Robotic Rehabilitation: An Opportunity to Improve Cognitive Functions in Subjects With Stroke. An Explorative Study

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).

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.

Effects of virtual reality with different modalities on upper limb recovery: a systematic review and network meta-analysis on optimizing stroke rehabilitation

Background

As a major cause of disability worldwide, stroke affects about 80% of survivors with upper limb (UL) motor dysfunction, significantly impairing their quality of life. Virtual reality (VR) has been recognized as an innovative rehabilitation tool; however, the effectiveness of VR systems with different immersion modalities is still uncertain. This systematic review and network meta-analysis (NMA) aims to evaluate the comparative effectiveness of intervention measures, including non-immersive gaming consoles, immersive VR (IVR), non-immersive VR (NIVR), and conventional therapy (CT) on upper limb motor function in stroke rehabilitation.

Materials and methods

A systematic search of PubMed, Embase, Cochrane Library, and Scopus identified randomized controlled trials (RCTs) published up to 12 June 2024. UL motor recovery was assessed using the Fugl-Meyer Upper Extremity (FMUE) scale. The NMA was performed using the Bayesian approach with the BUGSnet package in R software to calculate the relative effectiveness of each intervention.

Results

34 RCTs involving 1,704 participants were included. Among non-immersive gaming systems, Microsoft Kinect demonstrated the greatest effective in enhancing UL motor function, followed by Nintendo Wii, then NIVR and IVR head-mounted devices. CT showed the least effective. Specifically, Microsoft Kinect significantly improved FMUE scores (mean difference [MD] = 7.27, 95% confidence interval [CI]: 0.59 to 13.77, p < 0.05), followed by Nintendo Wii (MD = 4.53, 95% CI: 0.87 to 8.14, p < 0.05), and NIVR (MD = 3.57, 95% CI: 1.18 to 6.01, p < 0.05). In contrast, IVR head-mounted devices showed no statistically significant differences in outcomes, with MD of 4.16 (95% CI: -0.02 to 8.38).

Conclusion

Non-immersive gaming console of Microsoft Kinect is the most effective intervention for improving UL motor function in stroke survivors. In contrast, IVR head-mounted devices did not offer significant advantages over CT. These findings suggest that non-immersive gaming consoles of Microsoft Kinect could be a more cost-effective and accessible alternative for stroke rehabilitation.

Clinical validation of an individualized auto-adaptative serious game for combined cognitive and upper limb motor robotic rehabilitation after stroke

BACKGROUND

Intensive rehabilitation through challenging and individualized tasks are recommended to enhance upper limb recovery after stroke. Robot-assisted therapy (RAT) and serious games could be used to enhance functional recovery by providing simultaneous motor and cognitive rehabilitation.

OBJECTIVE

The aim of this study is to clinically validate the dynamic difficulty adjustment (DDA) mechanism of ROBiGAME, a robot serious game designed for simultaneous rehabilitation of motor impairments and hemispatial neglect.

METHODS

A proof of concept, with 24 participants in subacute and chronic stroke, was conducted using a 5-day protocol (two days were dedicated to assessment and three days to consecutive training sessions). Participants performed three consecutive ROBiGAME sessions during which overall task difficulty was determined through simultaneous DDA of motor and attentional parameters. Relationships between clinical and robotic assessment scores with respective task-difficulty parameters were analyzed using a multivariate regression model and a principal component analysis.

RESULTS

Game difficulty rapidly (within approximately thirty minutes) auto-adapted to match individual impairment levels. The relationship between task-difficulty parameters with motor (Fugl Meyer Assessment: r = 0.84 p < 0.05) and with attentional impairments (Bells test total omissions: r = 0.617 p < 0.05) showed that task-difficulty during RAT adapted to each participant's degree of impairment. Principal component analysis identified two data subsets determining overall task-difficulty, one subset for motor and the other for cognitive functional evaluation scores with respective task-difficulty parameters.

CONCLUSIONS

This proof of concept clinically validated a DDA mechanism and showed how task-difficulty adequately adapted to match individual degrees of impairment during RAT after stroke. ROBiGAME provided simultaneous motor and attentional exercises with parameters determining task-difficulty strongly related with respective clinical and robotic evaluation scores. Individualized levels of game difficulty and rapid adjustment of the system suggest implementation in clinical practice. Registry number This study was registered at ClinicalTrials.gov (NCT02543424).

Malnutrition Diagnosis and Food Consumption in Subacute Post-Stroke Patients During Rehabilitation

BACKGROUND

Stroke survivors frequently encounter malnutrition, adversely impacting clinical outcomes. Nevertheless, malnutrition and food consumption in post-stroke patients have not been frequently assessed, and their correlation with rehabilitation outcomes remains inadequately explored. The objective of this observational study was to evaluate malnutrition at admission in these patients, assess food consumption during a six-week rehabilitation program, and analyze their correlation with rehabilitation outcomes.

METHODS

Subacute post-stroke patients were evaluated at admission (T0) and after a six-week rehabilitation treatment (T1). At T0, we assessed clinical and demographic characteristics, and we diagnosed malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. Weight, BMI, hematochemical parameters, and activities of daily living with the modified Barthel Index (mBI) were evaluated at both T0 and T1; recovery was registered as a change in the mBI (ΔmBI = mBIT1 - mBIT0). Patients' food consumption was recorded through visual plate waste estimation of three meals a day, 5 days a week, for six weeks of hospitalization for rehabilitation.

RESULTS

A total of 109 patients completed the study (51 women, mean age 69 ± 11). According to the GLIM criteria, 105 of these patients were at risk of malnutrition, while 43 were malnourished, with 15 severely malnourished. Malnourished patients wasted more food, with respect to non-malnourished patients, as measured by visual plate waste of total meals (25 ± 17% vs. 15 ± 14%; p = 0.001) and reached a lower ΔmBI. A linear regression analysis found a significant correlation between the ΔmBI, the waste of a "second dish", which contained mainly protein, and serum albumin at admission, even after controlling for age.

CONCLUSIONS

Malnutrition assessed with the GLIM criteria at admission and food consumption are two important nutritional parameters to evaluate in post-stroke patients hospitalized for rehabilitation due to their association with recovery.

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.

Intervention and assessment of executive dysfunction in patients with stroke: A scoping review

Rehabilitation methods for executive dysfunction were focused on cognitive rehabilitation in patients with stroke and traumatic brain injury. However, no reviews have focused on the various rehabilitation methods and assessment of executive function in patients with only stroke and included various study designs. This study aimed to identify various interventions and assessments in patients with stroke and executive dysfunction via a scoping review. We searched for articles using the PubMed, Web of Science, and CINAHL databases. Two reviewers independently screened the articles based on the inclusion and exclusion criteria using the title, abstract, and full text. We subsequently determined the study design, sample size, time since stroke, intervention, and assessment. We extracted 1131 articles, of which 27 articles were selected. The study designs were randomized controlled trials (81.5%), pilot studies (11.1%), and feasibility studies (7.4%), with a total of 599 participants. Interventions varied from cognitive training (22.2%), virtual reality (22.2%), noninvasive brain stimulation (14.8%), and dual-task training (11.1%), with consistent results. The assessments used were the Trail Making Test Part B (70.4%), Stroop Color and Word Test (44.4%), Digit Symbol Test, Frontal Assessment Battery, and Tower of London test (11.1%). In conclusion, this scoping review provided various interventions and assessments in patients with stroke with executive dysfunction.

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

Efficacy of telerehabilitation with digital and robotic tools for the continuity of care of people with chronic neurological disorders: The TELENEURO@REHAB protocol for a randomized controlled trial

Context

Chronic Neurological Disorders (CNDs) are among the leading causes of disability worldwide, and their contribution to the overall need for rehabilitation is increasing. Therefore, the identification of new digital solutions to ensure early and continuous care is mandatory.

Objective

This protocol proposes to test the usability, acceptability, safety, and efficacy of Telerehabilitation (TR) protocols with digital and robotic tools in reducing the perceived level of disability in CNDs including Parkinson's Disease (PD), Multiple Sclerosis (MS), and post-stroke patients.

Design Setting and Subjects

This single-blinded, multi-site, randomized, two-treatment arms controlled clinical trial will involve PD (N = 30), MS (N = 30), and post-stroke (N = 30). Each participant will be randomized (1:1) to the experimental group (20 sessions of motor telerehabilitation with digital and robotic tools) or the active control group (20 home-based motor rehabilitation sessions according to the usual care treatment). Primary and secondary outcome measures will be obtained at the baseline (T0), post-intervention (T1, 5 weeks after baseline), and at follow-up (T2, 2 months after treatment).

Main Outcome Measures

a multifaceted evaluation including quality of life, motor, and clinical/functional measures will be conducted at each time-point of assessment. The primary outcome measures will be the change in the perceived level of disability as measured by the World Health Organization Disability Assessment Schedule 2.0.

Conclusion

The implementation of TR protocols will enable a more targeted and effective response to the growing need for rehabilitation linked to CNDs, ensuring accessibility to rehabilitation services from the initial stages of the disease.

A Multiaxial Rehabilitation Programme for Workers with COVID-19 Sequelae Using a Conventional and Technological-Robotic Approach: The Proposal of INAIL and Fondazione Don Carlo Gnocchi

The COVID-19 sequelae have been shown to affect respiratory and cardiological functions as well as neuro-psychological functions, and, in some cases, metabolic/nutritional aspects. The Italian National Institute for Insurance against Accidents at Work (Istituto Nazionale Assicurazione Infortuni sul Lavoro, INAIL) recorded that, until December 2022, 315,055 workers were affected by COVID-19; therefore, there is a need to identify an effective approach to treat such patients. Robotic and technological devices could be integrated into the rehabilitation programme of people with long COVID conditions. A review of the literature showed that telerehabilitation may improve functional capacity, dyspnoea, performance, and quality of life in these patients, but no studies were found evaluating the effects of robot-mediated therapy or virtual reality systems. Considering the above, Fondazione Don Carlo Gnocchi and INAIL propose a multi-axial rehabilitation for workers with COVID-19 sequelae. To accomplish this goal, the two institutions merged the epidemiological information gathered by INAIL, the expertise in robotic and technological rehabilitation of Fondazione Don Carlo Gnocchi, and the literature review. Our proposal aims to facilitate a multi-axial rehabilitation approach customized to meet the unique needs of each individual, with a particular emphasis on utilizing advanced technologies to address the current and future challenges of patient care.

Overview of the role of robots in upper limb disabilities rehabilitation: a scoping review

BACKGROUND

Neuromotor rehabilitation and improvement of upper limb functions are necessary to improve the life quality of patients who have experienced injuries or have pathological outcomes. Modern approaches, such as robotic-assisted rehabilitation can help to improve rehabilitation processes and thus improve upper limb functions. Therefore, the aim of this study was to investigate the role of robots in upper limb disability improvement and rehabilitation.

METHODS

This scoping review was conducted by search in PubMed, Web of Science, Scopus, and IEEE (January 2012- February 2022). Articles related to upper limb rehabilitation robots were selected. The methodological quality of all the included studies will be appraised using the Mixed Methods Appraisal Tool (MMAT). We used an 18-field data extraction form to extract data from articles and extracted the information such as study year, country, type of study, purpose, illness or accident leading to disability, level of disability, assistive technologies, number of participants in the study, sex, age, rehabilitated part of the upper limb using a robot, duration and frequency of treatment, methods of performing rehabilitation exercises, type of evaluation, number of participants in the evaluation process, duration of intervention, study outcomes, and study conclusions. The selection of articles and data extraction was made by three authors based on inclusion and exclusion criteria. Disagreements were resolved through consultation with the fifth author. Inclusion criteria were articles involving upper limb rehabilitation robots, articles about upper limb disability caused by any illness or injury, and articles published in English. Also, articles involving other than upper limb rehabilitation robots, robots related to rehabilitation of diseases other than upper limb, systematic reviews, reviews, and meta-analyses, books, book chapters, letters to the editor, and conference papers were also excluded. Descriptive statistics methods (frequency and percentage) were used to analyses the data.

RESULTS

We finally included 55 relevant articles. Most of the studies were done in Italy (33.82%). Most robots were used to rehabilitate stroke patients (80%). About 60.52% of the studies used games and virtual reality rehabilitate the upper limb disabilities using robots. Among the 14 types of applied evaluation methods, "evaluation and measurement of upper limb function and dexterity" was the most applied evaluation method. "Improvement in musculoskeletal functions", "no adverse effect on patients", and "Safe and reliable treatment" were the most cited outcomes, respectively.

CONCLUSIONS

Our findings show that robots can improve musculoskeletal functions (musculoskeletal strength, sensation, perception, vibration, muscle coordination, less spasticity, flexibility, and range of motion) and empower people by providing a variety of rehabilitation capabilities.

The Role of Technological Rehabilitation in Patients with Intensive Care Unit Weakness: A Randomized Controlled Pilot Study

Intensive-Care-Unit-Acquired Weakness (ICU-AW) is the most common neuromuscular impairment in critically ill patients and can have a significant impact on long-term disability. Early rehabilitation has been suggested to facilitate the natural recovery process. This is a pilot, randomized, single-blind study that aimed to evaluate the effectiveness of intensive combined technological rehabilitation treatment including focal muscle vibration and non-immersive virtual reality for patients with severe acquired brain injury (sABI) and ICU-AW. Twenty-four patients were randomized into the conventional group, which performed only conventional rehabilitation, and the experimental group, which also performed technological treatment. At baseline and after 3 weeks of treatment, assessments of motor function, autonomy, disability and quality of life were conducted. At the end of the intervention, both groups showed significant improvements. However, patients in the experimental group achieved greater improvements in disability (p = 0.001) and quality of life (p = 0.001). The results show that intensive structured rehabilitation is effective in improving the motor function, disability and quality of life of patients with severe acquired brain injury and acquired weakness. The combination of non-immersive virtual reality training and focal muscle vibration can result in a significant improvement in overall disability and quality of life compared with conventional treatment alone.

RObotic-Assisted Rehabilitation for balance and gait in Stroke patients (ROAR-S): study protocol for a preliminary randomized controlled trial

BACKGROUND

Stroke, the incidence of which increases with age, has a negative impact on motor and cognitive performance, quality of life, and the independence of the person and his or her family, leading to a number of direct and indirect costs. Motor recovery is essential, especially in elderly patients, to enable the patient to be independent in activities of daily living and to prevent falls. Several studies have shown how robotic training associated with physical therapy influenced functional and motor outcomes of walking after stroke by improving endurance and walking strategies. Considering data from previous studies and patients' needs in gait and balance control, we hypothesized that robot-assisted balance treatment associated with physical therapy may be more effective than usual therapy performed by a physical therapist in terms of improving static, dynamic balance and gait, on fatigue and cognitive performance.

METHODS

This is an interventional, single-blinded, preliminary randomized control trial. Twenty-four patients of both sexes will be recruited, evaluated, and treated at the UOC Rehabilitation and Physical Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome from January to December 2022. Patients will be randomized into two groups: the experimental group will perform specific rehabilitation for balance disorder using the Hunova® robotic platform (Movendo Technology srl, Genoa, IT) for 3 times a week, for 4 weeks (12 total sessions), and for 45 min of treatment, in addition to conventional treatment, while the conventional group (GC) will perform only conventional treatment as per daily routine. All patients will undergo clinical and instrumental evaluation at the beginning and end of the 4 weeks of treatment.

CONCLUSIONS

The study aims to evaluate the improvement in balance, fatigue, quality of life, and motor and cognitive performance after combined conventional and robotic balance treatment with Hunova® (Movendo Technology srl, Genoa, IT) compared with conventional therapy alone. Robotic assessment to identify the most appropriate and individualized rehabilitation treatment may allow reducing disability and improving quality of life in the frail population. This would reduce direct and indirect social costs of care and treatment for the National Health Service and caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05280587. Registered on March 15, 2022.

The Impact of Cognitive Impairment on Robot-Based Upper-Limb Motor Assessment in Chronic Stroke

BACKGROUND

Chronic upper extremity motor deficits are present in up to 65% of stroke survivors, and cognitive impairment is prevalent in 46-61% of stroke survivors even 10 years after their stroke. Robot-assisted therapy programs tend to focus on motor recovery and do not include stroke patients with cognitive impairment.

OBJECTIVE

This study aims to investigate performance on the individual cognitive domains evaluated in the MoCA and their relation to upper-limb motor performance on a robotic system.

METHODS

Participants were recruited from the stroke population with a wide range of cognitive and motor levels to complete a trajectory tracking task using the Haptic TheraDrive rehabilitation robot system. Motor performance was evaluated against standard clinical cognitive and motor assessments. Our hypothesis is that the cognitive domains involved in the visuomotor tracking task are significant predictors of performance on the robot-based task and that impairment in these domains results in worse motor performance on the task compared to subjects with no cognitive impairment.

RESULTS

Our results support the hypothesis that visuospatial and executive function have a significant impact on motor performance, with differences emerging between different functional groups on the various robot-based metrics. We also show that the kinematic metrics from this task differentiate cognitive-motor functional groups differently.

CONCLUSION

This study demonstrates that performance on a motor-based robotic assessment task also involves a significant visuospatial and executive function component and highlights the need to account for cognitive impairment in the assessment of motor performance.

Effects of robot-assisted therapy on upper limb and cognitive function in patients with stroke: study protocol of a randomized controlled study

Background

Impairments in upper limb motor function and cognitive ability are major health problems experienced by stroke patients, necessitating the development of novel and effective treatment options in stroke care. The aim of this study is to examine the effects of robot-assisted therapy on improving upper limb and cognitive functions in stroke patients.

Methods

This will be a single-blinded, 2-arm, parallel design, randomized controlled trial which will include a sample size of 86 acute and subacute stroke patients to be recruited from a single clinical hospital in Shanghai, China. Upon qualifying the study eligibility, participants will be randomly assigned to receive either robot-assisted therapy or conventional therapy with both interventions being conducted over a 6-week period in a clinical rehabilitation setting. In addition to comprehensive rehabilitation, the robot-assisted therapy group will receive a 30-min Armguider robot-assisted therapy intervention 5 days a week. Primary efficacy outcomes will include Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and Mini-Mental Status Examination (MMSE). Other secondary outcomes will include Trail Making Test (TMT), Auditory Verbal Learning Test (AVLT), Digit Symbol Substitution Test (DSST), and Rey–Osterrieth Complex Figure Test (ROCFT). All trial outcomes will be assessed at baseline and at 6-week follow-up. Intention-to-treat analyses will be performed to examine changes from baseline in the outcomes. Adverse events will be monitored throughout the trial period.

Discussion

This will be the first randomized controlled trial aimed at examining the effects of robot-assisted therapy on upper limb and cognitive functions in acute and subacute stroke patients. Findings from the study will contribute to our understanding of using a novel robotic rehabilitation approach to stroke care and rehabilitation.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100050856. Registered on 5 September 2021.

Effects of Training with a Brain-Computer Interface-Controlled Robot on Rehabilitation Outcome in Patients with Subacute Stroke: A Randomized Controlled Trial

INTRODUCTION

Stroke is always associated with a difficult functional recovery process. A brain-computer interface (BCI) is a technology which provides a direct connection between the human brain and external devices. The primary aim of this study was to determine whether training with a BCI-controlled robot can improve functions in patients with subacute stroke.

METHODS

Subacute stroke patients aged 32-68 years with a course of 2 weeks to 3 months were randomly assigned to the BCI group or to the sham group for a 4-week course. The primary outcome measures were Loewenstein Occupational Therapy Cognitive Assessment (LOCTA) and Fugl-Meyer Assessment for Lower Extremity (FMA-LE). Secondary outcome measures included Fugl-Meyer Assessment for Balance (FMA-B), Functional Ambulation Category (FAC), Modified Barthel Index (MBI), serum brain-derived neurotrophic factor (BDNF) levels and motor-evoked potential (MEP).

RESULTS

A total of 28 patients completed the study. Both groups showed a significant increase in mean LOCTA (sham: P < 0.001, Cohen's d =  - 2.972; BCI: P < 0.001, Cohen's d =  - 4.266) and FMA-LE (sham: P < 0.001, Cohen's d =  - 3.178; BCI: P < 0.001, Cohen's d =  - 3.063) scores. The LOCTA scores in the BCI group were 14.89% higher than in the sham group (P = 0.049, Cohen's d =  - 0.580). There were no significant differences between the two groups in terms of FMA-B (P = 0.363, Cohen's d =  - 0.252), FAC (P = 0.363), or MBI (P = 0.493, Cohen's d =  - 0.188) scores. The serum levels of BDNF were significantly higher within the BCI group (P < 0.001, Cohen's d =  - 1.167), and the MEP latency decreased by 3.75% and 4.71% in the sham and BCI groups, respectively.

CONCLUSION

Training with a BCI-controlled robot combined with traditional physiotherapy promotes cognitive function recovery, and enhances motor functions of the lower extremity in patients with subacute stroke. These patients also showed increased secretion of BDNF.

TRIAL REGISTRATION

Chinese clinical trial registry: ChiCTR-INR-17012874.

Evaluation of an upper limb robotic rehabilitation program on motor functions, quality of life, cognition, and emotional status in patients with stroke: a randomized controlled study

OBJECTIVE

This study aims to find out whether including robotic therapy in addition to a conventional rehabilitation program affects the quality of life, motor function, cognition, and emotional status of hemiplegic patients.

DESIGN

Thirty-seven stroke patients recruited between April 2016 and April 2019 were included in the study. The patients were randomized into 2 groups (Robotic rehabilitation group-RR n:17, Control group n:20), RR was arranged to be 30-45 min, 5 days per week for 4 weeks. All patients were assessed at the beginning of therapy and the end of 4th week with Brunnstrom stages of motor recovery, Fugl-Meyer Assessment (FMA), handgrip strength, Purdue peg test, Minnesota manual dexterity test, Modified Ashworth Scale (MAS), Functional Independence Measure (FIM), Stroke Specific Quality of Life Scale (SS-QOL), Nottingham Extended Activities of Daily Living (NEADL) Scale, Montreal Cognitive Assessment (MoCA) and Center for Epidemiological Studies Depression Scale (CES- D).

RESULTS

Improvements in motor function scores, spasticity, general functioning, activities of daily living, cognitive assessment were better in the robotic group when compared to the control group but this difference was not statistically significant (p > 0.05). Improvement in the CES-D in the RR-group was better in comparison to the control group (p = 0.018).

CONCLUSION

Improvements in motor functions were observed after the treatment in both groups. Although RR group improved better in numbers, none of the outcomes except the CES-D scale were significant. Robotic rehabilitation provides a favorable alternative bringing slight benefits, and also is advantageous in terms of work power and psychological recovery, making its addition to conventional neurological rehabilitation effective and useful in patient management after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04393480.

Serotonin Levels and Cognitive Recovery in Patients with Subacute Stroke after Rehabilitation Treatment

Post-stroke depression and cognitive impairment are common conditions affecting patients after stroke. Serotonin is a neurotransmitter involved in modulating, among others, mood, cognition, learning, and memory. Sub-optimal serotonin activity may be in part responsible for cognitive deficits seen in depression. In this pilot study serotonin levels were evaluated in 29 patients with sub-acute stroke before and after a rehabilitation treatment (consisting of a program of upper limb robotic rehabilitation in addition to conventional physical therapy treatment). We employed the Back Depression Inventory scale to evaluate symptoms of depression, and specific tools to evaluate cognitive functions. We found a significant reduction of the serotonin levels after rehabilitation in the whole group (T0: 85.9 ± 92.4 ng/mL; T1: 61.9 ± 58.4 ng/mL; p = 0.0018), as well as in the subgroup of patients untreated with Selective Serotonin Reuptake Inhibitors (SRRI), (mean serotonin at T0: 154.0 ± 102.3 ng/mL; mean serotonin at T1: 92.9. ± 68.7 ng/mL at T1; p = 0.005). We also found a correlation with cognitive assessment: in particular, the change from baseline of the serotonin (ΔSerotonin) was correlated with the changes from baseline of the Rey’s Figure (ΔROCF) (r = 0.535; p < 0.05), the Tower of London (ΔToL) (subscore point: r = 0.621; p < 0.005; subscore time: r = −0.619; p < 0.005) meaning that a serotonin levels decrease is associated with a worsening of cognitive functions. Considering patients treated and untreated with SSRIs separately, in patients treated with SSRIs (n = 16) we found only a positive correlation between ∆Serotonin and ∆ToL (subscore point: r= 0.587; p = 0.045), whereas in patients untreated with SSRIs (n = 13) we found a positive correlations between ΔSerotonin and ΔROCF (r = 0.700; p = 0.036), ∆Stroop (subscore time: r = 0.750; p = 0.020) and ∆Tol (subscore point: r = 0.740; p = 0.023) and a negative correlation between ΔSerotonin and ∆Tol (subscore time: r= −0.833; p = 0.005). These results suggest that variation of serotonin levels should be monitored in patients during a rehabilitation program, not only for their relationship with depression symptoms, but also for the correlation with cognitive performance.

Influence of Cognitive Impairment on the Recovery of Subjects with Subacute Stroke Undergoing Upper Limb Robotic Rehabilitation

Cognitive decline is often present in stroke survivors, with a significant impact on motor recovery. However, how specific cognitive domains could impact motor recovery after robotic rehabilitation in patients with stroke is still not well understood. In this study, we analyzed the relationship between cognitive impairment and the outcome of a robot-mediated upper limb rehabilitation intervention in a sample of 51 subacute stroke patients. Participants were enrolled and treated with a set of robotic and sensor-based devices. Before the intervention, patients underwent a cognitive assessment by means of the Oxford Cognitive Screen. To assess the effect of the 30-session rehabilitation intervention, patients were assessed twice with the following outcome measures: the Fugl-Meyer Assessment for Upper Extremity (FMA-UE), to evaluate motor function; the Upper limb Motricity Index (MI), to evaluate upper limb muscle strength; the Modified Barthel Index (mBI), to evaluate activities of daily living and mobility. We found that deficits in spatial attention and executive functions impacted the mBI improvement, while language, number processing, and spatial attention deficits reduced the gains in the FMA-UE. These results suggest the importance to evaluate the cognitive functions using an adequate tool in patients with stroke undergoing a robotic rehabilitation intervention.