the occupational therapists.

CONCLUSION

Both disciplines were accepting of RT-ULT, but it was physiotherapists who predominantly used RT-ULT in part due to the device being located in the physiotherapy rehabilitation gym. Other factors facilitating RT-ULT acceptance in practice included (1) increase in repetitive, intensive independent practice for stroke survivors, (2) ease of use, (3) strong patient acceptance, and (4) implementation process being clinician-led. Functional-based UL practice took priority over RT-ULT once stroke survivors demonstrated sufficient active movement and RT-ULT was not used in isolation but part of a combination of UL interventions.

PLAIN LANGUAGE SUMMARY

There is a little known about what therapists think about using robot-assisted upper limb therapy in their daily practice. The aim of this study was to explore Australian therapist perceptions of the use of robotics. Focus groups were conducted separately with five occupational therapists and four physiotherapists who had used robotics at their rehabilitation facility. In addition to the focus groups, each therapist scored the user-friendliness of the robotic device by completing a short survey. Both occupational therapists and physiotherapists believed the robotics was a beneficial addition to the rehabilitation facility. Physiotherapists used the device more than the occupational therapists with the device being located in the physiotherapy area of the rehabilitation facility. Therapists explained that robotics increased the amount of practice stroke survivors could do, was easy to use, and was motivating for stroke survivors. However, once stroke survivors had gained enough arm movement, the focus moved to practicing actual daily tasks rather than robotics. Also, robotics was not the only form of upper limb therapy offered to stroke survivors with multiple upper limb treatments used to aid their recovery.

Technology-Enabled Upper Limb Rehabilitation for Neurological Impairment: A Feasibility Randomized-Controlled Trial Protocol

Background. Technology-enabled upper limb (UL) rehabilitation improves therapy intensity and impairment outcomes, however clinical usage remains low and evidence for functional outcomes is limited. While benefits of single-mode technologies have been demonstrated, a combination of technology modes or "hybrid" approach is an emerging option with shoulder to fingertip capability. Investigation of this approach within a hospital setting is warranted to inform occupational therapy practice with neurological patients. Purpose. This study examines feasibility of hybrid technology-enabled UL rehabilitation for in-patients with neurological impairments. Method and Analyses. A Phase II feasibility randomized controlled trial (RCT) will compare usual care versus hybrid technology intervention using three technology modes (robotics, virtual reality, sensor-based therapy) plus usual care. Pre-post outcomes for UL impairment, activity, participation and self-reported function will be analyzed using 2 × 2 repeated measures ANOVA. Effect sizes will inform a power analysis for a full-scale RCT. Field observations and participant surveys will capture feasibility factors. It is anticipated hybrid technology for UL neurorehabilitation will be feasible in a hospital setting and show preliminary effectiveness for improving UL use in daily activities. Ethics and Dissemination. Ethics granted from RBWH Human Research Ethics Committee (HREC/2020/QRBW/67076) and The University of Queensland (2021/HE002211).

Clinician perceptions of a novel wearable robotic hand orthosis for post-stroke hemiparesis

PURPOSE

Wearable robotic devices are currently being developed to improve upper limb function for individuals with hemiparesis after stroke. Incorporating the views of clinicians during the development of new technologies can help ensure that end products meet clinical needs and can be adopted for patient care.

METHODS

In this cross-sectional mixed-methods study, an anonymous online survey was used to gather clinicians' perceptions of a wearable robotic hand orthosis for post-stroke hemiparesis. Participants were asked about their clinical experience and provided feedback on the prototype device after viewing a video.

RESULTS

154 participants completed the survey. Only 18.8% had previous experience with robotic technology. The majority of participants (64.9%) reported that they would use the device for both rehabilitative and assistive purposes. Participants perceived that the device could be used in supervised clinical settings with all phases of stroke. Participants also indicated a need for insurance coverage and quick setup time.

CONCLUSIONS

Engaging clinicians early in the design process can help guide the development of wearable robotic devices. Both rehabilitative and assistive functions are valued by clinicians and should be considered during device development. Future research is needed to understand a broader set of stakeholders' perspectives on utility and design.

Novel Robotic Balloon-Based Device for Wrist-Extension Therapy of Hemiparesis Stroke Patients

Upper-limb paresis is one of the main complications after stroke. It is commonly associated with impaired wrist-extension function. Upper-limb paresis can place a tremendous burden on stroke survivors and their families. A novel soft-actuator device, the Balonikotron, was designed to assist in rehabilitation by utilizing a balloon mechanism to facilitate wrist-extension exercises. This pilot study aimed to observe the functional changes in the paralyzed upper limb and improvements in independent and cognitive functions following a 4-week regimen using the device, which incorporates a multimedia tablet application providing audiovisual feedback. The device features a cardboard construction with a hinge at wrist level and rails that guide hand movement as the balloon inflates, controlled by a microcontroller and a tablet-based application. It operates on the principle of moving the hand at the wrist by pushing the palm upwards through a surface actuated by a balloon. A model was developed to describe the relationship between the force exerted on the hand, the angle on hinge, the pressure within the balloon, and its volume. Experimental validation demonstrated a Pearson correlation of 0.936 between the model's force predictions and measured forces, supporting its potential for real-time safety monitoring by automatically shutting down when force thresholds are exceeded. A pilot study was conducted with 12 post-stroke patients (six experimental, six control), who participated in a four-week wrist-extension training program. Clinical outcomes were assessed using the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE), Modified Rankin Scale (mRS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), wrist Range of Motion (ROM), and Barthel Index (BI). Statistically significant results were obtained for the Barthel index (p < 0.05) and FMA-UE, indicating that the experimental use of the device significantly improved functional independence and self-care abilities. The results of our pilot study suggest that the Balonikotron device, which uses the principles of mirror therapy, may serve as a valuable adjunct to conventional rehabilitation for post-stroke patients with hemiparetic hands (BI p = 0.009, MMSE p = 0.151, mRS p = 0.640, FMA-UE p = 0.045, MOCA p = 0.187, ROM p = 0.109).

Design priorities for an at-home upper limb stroke rehabilitation robot

OBJECTIVE

The design of at-home stroke rehabilitation robots must be closely linked to the needs of users, especially stroke survivors and therapists, to ensure that such designs are effective in the home environment, which is less controlled than clinical environments. Translating user needs into the technical descriptors of a design is essential to this design process. This paper analyses user needs identified from interviews with stroke survivors and therapists in previous work.

METHODS

The relationship between user needs and the broad technical properties of rehabilitation robot design are related using the House of Quality, an approach from Quality Function Deployment. Technical benchmarks are identified from previous rehabilitation robot designs and technical priorities are determined from the House of Quality. An at-home upper limb stroke rehabilitation robot concept for supporting therapy activities in a vertical planar workspace is described and evaluated using the identified technical priorities.

IMPACT

The proposed design, a constrained cable robot, is determined to be appropriate for the desired application based on the technical priorities from the House of Quality.

Safety and Selection Criteria of Single-joint Hybrid Assistive Limb for Upper Limb Paralysis After Stroke: A Phase I Trial

Robotic rehabilitation is a high-intensity intervention for upper limb paralysis after a stroke. This study explored the safety and feasibility of using a single-joint hybrid assistive limb (HAL-SJ) exoskeletal device for upper limb paralysis in patients with acute stroke. In total, 11 patients with stroke (6 with moderate paralysis and 5 with severe paralysis) were enrolled between October 2021 and October 2023 in a stroke care unit. The patients underwent HAL training 3 times a week for 6 sessions. No serious adverse events related to HAL-SJ occurred, and participants demonstrated significant improvements in the Fugl-Meyer Assessment Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) (pre- vs. post-intervention; p < 0.05). The minimal clinically important difference (MCID) for FMA-UE was surpassed in 5 patients (83.3%) with moderate paralysis and 2 (40.0%) with severe paralysis. Regarding ARAT, 4 patients (66.7%) with moderate paralysis exceeded the MCID, whereas none (0.0%) with severe paralysis did. These findings suggest that HAL-SJ is both safe and feasible, particularly for individuals with moderate paralysis.

A pilot study for assessing NAO humanoid robot assistance in shoulder rehabilitation

Purpose

This study aimed to explore the potential application of NAO in guiding patients through rehabilitative exercises using external audiovisual stimuli, focusing on temporospatial control in terms of range of motion (ROM), execution time and movement smoothness.

Methods

This is a preliminary analysis involving ten healthy volunteers and two patients with shoulder musculoskeletal disorders. The protocol was developed in two phases (III and IV) with different ROM limits and including flexion-extension (FE), external-rotation (ER) and internal-rotation (IR) exercises, performed at two speeds and both with and without NAO assistance. Simultaneously, upper limb kinematics were assessed using a stereophotogrammetric system as a reference. Performance was evaluated by mean absolute error (MAE) for ROM and execution time, with smoothness assessed through Log Dimensionless Jerk analysis.

Results

In phase III, results for volunteers showed ROM differences in FE and ER, while IR was unaffected by NAO presence. In phase IV, NAO assistance resulted in reduced MAE across nearly all exercises. Patients who only performed phase III exercises at lower speed stayed within ROM limits for all movements performed with NAO, except for ER. For all the participants, results showed a significant reduction in the time MAE when using NAO. Patients exhibit greater smoothness during FE performed with NAO.

Conclusions

NAO showed potential in aiding patients with shoulder musculoskeletal disorders to replicate rehabilitation exercises, guiding both ROM and timing while influencing movement smoothness. NAO imitation could lead to improved rehabilitation outcomes and enhanced motor learning of motor skills, fostering greater adherence to prescribed therapy.

Level of Evidence

Level V, diagnostic.

Predicting upper limb motor recovery in subacute stroke patients via fNIRS-measured cerebral functional responses induced by robotic training

BACKGROUND

Neural activation induced by upper extremity robot-assisted training (UE-RAT) helps characterize adaptive changes in the brains of poststroke patients, revealing differences in recovery potential among patients. However, it remains unclear whether these task-related neural activities can effectively predict rehabilitation outcomes. In this study, we utilized functional near-infrared spectroscopy (fNIRS) to measure participants' neural activity profiles during resting and UE-RAT tasks and developed models via machine learning to verify whether task-related functional brain responses can predict the recovery of upper limb motor function.

METHODS

Cortical activation and brain network functional connectivity (FC) in brain regions such as the superior frontal cortex, premotor cortex, and primary motor cortex were measured using fNIRS in 82 subacute stroke patients in the resting state and during UE-RAT. The Fugl-Meyer Upper Extremity Assessment Scale (FMA-UE) was chosen as the index for assessing upper extremity motor function, and clinical information such as demographic and neurophysiological data was also collected. Robust features were screened in 100 randomly divided training sets using the least absolute shrinkage and selection operator (LASSO) method. Based on the selected robust features, machine learning algorithms were used to develop clinical models, fNIRS models, and combined models that integrated both clinical and fNIRS features. Finally, Shapley Additive Explanations (SHAP) was applied to interpret the prediction process and analyze key predictive factors.

RESULTS

Compared to the resting state, task-related FC is a more robust feature for modeling, with screening frequencies above 90%. The combined models built using artificial neural networks (ANNs) and support vector machines (SVMs) significantly outperformed the other algorithms, with an average AUC of 0.861 (± 0.087) for the ANN and an average correlation coefficient (r) of 0.860 (± 0.069) for the SVM. Furthermore, predictive factor analysis of the models revealed that FC measured during tasks is the most important factor for predicting upper limb motor function.

CONCLUSION

This study confirmed that UE-RAT-induced FC can serve as an important predictor of rehabilitation, especially when combined with clinical information, further enhancing the accuracy of model predictions. These findings provide new insights for the early prediction of patients' recovery potential, which may contribute to personalized rehabilitation decisions.

Effectiveness of robot-assisted training in adults with Parkinson's disease: a systematic review and meta-analysis

AIM

This work aimed to update and summarize the existing evidence on the effectiveness of robot-assisted training (RAT) in adults with Parkinson's disease (PD).

METHODS

We conducted a systematic review with meta-analysis, reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42022371124). Seven databases and two trial registries were searched for randomized-controlled trials (RCTs) addressing RAT alone or in addition to other treatments in adults with PD up to January 2024. Primary outcomes were disease-specific motor impairment, balance, mobility, freezing of gait, falls, number of people who fell at least once, and adverse events. Meta-analysis using a random-effects model was performed. Risk of bias (RoB) and certainty of the evidence for the primary outcomes were assessed using the Cochrane RoB Tool and the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach, respectively.

RESULTS

Fifteen RCTs (629 randomized adults with PD) were included. Our results show that the evidence is very uncertain about the effectiveness of any kind of RAT, either focused on gait, balance or upper limb impairment, compared to any comparator (treadmill training, overground gait training, exercises without the exoskeleton, conventional physical therapy, balance training, and no treatment), mainly because of RoB, inconsistency in individual studies results, and very limited number (less than 200) of participants considered in each comparison.

CONCLUSION

In light of the aforementioned very low certainty evidence, clinical considerations should be drawn very carefully. High-quality studies are thus highly needed to investigate potential benefits, risks, and cost/benefit ratio of RAT in adults with PD.

Effects of robot-assisted arm training on respiratory muscle strength, activities of daily living, and quality of life in patients with stroke: a single-blinded randomized controlled trial

BACKGROUND

Post-stroke clinical changes not only affect extremities and trunk muscles but also the respiratory muscles.

PURPOSE

To determine the effect of robot-assisted arm training with conventional rehabilitation (CombT) on respiratory muscle strength, activities of daily living (ADL), and quality of life in patients with stroke and to compare the results with conventional rehabilitation (CR).

METHODS

It was a two-arm, single-blinded, randomized controlled trial in which 66 patients were randomly allocated to either CombT or CR to receive 30 sessions (5/week) over 6 weeks. The respiratory muscle strength (maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP)), activities of daily life (ABILHAND questionnaire), and quality of life (Stroke Impact Scale (SIS)) were measured before and 6 weeks after training.

RESULTS

The CombT group showed significantly better MIP, MEP, and performance in ADLs after 6 weeks of training compared to the CR group (p < .01). The effect size was large for MIP (d = 0.9) and MEP (d = 0.9), whereas medium for performance in ADLs (d = 0.62). Also, the SIS-arm strength (p < .01), hand function (p = .04), ADLs (p = .02), and recovery (p = .04) were significantly better in CombT group with a medium (d = 0.6, d = 0.5, d = 0.5, and d = 0.5, respectively) effect size compared with CR group.

CONCLUSIONS

Both CombT and CR groups improved respiratory muscle strength, performance in ADLs, and quality of life in patients with stroke. However, CombT appears to offer more comprehensive benefits, highlighting its valuable role in respiratory and functional recovery after stroke.

Telerehabilitation using a 2-D planar arm rehabilitation robot for hemiparetic stroke: a feasibility study of clinic-to-home exergaming therapy

BACKGROUND

We evaluated the feasibility, safety, and efficacy of a 2D-planar robot for minimally supervised home-based upper-limb therapy for post-stroke hemiparesis.

METHODS

The H-Man, end effector robot, combined with web-based software application for remote tele-monitoring were evaluated at homes of participants. Inclusion criteria were: strokes > 28 days, Fugl-Meyer Motor Assessment (FMA) > 10-60/66, presence of a carer and absence of medical contraindications. Participants performed self-directed, minimally supervised robotics-assisted therapy (RAT) at home for 30 consecutive days, after 2 therapist-supervised clinic on-boarding sessions. Web-based compliance measures were: accessed sessions of > 20 min/day, training minutes/day and active training hours/30 days. Clinical outcomes at weeks 0, 5 (post-training), 12 and 24 (follow-up) consisted of FMA, Action Research Arm Test (ARAT) and WHO-Stroke Specific Quality of Life (SSQOL). To estimate immediate economic benefits of the home-based robotic therapy, we performed cost-effectiveness analysis (CEA), followed by budget impact analysis (BIA).

RESULTS

Altogether, all 12 participants completed Home-RAT without adverse events; 9 (75.0%) were males, mean (SD) age, 59.4 years (9.5), median (IQR) stroke duration 38.6 weeks (25.4, 79.6) baseline FMA (0-66) 42.1 ± 13.2, ARAT (0-57) 25.4 ± 19.5, SSQOL (0-245) 185.3 ± 32.8. At week 5 follow-up, mean (SD) accessed days were 26.3 days ± 6.4, active training hours of 35.3 h ± 14.7/30 days, or ~ 6 days/week and 77 training minutes ± 20.9/day were observed. Significant gains were observed from baseline across time; ΔFMA 2.4 at week 5 (FMA 44.5, CI 95% 39.7-49.3, p < 0.05) and ΔFMA 3.7 at week 24 (FMA 45.8, CI 95% 40.5-51, p < 0.05); ΔARAT 2.6 at week 5 (ARAT 28.0, CI 95% 19.3-36.7, p < 0.05), and ΔARAT 4.8 at week 24 (ARAT 30.2, CI 95% 21.2-39.1, p < 0.05). At week 5 follow-up, 91% of participants rated their overall experience as satisfied or very satisfied. Incremental CEA observed savings of -S$144/per cure over 24 weeks, BIA-potentially 12% impact reduction over five years.

CONCLUSIONS

This study demonstrates the feasibility, acceptability, safety, clinical efficacy, and cost-effectiveness of a home-based, web-enabled telemonitored carer-supervised robotics-aided therapy.

TRIAL REGISTRATION

NCT05212181  ( https://clinicaltrials.gov ).

Kinematic Assessment of Upper Limb Movements Using the ArmeoPower Robotic Exoskeleton

After a neurological injury, neurorehabilitation aims to restore sensorimotor function of patients. Technological assessments can provide high-quality data on a patient's performance and support clinical decision making towards the most appropriate therapy. In this study, the ArmeoPower, a robotic exoskeleton for the upper extremities, was used to assess 12 neurological patients and 31 non-disabled participants performing various standardized single joint and frontal plane game-like exercises. From the collected data, kinematic metrics (End-Point Error, Hand-Path Ratio, reaction time, stability, Number of Velocity Peaks, peak, and mean Velocity) and the game score, were calculated and analyzed according to three criteria: the reliability (a), the difference between patients and non-disabled participants (b), as well as the influence of robotic movement assistance (c). In total, 39 metrics were analyzed and the following five most promising assessment variables for different exercises could be identified based on the three above-mentioned criteria: smoothness (RainMug (wrist)), mean speed (RainMug (wrist)), reaction time (Goalkeeper), maximum speed (HighFlyer (elbow)) and accuracy (Connect the dots), with the former showing good validity (rho=0.82, p=0.02) when comparing to the patient's severity level. The results demonstrate feasibility to extract and analyze various kinematic metrics from the ArmeoPower, which can provide quantitative information about human performance during training and therapy. The generated data increases the understanding of the patient's movement and can be used in the future in clinical research for better performance evaluation and providing more feedback options, leading towards a more personalized and patient-centric therapy.

Effectiveness of Robotic Devices for Medical Rehabilitation: An Umbrella Review

Background/Objectives: Clinical trials have investigated the efficacy of rehabilitation robotics for various pathological conditions, but the overall impact on rehabilitation practice remains unclear. We comprehensively examined and analyzed systematic reviews (SRs) of randomized controlled trials (RCTs) investigating rehabilitative interventions with robotic devices. Methods: Four databases were searched using term combinations of keywords related to robotic devices, rehabilitation, and SRs. The SR meta-analyses were categorized into "convincing", "highly suggestive", "suggestive", "weak", or "non-significant" depending on evidence strength and validity. Results: Overall, 62 SRs of 341 RCTs involving 14,522 participants were identified. Stroke was most frequently reported (40 SRs), followed by spinal cord injury (eight SRs), multiple sclerosis (four SRs), cerebral palsy (four SRs), Parkinson's disease (three SRs), and neurological disease (any disease causing limited upper- and lower-limb functioning; three SRs). Furthermore, 38, 21, and 3 SRs focused on lower-limb devices, upper-limb devices, and both upper- and lower-limb devices, respectively. Quantitative synthesis of robotic intervention effects was performed by 51 of 62 SRs. Robot-assisted training was effective for various outcome measures per disease. Meta-analyses offering suggestive evidence were limited to studies on stroke. Upper-limb devices were effective for motor control and activities of daily living, and lower-limb devices for walking independence in stroke. Conclusions: Robotic devices are useful for improving impairments and disabilities in several diseases. Further high-quality SRs including RCTs with large sample sizes and meta-analyses of these RCTs, particularly on non-stroke-related diseases, are required. Further research should also ascertain which type of robotic device is the most effective for improving each specific impairment or disability.

Effectiveness of robotic rehabilitation for gait and balance in people with multiple sclerosis: a systematic review

This review investigated the effectiveness of robotic-assisted gait training (RAGT) in improving gait and balance performance in adults with multiple sclerosis (MS). Databases and registers were searched from inception to December 2023 to identify randomized controlled trials (RCTs) that analyzed the effects of RAGT on gait speed, function, balance, fatigue, and adverse events. Three reviewers screened studies for eligibility and extracted key information such as participants and intervention characteristics, as well as outcomes of interest. The reviewers assessed the risk of bias of included studies using Cochrane Risk of Bias tool. From the 948 records identified, 8 RCTs were included, involving 335 participants. The studies have demonstrated significant heterogeneity in patient characteristics, intervention protocols, and outcomes measured. The risk of bias assessment revealed concerns, mainly in terms of performance and detection bias. The evidence is uncertain on the effectiveness of RAGT on balance and gait in people with MS, but a multimodal rehabilitation approach, including RAGT, should be encouraged. No serious adverse events seem to be associated with RAGT, suggesting that these interventions are generally safe for use in people with MS. Further studies of higher methodological quality should be led to confirm these positive results.

Cost analysis of technological vs. conventional upper limb rehabilitation for patients with neurological disorders: an Italian real-world data case study

Introduction

Most patients suffering from neurological disorders endure varying degrees of upper limb dysfunction, limiting their everyday activities, with only a limited number regaining full arm use. Robotic and technological rehabilitation has been demonstrated to be a feasible solution to guarantee an effective rehabilitation to recover upper limb performance or to prevent complications of upper limb immobility. However, there is currently a lack of studies which analyze the sustainability of robotic and technological rehabilitation by comparing its costs to conventional rehabilitation pathways.

Methods

Since technology-based and conventional rehabilitation of the upper limb have been demonstrated to have comparable efficacy when the rehabilitation dose is matched, our study concentrates on a cost minimization analysis. The aim of the study is to compare the costs of a "mixed" rehabilitation cycle, which combines conventional and technology-based treatments (the latter delivered with a single therapist supervising several patients), with a cycle of purely conventional treatments. This has been done by developing a cost model and retrospectively analyzing the costs sustained by an Italian hospital which has adopted such a mixed model. A sensitivity analysis has been done to identify the parameters of the model that have the greatest influence on cost difference and to evaluate their optimal values in terms of efficiency of mixed rehabilitation. Finally, probabilistic simulations have been applied to consider the variability of model parameters around such optimized values and evaluate the probability of achieving a given level of savings.

Results

We found a cost difference of 49.60 € per cycle in favor of mixed rehabilitation. The sensitivity analysis demonstrated that, in the situation of the hospital under investigation, the parameter having the largest influence on the cost difference is the number of robotic treatments in a mixed rehab cycle. Probabilistic simulations indicate a probability higher than 98% of an optimized mixed rehabilitation cycle being less expensive than a pure conventional one.

Conclusion

Through a retrospective cost analysis, we found that the technology-based mixed rehabilitation approach, within a specific organizational model allowing a single physiotherapist to supervise up to four patients concurrently, allowed cost savings compared to the conventional rehabilitation model.

Muscle synergies in upper limb stroke rehabilitation: a scoping review

INTRODUCTION

Upper limb impairment is a common consequence of stroke, significantly affecting the quality of life and independence of survivors. This scoping review assesses the emerging field of muscle synergy analysis in enhancing upper limb rehabilitation, focusing on the comparison of various methodologies and their outcomes. It aims to standardize these approaches to improve the effectiveness of rehabilitation interventions and drive future research in the domain.

EVIDENCE ACQUISITION

Studies included in this scoping review focused on the analysis of muscle synergies during longitudinal rehabilitation of stroke survivors' upper limbs. A systematic literature search was conducted using PubMed, Scopus, and Web of Science databases, until September 2023, and was guided by the PRISMA for scoping review framework.

EVIDENCE SYNTHESIS

Fourteen studies involving a total of 247 stroke patients were reviewed, featuring varied patient populations and rehabilitative interventions. Protocols differed among studies, with some utilizing robotic assistance and others relying on traditional therapy methods. Muscle synergy extraction was predominantly conducted using Non-Negative Matrix Factorization from electromyography data, focusing on key upper limb muscles essential for shoulder, elbow, and wrist rehabilitation. A notable observation across the studies was the heterogeneity in findings, particularly in the changes observed in the number, weightings, and temporal coefficients of muscle synergies. The studies indicated varied and complex relationships between muscle synergy variations and clinical outcomes. This diversity underscored the complexity involved in interpreting muscle coordination in the stroke population. The variability in results was also influenced by differing methodologies in muscle synergy analysis, highlighting a need for more standardized approaches to improve future research comparability and consistency.

CONCLUSIONS

The synthesis of evidence presented in this scoping review highlights the promising role of muscle synergy analysis as an indicator of motor control recovery in stroke rehabilitation. By offering a comprehensive overview of the current state of research and advocating for harmonized methodological practices in future longitudinal studies, this scoping review aspires to advance the field of upper limb rehabilitation, ensuring that post-stroke interventions are both scientifically grounded and optimally beneficial for patients.

Robot-assisted therapy in stratified intervention: a randomized controlled trial on poststroke motor recovery

Objective

To compare the effects of robot-assisted therapy with conventional therapy for accelerating stratified intervention in poststroke patients with upper limb dysfunction.

Background

For stroke survivors, recovery of upper extremity function remains a major challenge in rehabilitation. Literature has suggested that the rate of recovery may improve if treatments can be individualized to their clinical profiles. However, there still lack clinical evidence on how to create treatment tailored to individual patients. Robot-assisted Therapy (RT) provides a straightforward approach to adjustment of the assistance-resistance continuum for individual patients. In early Brunnstrom stages of recovery, patients benefit from assistance training, whereas in later stages the training is favored with resistance. Therefore, RT may enhance Conventional Therapy (CT) but the use of RT in stratified intervention has not been investigated. This study evaluated the possible benefit of adopting RT following a protocol of upper-limb training, which was stratified with the Brunnstrom stage of each individual.

Methods

This study was a single-blinded randomized controlled trial. A total of 53 patients with stroke were recruited and randomized into 2 groups (CT, n = 27, 3 dropped out and RT, n = 26, 2 dropped out). Both groups were trained once per day, 5 days per week for 4 weeks. The CT group received 30 min of conventional therapy; the RT group received 30 min of upper limb robot-assisted training. Patients were assessed at the beginning, week-2, and week-4 of the treatment. The outcome measures included the Fugl-Meyer Assessment Upper-Extremity (FMA-UE) and the Modified Barthel Index (MBI).

Results

Across the 4-week intervention, participants in the RT group recovered 1.979 points of FMA-UE per week, compared to 1.198 points per week in the CT group (t94 = 3.333, p < 0.01); the recovery rate was 0.781 points/week higher in the RT group than in the CT group. Moreover, the recovery of FMA-UE was faster in proximal joints (t94 = 3.199, p < 0.01), and for patients in Brunnstrom Stage III (t34 = 2.526, p < 0.05). The improvements in MBI were not significantly different between RT and CT.

Conclusion

Robot-assisted therapy showed initial evidence for the acceleration of post-stroke recovery of motor function in the upper limb. Initial observations suggested that patients in Brunnstrom recovery stage III might benefit the most from the stratified intervention assisted by robotics.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=61834, Identifier [ChiCTR2000039010]. Registered 13 March 2020.

Advanced rehabilitation in ischaemic stroke research

At present, due to the rapid progress of treatment technology in the acute phase of ischaemic stroke, the mortality of patients has been greatly reduced but the number of disabled survivors is increasing, and most of them are elderly patients. Physicians and rehabilitation therapists pay attention to develop all kinds of therapist techniques including physical therapy techniques, robot-assisted technology and artificial intelligence technology, and study the molecular, cellular or synergistic mechanisms of rehabilitation therapies to promote the effect of rehabilitation therapy. Here, we discussed different animal and in vitro models of ischaemic stroke for rehabilitation studies; the compound concept and technology of neurological rehabilitation; all kinds of biological mechanisms of physical therapy; the significance, assessment and efficacy of neurological rehabilitation; the application of brain-computer interface, rehabilitation robotic and non-invasive brain stimulation technology in stroke rehabilitation.

Avoidance of specific calibration sessions in motor intention recognition for exoskeleton-supported rehabilitation through transfer learning on EEG data

Exoskeleton-based support for patients requires the learning of individual machine-learning models to recognize movement intentions of patients based on the electroencephalogram (EEG). A major issue in EEG-based movement intention recognition is the long calibration time required to train a model. In this paper, we propose a transfer learning approach that eliminates the need for a calibration session. This approach is validated on healthy subjects in this study. We will use the proposed approach in our future rehabilitation application, where the movement intention of the affected arm of a patient can be inferred from the EEG data recorded during bilateral arm movements enabled by the exoskeleton mirroring arm movements from the unaffected to the affected arm. For the initial evaluation, we compared two trained models for predicting unilateral and bilateral movement intentions without applying a classifier transfer. For the main evaluation, we predicted unilateral movement intentions without a calibration session by transferring the classifier trained on data from bilateral movement intentions. Our results showed that the classification performance for the transfer case was comparable to that in the non-transfer case, even with only 4 or 8 EEG channels. Our results contribute to robotic rehabilitation by eliminating the need for a calibration session, since EEG data for training is recorded during the rehabilitation session, and only a small number of EEG channels are required for model training.

Direct Comparisons of Upper-Limb Motor Learning Performance Among Three Types of Haptic Guidance With Non-Assisted Condition in Spiral Drawing Task

In robot-assisted rehabilitation, it is unclear which type of haptic guidance is effective for regaining motor function because of the lack of direct comparisons among multiple types of haptic guidance. The objective of this study was to investigate the effects of different types of haptic guidance on upper limb motor learning in a spiral drawing task. Healthy young participants performed two experiments in which they practiced the drawing movement using a robotic manipulandum with a virtual wall (Path guidance), running direction pushing and virtual wall (Path & Push guidance), restriction to the target movement (Target guidance), or without haptic guidance (Free guidance). Experiment 1 compared the learning effects of the four types of guidance. Experiment 2 investigated the effects of pre-learning with Path, Path & Push, or Target guidance on post-learning with Free guidance. In Experiment 1, Free guidance demonstrated the greatest learning effect, followed by Path guidance, which showed a significantly greater improvement in task performance than the other two types of guidance. In Experiment 2, the type of pre-learning did not influence post-learning with Free guidance. The results suggested that learning with Path guidance showed a slightly slower but comparable effect to Free guidance and was the most effective among the three types of haptic guidance. The superiority of Path guidance over other haptic guidance was interpreted within the framework of error-based learning, in which the intensity of sensory feedback and voluntary motor control play important roles.

Effects of robot-assisted upper limb training combined with functional electrical stimulation in stroke patients: study protocol for a randomized controlled trial

INTRODUCTION

About 17-80% stroke survivors experience the deficit of upper limb function, which strongly influences their independence and quality of life. Robot-assisted training and functional electrical stimulation are commonly used interventions in the rehabilitation of hemiplegia upper extremities, while the effect of their combination remains unclear. The aim of this trial is to explore the effect of robot-assisted upper limb training combined with functional electrical stimulation, in terms of neuromuscular rehabilitation, compared with robot-assisted upper limb training alone.

METHODS

Individuals (n = 60) with the first onset of stroke (more than 1 week and less than 1 year after stroke onset) will be considered in the recruitment of this single-blinded, three-arm randomized controlled trial. Participants will be allocated into three groups (robot-assisted training combined with functional electrical stimulation group, robot-assisted training group, and conventional rehabilitation therapies group) with a ratio of 1:1:1. All interventions will be executed for 45 min per session, one session per day, 5 sessions per week for 6 weeks. The neuromuscular function of the upper limb (Fugl-Meyer Assessment of upper extremity), ability of daily life (modified Barthel Index), pain (visual analogue scale), and quality of life (EQ-5D-5L) will be assessed at the baseline, at the end of this trial and after 3 months follow-up. Two-way repeated measures analysis of variance will be used to compare the outcomes if the data are normally distributed. Simple effects tests will be used for the further exploration of interaction effects by time and group. Scheirer-Ray-Hare test will be used if the data are not satisfied with normal distribution.

DISCUSSION

We expect this three-arm randomized controlled trial to explore the effectiveness of robot-assisted training combined with functional electrical stimulation in improving post-stroke upper limb function compared with robot-assisted training alone.

TRIAL REGISTRATION

Effect of upper limb robot on improving upper limb function after stroke, identifier: ChiCTR2300073279. Registered on 5 July 2023.

Improvements in motor control are associated with improved quality of life following an at-home muscle biofeedback program for chronic stroke

Introduction

Chronic stroke survivors with severe arm impairment have limited options for effective rehabilitation. High intensity, repetitive task practice (RTP) is known to improve upper limb function among stroke survivors who have some volitional muscle activation. However, clients without volitional movement of their arm are ineligible for RTP-based interventions and require hands-on facilitation from a clinician or robotic therapy to simulate task practice. Such approaches can be expensive, burdensome, and have marginal effects. Alternatively, supervised at-home telerehabilitation using muscle biofeedback may provide a more accessible, affordable, and effective rehabilitation option for stroke survivors with severe arm impairment, and could potentially help people with severe stroke regain enough volitional activation to be eligible for RTP-types of therapies. Feedback of muscle activity via electromyography (EMG) has been previously used with clients who have minimal or no movement to improve functional performance. Specifically, training to reduce unintended co-contractions of the impaired hand using EMG biofeedback may modestly improve motor control in people with limited movement. Importantly, these modest and covert functional changes may influence the perceived impact of stroke-related disability in daily life. In this manuscript, we examine whether physical changes following use of a portable EMG biofeedback system (Tele-REINVENT) for severe upper limb hemiparesis also relate to perceived quality of life improvements. Secondarily, we examined the effects of Tele-REINVENT, which uses EMG to quantify antagonistic muscle activity during movement attempt trials and transform individuated action into computer game control, on several different domains of stroke recovery.

Methods

For this pilot study, nine stroke survivors (age = 37-73 years) with chronic impairment (Fugl-Meyer = 14-40/66) completed 30 1-hour sessions of home-based training, consisting of six weeks of gaming that reinforced wrist extensor muscle activity while attenuating coactivation of flexor muscles. To assess motor control and performance, we measured changes in active wrist ranges of motion, the Fugl-Meyer Assessment, and Action Research Arm Test. We also collected an EMG-based test of muscle control to examine more subtle changes. To examine changes in perceived quality of life, we utilized the Stroke Impact Scale along with participant feedback.

Results

Results from our pilot data suggest that 30 sessions of remote training can induce modest changes on clinical and functional assessments, showing a statistically significant improvement of active wrist ranges of motion at the group level, changes that could allow some people with severe stroke to be eligible for other therapeutic approaches, such as RTP. Additionally, changes in motor control were correlated with the perceived impact of stroke on participation and impairment after training. We also report changes in corticomuscular coherence, which showed a laterality change from the ipsilesional motor cortex towards the contralesional hemisphere during wrist extension attempts. Finally, all participants showed high adherence to the protocol and reported enjoying using the system.

Conclusion

Overall, Tele-REINVENT represents a promising telerehabilitation intervention that might improve sensorimotor outcomes in severe chronic stroke, and that improving sensorimotor abilities even modestly may improve quality of life. We propose that Tele-REINVENT may be used as a precursor to help participants gain enough active movement to participate other occupational therapy interventions, such as RTP. Future work is needed to examine if home-based telerehabilitation to provide feedback of individuated muscle activity could increase meaningful rehabilitation accessibility and outcomes for underserved populations.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of reminiscent music therapy and robot-assisted rehabilitation on older stroke patients: a protocol for a randomized controlled trial

Background

Stroke is the main disease that causes the burden of neurological disease, leading to upper limb dysfunction and affecting their self-care abilities. Robot-assisted rehabilitation therapy has been gradually used in the rehabilitation of upper limb function after stroke. However, it would be beneficial to explore auxiliary interventions such as reminiscent music therapy, a combination of music and reminiscent, to relieve negative emotions and post-stroke fatigue and improve rehabilitation outcomes. This protocol aims to evaluate the effectiveness of reminiscent music therapy combined with robot-assisted rehabilitation in older stroke patients.

Methods

This trial is a single-blind, three-arm randomized controlled trial. Older stroke patients with upper limb dysfunction will be recruited. Participants will be randomly assigned to receive usual rehabilitation treatment and care, usual rehabilitation treatment and care plus robot-assisted rehabilitation and reminiscent music therapy, or usual rehabilitation treatment and care plus robot-assisted rehabilitation. Robot-assisted rehabilitation will be conducted by rehabilitation doctors five times per week for 3 weeks. In experimental group 1, a reminiscent song list will be played for patients. The primary outcome is activities of daily living. All outcomes will be evaluated at baseline and in the week immediately post-intervention.

Discussion

We are conducting the first randomized controlled trial on the effects of reminiscent music therapy combined with robot-assisted rehabilitation in older stroke patients. It is expected that this study, if proven effective in improving the activities of daily living in older stroke patients with upper limb dysfunction, will provide evidence-based rehabilitation strategies for medical staff.Clinical Trial Registration: ChiCTR2200063738.

PDMS-embedded wearable FBG sensors for gesture recognition and communication assistance

This study introduces fiber Bragg grating (FBG) sensors embedded in polydimethylsiloxane (PDMS) silicone elastomer specifically engineered for recognizing intricate gestures like wrist pitch, finger bending, and mouth movement. Sensors with different PDMS patch thicknesses underwent evaluation including thermal, tensile strain, and bending deformation characterization, demonstrating a stability of at least four months. Experiments revealed the FBG sensors' accurate wrist pitch recognition across participants after calibration, confirmed by statistical metrics and Bland-Altman plots. Utilizing finger and mouth movements, the developed system shows promise in assisting post-stroke patients and individuals with disabilities, enhancing their interaction capabilities with the external surroundings.

Is the Combination of Robot-Assisted Therapy and Transcranial Direct Current Stimulation Useful for Upper Limb Motor Recovery? A Systematic Review with Meta-Analysis

Stroke is the third leading cause of disability in the world, and effective rehabilitation is needed to improve lost functionality post-stroke. In this regard, robot-assisted therapy (RAT) and transcranial direct current stimulation (tDCS) are promising rehabilitative approaches that have been shown to be effective in motor recovery. In the past decade, they have been combined to study whether their combination produces adjuvant and greater effects on stroke recovery. The aim of this study was to estimate the effectiveness of the combined use of RATs and tDCS in the motor recovery of the upper extremities after stroke. After reviewing 227 studies, we included nine randomised clinical trials (RCTs) in this study. We analysed the methodological quality of all nine RCTs in the meta-analysis. The analysed outcomes were deficit severity, hand dexterity, spasticity, and activity. The addition of tDCS to RAT produced a negligible additional benefit on the effects of upper limb function (SMD -0.09, 95% CI -0.31 to 0.12), hand dexterity (SMD 0.12, 95% CI -0.22 to 0.46), spasticity (SMD 0.04, 95% CI -0.24 to 0.32), and activity (SMD 0.66, 95% CI -1.82 to 3.14). There is no evidence of an additional effect when adding tDCS to RAT for upper limb recovery after stroke. Combining tDCS with RAT does not improve upper limb motor function, spasticity, and/or hand dexterity. Future research should focus on the use of RAT protocols in which the patient is given an active role, focusing on the intensity and dosage, and determining how certain variables influence the success of RAT.

Bilateral upper limb robot-assisted rehabilitation improves upper limb motor function in stroke patients: a study based on quantitative EEG

BACKGROUND

Upper limb dysfunction after stroke seriously affects quality of life. Bilateral training has proven helpful in recovery of upper limb motor function in these patients. However, studies evaluating the effectiveness of bilateral upper limb robot-assisted training on improving motor function and quality of life in stroke patients are lacking. Quantitative electroencephalography (EEG) is non-invasive, simple, and monitors cerebral cortical activity, which can be used to evaluate the effectiveness of interventions. In this study, EEG was used to evaluate the effect of end-drive bilateral upper extremity robot-assisted training on upper extremity functional recovery in stroke patients.

METHODS

24 stroke patients with hemiplegia were randomly divided into a conventional training (CT, n = 12) group or a bilateral upper limb robot-assisted training (BRT, n = 12) group. All patients received 60 min of routine rehabilitation treatment including rolling, transferring, sitting, standing, walking, etc., per day, 6 days a week, for three consecutive weeks. The BRT group added 30 min of bilateral upper limb robot-assisted training per day, while the CT group added 30 min of upper limb training (routine occupational therapy) per day, 6 days a week, for 3  weeks. The primary outcome index to evaluate upper limb motor function was the Fugl-Meyer functional score upper limb component (FMA-UE), with the secondary outcome of activities of daily living (ADL), assessed by the modified Barthel index (MBI) score. Quantitative EEG was used to evaluate functional brain connectivity as well as alpha and beta power current source densities of the brain.

RESULTS

Significant (p < 0.05) within-group differences were found in FMA-UE and MBI scores for both groups after treatment. A between-group comparison indicated the MBI score of the BRT group was significantly different from that of the CT group, whereas the FMA-UE score was not significantly different from that of the CT group after treatment. The differences of FMA-UE and MBI scores before and after treatment in the BRT group were significantly different as compared to the CT group. In addition, beta rhythm power spectrum energy was higher in the BRT group than in the CT group after treatment. Functional connectivity in the BRT group, under alpha and beta rhythms, was significantly increased in both the bilateral frontal and limbic lobes as compared to the CT group.

CONCLUSIONS

BRT outperformed CT in improving ADL in stroke patients within three months, and BRT facilitates the recovery of upper limb function by enhancing functional connectivity of the bilateral cerebral hemispheres.

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

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

The effect of sequential combination of mirror therapy and robot-assisted therapy on motor function, daily function, and self-efficacy after stroke

Robot-assisted therapy and mirror therapy are both effective in promoting upper limb function after stroke and combining these two interventions might yield greater therapeutic effects. We aimed to examine whether using mirror therapy as a priming strategy would augment therapeutic effects of robot-assisted therapy. Thirty-seven chronic stroke survivors (24 male/13 female; age = 49.8 ± 13.7 years) were randomized to receive mirror therapy or sham mirror therapy prior to robot-assisted therapy. All participants received 18 intervention sessions (60 min/session, 3 sessions/week). Outcome measures were evaluated at baseline and after the 18-session intervention. Motor function was assessed using Fugl-Meyer Assessment and Wolf Motor Function Test. Daily function was assessed using Nottingham Extended Activities of Daily Living Scale. Self-efficacy was assessed using Stroke Self-Efficacy Questionnaires and Daily Living Self-Efficacy Scale. Data was analyzed using mixed model analysis of variance. Both groups demonstrated statistically significant improvements in measures of motor function and daily function, but no significant between-group differences were found. Participants who received mirror therapy prior to robot-assisted therapy showed greater improvements in measures of self-efficacy, compared with those who received sham mirror therapy. Our findings suggest that sequentially combined mirror therapy with robot-assisted therapy could be advantageous for enhancing self-efficacy post-stroke.Trial registration: ClinicalTrials.gov Identifier: NCT03917511. Registered on 17/04/2019, https://clinicaltrials.gov/ct2/show/ NCT03917511.

Effectiveness of Visual Feedback in Reducing Trunk Compensation During Arm Reaching for Home-Based Stroke Rehabilitation

This study investigates the effectiveness of visual feedback in reducing trunk compensation during one-arm reaching exercises using an end-effector robot. Results suggest that visual feedback is more effective than verbal feedback in suppressing trunk compensation, as evidenced by lower trunk movements. Synchronized target position with respect to trunk motion exhibited a suppressive effect on trunk motion, as observed by a reduction in trunk standard deviation, trunk root mean square, and trunk difference between the starting and ending positions. These findings have important implications for developing feedback techniques to address unnatural upper limb reach movements in stroke survivors during rehabilitation programs. However, the study's limitations, such as small sample size, should be considered. Future research should explore feedback techniques in different patient populations and exercise types and evaluate their long-term effects.

Home-based upper limb stroke rehabilitation mechatronics: challenges and opportunities

Interest in home-based stroke rehabilitation mechatronics, which includes both robots and sensor mechanisms, has increased over the past 12 years. The COVID-19 pandemic has exacerbated the existing lack of access to rehabilitation for stroke survivors post-discharge. Home-based stroke rehabilitation devices could improve access to rehabilitation for stroke survivors, but the home environment presents unique challenges compared to clinics. The present study undertakes a scoping review of designs for at-home upper limb stroke rehabilitation mechatronic devices to identify important design principles and areas for improvement. Online databases were used to identify papers published 2010-2021 describing novel rehabilitation device designs, from which 59 publications were selected describing 38 unique designs. The devices were categorized and listed according to their target anatomy, possible therapy tasks, structure, and features. Twenty-two devices targeted proximal (shoulder and elbow) anatomy, 13 targeted distal (wrist and hand) anatomy, and three targeted the whole arm and hand. Devices with a greater number of actuators in the design were more expensive, with a small number of devices using a mix of actuated and unactuated degrees of freedom to target more complex anatomy while reducing the cost. Twenty-six of the device designs did not specify their target users' function or impairment, nor did they specify a target therapy activity, task, or exercise. Twenty-three of the devices were capable of reaching tasks, 6 of which included grasping capabilities. Compliant structures were the most common approach of including safety features in the design. Only three devices were designed to detect compensation, or undesirable posture, during therapy activities. Six of the 38 device designs mention consulting stakeholders during the design process, only two of which consulted patients specifically. Without stakeholder involvement, these designs risk being disconnected from user needs and rehabilitation best practices. Devices that combine actuated and unactuated degrees of freedom allow a greater variety and complexity of tasks while not significantly increasing their cost. Future home-based upper limb stroke rehabilitation mechatronic designs should provide information on patient posture during task execution, design with specific patient capabilities and needs in mind, and clearly link the features of the design to users' needs.

Spasticity evaluation with the Amadeo Tyromotion device in patients with hemispheric stroke

Objective

The objective of this study is to verify the reliability and the concurrent and discriminant validity of the measurements of spasticity offered by the robotic device, quantifying the (1) test-retest reliability, (2) correlation with the clinical evaluation using the Modified Ashworth Scale (MAS), (3) inter-rater reliability between the two physiotherapists, and (4) ability to discriminate between healthy and stroke patients.

Methods

A total of 20 stroke patients and 20 healthy volunteers participated in the study. Two physical therapists (PT1 and PT2) independently evaluated the hand spasticity of stroke subjects using the MAS. Spasticity was assessed, both in healthy and stroke patients, with the Amadeo device at three increasing velocities of passive movement for three consecutive repeated assessments, while raw data of force and position were collected through an external program.

Data analysis

The intraclass correlation coefficient (ICC) and the weighted kappa were computed to estimate the reliability of the Amadeo device measurements, the inter-rater reliability of MAS, and the correlation between the MAS and Amadeo device measurements. The discriminant ability of the Amadeo device was assessed by comparing the stroke and healthy subjects' spasticity measurements with the percentage of agreements with 0 in MAS for healthy subjects.

Results

The test-retest reliability of the Amadeo device was high with ICC at all three velocities (ICC = 0.908, 0.958, and 0.964, respectively) but lower if analyzed with weighted kappa correlation (0.584, 0.748, and 0.749, respectively) as mean values for each velocity. The correlation between Amadeo and the clinical scale for stroke patients with weighted kappa correlation was poor (0.280 ± 0.212 for PT1 and 0.290 ± 0.155 for PT2). The inter-rater reliability of the clinical MAS was high (ICC = 0.911).

Conclusion

Both MAS and Amadeo spasticity scores showed good reliability. The Amadeo scores did not show a strong clinical correlation with the MAS in stroke patients. Hitherto, Amadeo evaluation shows trends that are consistent with the characteristics of spasticity, such as an increase in spasticity as the speed of muscle stretching increases. The ability of the device to discriminate between stroke patients and healthy controls is low. Future studies adopting an instrumental gold standard for spasticity may provide further insight into the validity of these measurements.

Exoskeleton-Assisted Anthropomorphic Movement Training for the Upper Limb After Stroke: The EAMT Randomized Trial

BACKGROUND

Robot-assisted arm training is generally delivered in the robot-like manner of planar or mechanical 3-dimensional movements. It remains unclear whether integrating upper extremity (UE) natural coordinated patterns into a robotic exoskeleton can improve outcomes. The study aimed to compare conventional therapist-mediated training to the practice of human-like gross movements derived from 5 typical UE functional activities managed with exoskeletal assistance as needed for patients after stroke.

METHODS

In this randomized, single-blind, noninferiority trial, patients with moderate-to-severe UE motor impairment due to subacute stroke were randomly assigned (1:1) to receive 20 sessions of 45-minute exoskeleton-assisted anthropomorphic movement training or conventional therapy. Treatment allocation was masked from independent assessors, but not from patients or investigators. The primary outcome was the change in the Fugl-Meyer Assessment for Upper Extremity from baseline to 4 weeks against a prespecified noninferiority margin of 4 points. Superiority would be tested if noninferiority was demonstrated. Post hoc subgroup analyses of baseline characteristics were performed for the primary outcome.

RESULTS

Between June 2020 and August 2021, totally 80 inpatients (67 [83.8%] males; age, 51.9±9.9 years; days since stroke onset, 54.6±38.0) were enrolled, randomly assigned to the intervention, and included in the intention-to-treat analysis. The mean Fugl-Meyer Assessment for Upper Extremity change in exoskeleton-assisted anthropomorphic movement training (14.73 points; [95% CI, 11.43-18.02]) was higher than that of conventional therapy (9.90 points; [95% CI, 8.15-11.65]) at 4 weeks (adjusted difference, 4.51 points [95% CI, 1.13-7.90]). Moreover, post hoc analysis favored the patient subgroup (Fugl-Meyer Assessment for Upper Extremity score, 23-38 points) with moderately severe motor impairment.

CONCLUSIONS

Exoskeleton-assisted anthropomorphic movement training appears to be effective for patients with subacute stroke through repetitive practice of human-like movements. Although the results indicate a positive sign for exoskeleton-assisted anthropomorphic movement training, further investigations into the long-term effects and paradigm optimization are warranted.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2100044078.

Challenges and opportunities in vascularized composite allotransplantation of joints: a systematic literature review

Background

Joint allotransplantation (JA) within the field of vascularized composite allotransplantation (VCA) holds great potential for functional and non-prosthetic reconstruction of severely damaged joints. However, clinical use of JA remains limited due to the immune rejection associated with all forms of allotransplantation. In this study, we aim to provide a comprehensive overview of the current state of JA through a systematic review of clinical, animal, and immunological studies on this topic.

Methods

We conducted a systematic literature review in accordance with the PRISMA guidelines to identify relevant articles in PubMed, Cochrane Library, and Web of Science databases. The results were analyzed, and potential future prospects were discussed in detail.

Results

Our review included 14 articles describing relevant developments in JA. Currently, most JA-related research is being performed in small animal models, demonstrating graft survival and functional restoration with short-term immunosuppression. In human patients, only six knee allotransplantations have been performed to date, with all grafts ultimately failing and a maximum graft survival of 56 months.

Conclusion

Research on joint allotransplantation has been limited over the last 20 years due to the rarity of clinical applications, the complex nature of surgical procedures, and uncertain outcomes stemming from immune rejection. However, the key to overcoming these challenges lies in extending graft survival and minimizing immunosuppressive side effects. With the emergence of new immunosuppressive strategies, the feasibility and clinical potential of vascularized joint allotransplantation warrants further investigation.

Effects of EMG-based robot for upper extremity rehabilitation on post-stroke patients: a systematic review and meta-analysis

Objective: A growing body of research shows the promise and efficacy of EMG-based robot interventions in improving the motor function in stroke survivors. However, it is still controversial whether the effect of EMG-based robot is more effective than conventional therapies. This study focused on the effects of EMG-based robot on upper limb motor control, spasticity and activity limitation in stroke survivors compared with conventional rehabilitation techniques. Methods: We searched electronic databases for relevant randomized controlled trials. Outcomes included Fugl-Meyer assessment scale (FMA), Modified Ashworth Scale (MAS), and activity level. Result: Thirteen studies with 330 subjects were included. The results showed that the outcomes post intervention was significantly improved in the EMG-based robot group. Results from subgroup analyses further revealed that the efficacy of the treatment was better in patients in the subacute stage, those who received a total treatment time of less than 1000 min, and those who received EMG-based robotic therapy combined with electrical stimulation (ES). Conclusion: The effect of EMG-based robot is superior to conventional therapies in terms of improving upper extremity motor control, spasticity and activity limitation. Further research should explore optimal parameters of EMG-based robot therapy and its long-term effects on upper limb function in post-stroke patients. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/; Identifier: 387070.

Fuzzy Adaptive Passive Control Strategy Design for Upper-Limb End-Effector Rehabilitation Robot

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.

Effects of a remote-handling-concept-based task-oriented arm training (ReHab-TOAT) on arm-hand skill performance in chronic stroke: a study protocol for a two-armed randomized controlled trial

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation and needs intensive and varied training. However, guided treatment time is limited. Technology can assist in the training of patients, offering a higher intensity and more variety in content. A new task-oriented arm training approach was developed, using a 'Remote Handling concept based' device to provide haptic feedback during the performance of daily living activities (ReHab-TOAT). This study aims to investigate the effects of ReHab-TOAT on patients' arm-hand function and arm-hand skill performance, quality of life of both patients in the chronic phase after stroke and their caregivers and the patients' perception regarding the usability of the intervention.

METHODS

A randomized clinical trial was designed. Adult chronic stroke patients suffering from hemiparesis and arm-hand problems, with an Utrechtse Arm-hand Test score of 1-3, will be invited to participate. Participants in the experimental group receive ReHab-TOAT additional to care as usual. ReHab-TOAT contains task-oriented arm training for stroke patients in combination with haptic feedback, generated by a remote handling device. They will train for 4 weeks, 3× per week, 1.5h per day. Participants in the control group will receive no additional therapy apart from care as usual. The Fugl-Meyer Assessment (FMA), measuring participants' motor performance of the affected arm, is used as the primary outcome measure. Secondary outcome measures are arm-hand capacity of the patient (ARAT), perceived arm-hand skill performance (MAL), actual arm-hand skill performance (accelerometry), patients' quality of life (EuoQol-5D) and caregivers' quality of life (CarerQoL). Participants' perception regarding the usability of the intervention, including both the developed approach and technology used, will be evaluated by the System Usability Scale and a questionnaire on the user experience of technology. Measurements will be performed at 1, 2, 3 and 4 weeks pre-intervention (baseline); immediately post-intervention; and 3, 6 and 9 months post-intervention. Statistical analysis includes linear mixed model analysis.

DISCUSSION

This study is designed to investigate the evidence regarding the effects of ReHab-TOAT on patients' performance at different levels of the International Classification of Functioning, disability and health (ICF) model, i.e. a framework measuring functioning and disability in relation to a health condition, and to provide insights on a successful development and research process regarding technology-assisted training in co-creation.

TRIAL REGISTRATION

Netherlands Trial Register NL9541. Registered on June 22, 2021.

Effects of Upper Limb Robot-Assisted Rehabilitation Compared with Conventional Therapy in Patients with Stroke: Preliminary Results on a Daily Task Assessed Using Motion Analysis

Robotic rehabilitation of the upper limb has demonstrated promising results in terms of the improvement of arm function in post-stroke patients. The current literature suggests that robot-assisted therapy (RAT) is comparable to traditional approaches when clinical scales are used as outcome measures. Instead, the effects of RAT on the capacity to execute a daily life task with the affected upper limb are unknown, as measured using kinematic indices. Through kinematic analysis of a drinking task, we examined the improvement in upper limb performance between patients following a robotic or conventional 30-session rehabilitation intervention. In particular, we analyzed data from nineteen patients with subacute stroke (less than six months following stroke), nine of whom treated with a set of four robotic and sensor-based devices and ten with a traditional approach. According to our findings, the patients increased their movement efficiency and smoothness regardless of the rehabilitative approach. After the treatment (either robotic or conventional), no differences were found in terms of movement accuracy, planning, speed, or spatial posture. This research seems to demonstrate that the two investigated approaches have a comparable impact and may give insight into the design of rehabilitation therapy.

A bibliometric and visual analysis of publications on artificial intelligence in colorectal cancer (2002-2022)

Background

Colorectal cancer (CRC) has the third-highest incidence and second-highest mortality rate of all cancers worldwide. Early diagnosis and screening of CRC have been the focus of research in this field. With the continuous development of artificial intelligence (AI) technology, AI has advantages in many aspects of CRC, such as adenoma screening, genetic testing, and prediction of tumor metastasis.

Objective

This study uses bibliometrics to analyze research in AI in CRC, summarize the field's history and current status of research, and predict future research directions.

Method

We searched the SCIE database for all literature on CRC and AI. The documents span the period 2002-2022. we used bibliometrics to analyze the data of these papers, such as authors, countries, institutions, and references. Co-authorship, co-citation, and co-occurrence analysis were the main methods of analysis. Citespace, VOSviewer, and SCImago Graphica were used to visualize the results.

Result

This study selected 1,531 articles on AI in CRC. China has published a maximum number of 580 such articles in this field. The U.S. had the most quality publications, boasting an average citation per article of 46.13. Mori Y and Ding K were the two authors with the highest number of articles. Scientific Reports, Cancers, and Frontiers in Oncology are this field's most widely published journals. Institutions from China occupy the top 9 positions among the most published institutions. We found that research on AI in this field mainly focuses on colonoscopy-assisted diagnosis, imaging histology, and pathology examination.

Conclusion

AI in CRC is currently in the development stage with good prospects. AI is currently widely used in colonoscopy, imageomics, and pathology. However, the scope of AI applications is still limited, and there is a lack of inter-institutional collaboration. The pervasiveness of AI technology is the main direction of future housing development in this field.

The identification of interacting brain networks during robot-assisted training with multimodal stimulation

Objective.Robot-assisted rehabilitation training is an effective way to assist rehabilitation therapy. So far, various robotic devices have been developed for automatic training of central nervous system following injury. Multimodal stimulation such as visual and auditory stimulus and even virtual reality technology were usually introduced in these robotic devices to improve the effect of rehabilitation training. This may need to be explained from a neurological perspective, but there are few relevant studies.Approach.In this study, ten participants performed right arm rehabilitation training tasks using an upper limb rehabilitation robotic device. The tasks were completed under four different feedback conditions including multiple combinations of visual and auditory components: auditory feedback; visual feedback; visual and auditory feedback (VAF); non-feedback. The functional near-infrared spectroscopy devices record blood oxygen signals in bilateral motor, visual and auditory areas. Using hemoglobin concentration as an indicator of cortical activation, the effective connectivity of these regions was then calculated through Granger causality.Main results.We found that overall stronger activation and effective connectivity between related brain regions were associated with VAF. When participants completed the training task without VAF, the trends in activation and connectivity were diminished.Significance.This study revealed cerebral cortex activation and interacting networks of brain regions in robot-assisted rehabilitation training with multimodal stimulation, which is expected to provide indicators for further evaluation of the effect of rehabilitation training, and promote further exploration of the interaction network in the brain during a variety of external stimuli, and to explore the best sensory combination.

Analysis of the therapeutic interaction provided by a humanoid robot serving stroke survivors as a therapeutic assistant for arm rehabilitation

Objective: To characterize a socially active humanoid robot's therapeutic interaction as a therapeutic assistant when providing arm rehabilitation (i.e., arm basis training (ABT) for moderate-to-severe arm paresis or arm ability training (AAT) for mild arm paresis) to stroke survivors when using the digital therapeutic system Evidence-Based Robot-Assistant in Neurorehabilitation (E-BRAiN) and to compare it to human therapists' interaction. Methods: Participants and therapy: Seventeen stroke survivors receiving arm rehabilitation (i.e., ABT [n = 9] or AAT [n = 8]) using E-BRAiN over a course of nine sessions and twenty-one other stroke survivors receiving arm rehabilitation sessions (i.e., ABT [n = 6] or AAT [n = 15]) in a conventional 1:1 therapist-patient setting. Analysis of therapeutic interaction: Therapy sessions were videotaped, and all therapeutic interactions (information provision, feedback, and bond-related interaction) were documented offline both in terms of their frequency of occurrence and time used for the respective type of interaction using the instrument THER-I-ACT. Statistical analyses: The therapeutic interaction of the humanoid robot, supervising staff/therapists, and helpers on day 1 is reported as mean across subjects for each type of therapy (i.e., ABT and AAT) as descriptive statistics. Effects of time (day 1 vs. day 9) on the humanoid robot interaction were analyzed by repeated-measures analysis of variance (rmANOVA) together with the between-subject factor type of therapy (ABT vs. AAT). The between-subject effect of the agent (humanoid robot vs. human therapist; day 1) was analyzed together with the factor therapy (ABT vs. AAT) by ANOVA. Main results and interpretation: The overall pattern of the therapeutic interaction by the humanoid robot was comprehensive and varied considerably with the type of therapy (as clinically indicated and intended), largely comparable to human therapists' interaction, and adapted according to needs for interaction over time. Even substantially long robot-assisted therapy sessions seemed acceptable to stroke survivors and promoted engaged patients' training behavior. Conclusion: Humanoid robot interaction as implemented in the digital system E-BRAiN matches the human therapeutic interaction and its modification across therapies well and promotes engaged training behavior by patients. These characteristics support its clinical use as a therapeutic assistant and, hence, its application to support specific and intensive restorative training for stroke survivors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

fNIRS-based brain functional response to robot-assisted training for upper-limb in stroke patients with hemiplegia

Background

Robot-assisted therapy (RAT) has received considerable attention in stroke motor rehabilitation. Characteristics of brain functional response associated with RAT would provide a theoretical basis for choosing the appropriate protocol for a patient. However, the cortical response induced by RAT remains to be fully elucidated due to the lack of dynamic brain functional assessment tools.

Objective

To guide the implementation of clinical therapy, this study focused on the brain functional responses induced by RAT in patients with different degrees of motor impairment.

Methods

A total of 32 stroke patients were classified into a low score group (severe impairment, n = 16) and a high score group (moderate impairment, n = 16) according to the motor function of the upper limb and then underwent RAT training in assistive mode with simultaneous cerebral haemodynamic measurement by functional near-infrared spectroscopy (fNIRS). Functional connectivity (FC) and the hemisphere autonomy index (HAI) were calculated based on the wavelet phase coherence among fNIRS signals covering bilateral prefrontal, motor and occipital areas.

Results

Specific cortical network response related to RAT was observed in patients with unilateral moderate-to-severe motor deficits in the subacute stage. Compared with patients with moderate dysfunction, patients with severe impairment showed a wide range of significant FC responses in the bilateral hemispheres induced by RAT with the assistive mode, especially task-related involvement of ipsilesional supplementary motor areas.

Conclusion

Under assisted mode, RAT-related extensive cortical response in patients with severe dysfunction might contribute to brain functional organization during motor performance, which is considered the basic neural substrate of motor-related processes. In contrast, the limited cortical response related to RAT in patients with moderate dysfunction may indicate that the training intensity needs to be adjusted in time according to the brain functional state. fNIRS-based assessment of brain functional response assumes great importance for the customization of an appropriate protocol training in the clinical practice.