Effectiveness of soft robotic glove versus repetitive transcranial magnetic stimulation in post-stroke patients with severe upper limb dysfunction: A randomised controlled trial

Does the alternating timing of rTMS combined with soft-hand rehabilitation robot affect the recovery of hand function in patients after stroke? A study protocol for a multicentre randomised controlled trial

INTRODUCTION

Combining repetitive transcranial magnetic stimulation (rTMS) with robotic training could result in more significant improvements in motor function than either treatment alone. The efficacy of this combination may depend on the sequencing of the interventions. However, few studies have explored the possibility of interleaving or alternating between the two treatment modalities within a single session or over a shorter time frame. The objective of this study is to evaluate the efficacy of alternating rTMS and soft-hand rehabilitation robot therapy to enhance upper limb and hand function in patients with ischaemic stroke.

METHODS AND ANALYSIS

This multicentre study will be conducted as a single-blind, controlled, randomised trial, enrolling 132 post-stroke patients with a disease duration ranging from 1 week to 3 months. The study participants will be randomly assigned to group A (n=44), group B (n=44) and group C (n=44). All participants will undergo a 4-week neurological rehabilitation programme, which includes standardised physical and occupational therapy administered by experienced therapists. Group A will receive 10 Hz high-frequency rTMS (HF-rTMS) over the ipsilesional primary motor cortex (iM1) for 20 min, followed by 20 min of soft-hand rehabilitation robot training. Group B will receive 5 min of 10 Hz HF-rTMS over the iM1 followed by 5 min of soft-hand rehabilitation robot training, repeated four times. Group C will receive sham rTMS with other parameters identical to those of group A. The above treatments will be administered once daily, 5 days a week, for 4 weeks. The primary outcome measurement is the Fugl-Meyer assessment of upper extremity (FMA-UE). The secondary outcome measurements include the Hong Kong edition of Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK), the Modified Ashworth Scale (MAS), and the International Classification of Functioning, Disability and Health upper extremity entries (ICF-Upper Extremity Entries). Assessments will be conducted at baseline and after 4 weeks of treatment.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (2024-SR-515). The findings of this study will be spread through networks of scientists, professionals and the general public, as well as peer-reviewed scientific papers and presentations at pertinent conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2400089583.

Repetitive transcranial magnetic stimulation for motor function in stroke: a systematic review and meta-analysis of randomized controlled studies

OBJECTIVE

This study aimed to systematically evaluate the safety and effectiveness of repetitive transcranial magnetic stimulation (rTMS) in treating motor dysfunction in stroke patients.

METHODS

A systematic search was conducted in five online databases, namely, Medline, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and SPORTDiscus, from their inception to July 29, 2024. Studies meeting the predetermined inclusion criteria were included. The data were analyzed using RevMan 5.4.1 software and Stata 15.0. The subgroup analysis was conducted based on various disease stages and intervention frequencies. The overall effects were estimated using either the fixed effects model or the random effects model, with standardized mean differences (SMDs). The level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework.

RESULTS

A total of 70 studies encompassing 2951 stroke survivors were included. The results of the quantitative analysis revealed that the application of 1 Hz rTMS over the contralesional primary motor cortex (M1) significantly improved motor function during both the early stage (< 1 month) with moderate effect size (n = 443, SMD = 0.44, 95% CI 0.24 to 0.63, P < 0.00001, I2 = 47%, fixed-effect model) and recovery period (1-6 months) with moderate effect size (n = 233, SMD = 0.61, 95% CI 0.34 to 0.87, P < 0.0001, I2 = 33%, fixed-effect model). In the context of activities of daily living (ADLs), the application of 1 Hz rTMS over the contralesional M1 can lead to improvements in ADLs among individuals in the early stages of stroke with moderate effect size (n = 343, SMD = 0.67, 95% CI 0.44 to 0.89, I2 = 79%, P < 0.00001, fixed-effect model). However, evidence to support that 1 Hz rTMS over contralesional M1 can improve motor dysfunction in the chronic phase of stroke (> 6 months) is insufficient.

CONCLUSION

Moderate- to high-quality evidence suggests that 1 Hz rTMS over the contralesional M1 may enhance motor function and independence in ADL during the early stages of stroke and the recovery period (within 6 months) with moderate effect. Nonetheless, as for the efficacy of 3, 5, 10, and 20 Hz rTMS in the treatment of motor dysfunction after stroke, it needs to be further determined. It is important to interpret these findings with caution in clinical practice due to the small sample sizes and low quality of the studies reviewed.

SYSTEMATIC REVIEW REGISTRATION

INPLASY, Registration number is INPLASY202360042. DOI number is https://doi.org/10.37766/inplasy2023.6.0042 .

Effectiveness of robot-assisted task-oriented training intervention for upper limb and daily living skills in stroke patients: A meta-analysis

PURPOSE

Stroke is one of the leading causes of acquired disability in adults in high-income countries. This study aims to determine the intervention effects of robot-assisted task-oriented training on enhancing the upper limb function and daily living skills of stroke patients.

METHODS

A systematic search was conducted across PubMed, China National Knowledge Infrastructure, Web of Science, Cochrane Library, Embase, and Scopus databases through March 1, 2024. This process yielded 1,649 articles, from which 15 studies with 574 samples met the inclusion criteria for analysis. The quality of the included studies was evaluated using the Cochrane Risk of Bias tool. We performed meta-analyses, subgroup analyses, regression analyses, and sensitivity analyses using Review Manager 5.4 and Stata 17.0. Furthermore, publication bias was assessed using Begg's and Egger's tests. This study is registered with PROSPERO (No. CRD42024513483).

RESULTS

A random effects model was utilized. The results indicated that robot-assisted task-oriented training significantly improved Fugl-Meyer Assessment-Upper Extremity scores compared to the control group [SMD = 1.01, 95% CI (0.57, 1.45)]. Similarly, robot-assisted task-oriented training demonstrated a significant effect on the Modified Barthel Index scores [SMD = 0.61, 95% CI (0.41, 0.82)]. Subgroup and regression analyses revealed that the use of combined interventions, the geographical region of the first author, and the age of the subjects did not appear to be sources of high heterogeneity. Publication bias tests using the FMA-UE as an outcome measure yielded Begg's test (p = 0.76) and Egger's test (p = 0.93), suggesting no significant publication bias. Sensitivity analyses confirmed the robustness of the study findings.

CONCLUSIONS

Robot-assisted task-oriented training significantly enhances the rehabilitation of upper limb function and the recovery of daily living skills in stroke patients.

Effectiveness of Two Models of Telerehabilitation in Improving Recovery from Subacute Upper Limb Disability after Stroke: Robotic vs. Non-Robotic

BACKGROUND/OBJECTIVES

Finding innovative digital solutions is fundamental to ensure prompt and continuous care for patients with chronic neurological disorders, whose demand for rehabilitation also in home-based settings is steadily increasing. The aim is to verify the safety and the effectiveness of two telerehabilitation (TR) models in improving recovery from subacute upper limb (UL) disability after stroke, with and without a robotic device.

METHODS

One hundred nineteen subjects with subacute post-stroke UL disability were assessed for eligibility. Of them, 30 patients were enrolled in the study and randomly assigned to either the Robotic Group (RG), undergoing a 20-session TR program, using a robotic device, or the Non-Robotic Group (NRG), undergoing a 20-session TR program without robotics. Clinical evaluations were measured at baseline (T0) and post-intervention (T1, 5 weeks after baseline), and included assessments of quality of life, motor skills, and clinical/functional status. The primary outcome measure was the World Health Organization Disability Assessment Schedule 2.0, evaluating the change in perceived disability.

RESULTS

Statistical analysis shows that patients of both groups improved significantly over time in all domains analyzed (mean decrease from baseline in the WHODAS 2.0 of 6.09 ± 2.62% for the NRG, and of 0.76 ± 2.21% for the RG), with a greater improvement of patients in the NRG in motor (Fugl-Meyer Assessment Upper Extremity-motor function, Box and Block Test) and cognitive skills (Trail Making Test-A).

CONCLUSIONS

This study highlights the potential of TR programs to transform stroke rehabilitation by enhancing accessibility and patient-centered care, promoting autonomy, improving adherence, and leading to better outcomes and quality of life for stroke survivors.

A Scoping Review of Technology-Based Approaches for Upper Limb Motor Rehabilitation after Stroke: Are We Really Targeting Severe Impairment?

Technology-based approaches for upper limb (UL) motor rehabilitation after stroke are mostly designed for severely affected patients to increase their recovery chances. However, the available randomized controlled trials (RCTs) focused on the efficacy of technology-based interventions often include patients with a wide range of motor impairment. This scoping review aims at overviewing the actual severity of stroke patients enrolled in RCTs that claim to specifically address UL severe motor impairment. The literature search was conducted on the Scopus and PubMed databases and included articles from 2008 to May 2024, specifically RCTs investigating the impact of technology-based interventions on UL motor functional recovery after stroke. Forty-eight studies were selected. They showed that, upon patients' enrollment, the values of the UL Fugl-Meyer Assessment and Action Research Arm Test covered the whole range of both scales, thus revealing the non-selective inclusion of severely impaired patients. Heterogeneity in terms of numerosity, characteristics of enrolled patients, trial design, implementation, and reporting was present across the studies. No clear difference in the severity of the included patients according to the intervention type was found. Patient stratification upon enrollment is crucial to best direct resources to those patients who will benefit the most from a given technology-assisted approach (personalized rehabilitation).

Stolwijk-Swüste JM, Brink SM, Voet NBM, Rietman JS, Prange-Lasonder GB. Therapy effect on hand function after home use of a wearable assistive soft-robotic glove supporting grip strength

BACKGROUND

Soft-robotic gloves with an assist-as-needed control have the ability to assist daily activities where needed, while stimulating active and highly functional movements within the user's possibilities. Employment of hand activities with glove support might act as training for unsupported hand function.

OBJECTIVE

To evaluate the therapeutic effect of a grip-supporting soft-robotic glove as an assistive device at home during daily activities.

METHODS

This multicentre intervention trial consisted of 3 pre-assessments (averaged if steady state = PRE), one post-assessment (POST), and one follow-up assessment (FU). Participants with chronic hand function limitations were included. Participants used the Carbonhand glove during six weeks in their home environment on their most affected hand. They were free to choose which activities to use the glove with and for how long. The primary outcome measure was grip strength, secondary outcome measures were pinch strength, hand function and glove use time.

RESULTS

63 patients with limitations in hand function resulting from various disorders were included. Significant improvements (difference PRE-POST) were found for grip strength (+1.9 kg, CI 0.8 to 3.1; p = 0.002) and hand function, as measured by Jebson-Taylor Hand Function Test (-7.7 s, CI -13.4 to -1.9; p = 0.002) and Action Research Arm Test (+1.0 point, IQR 2.0; p≤0.001). Improvements persisted at FU. Pinch strength improved slightly in all fingers over six-week glove use, however these differences didn't achieve significance. Participants used the soft-robotic glove for a total average of 33.0 hours (SD 35.3), equivalent to 330 min/week (SD 354) or 47 min/day (SD 51). No serious adverse events occurred.

CONCLUSION

The present findings showed that six weeks use of a grip-supporting soft-robotic glove as an assistive device at home resulted in a therapeutic effect on unsupported grip strength and hand function. The glove use time also showed that this wearable, lightweight glove was able to assist participants with the performance of daily tasks for prolonged periods.

Addressing Data Absenteeism and Technology Chauvinism in the Use of Gamified Wearable Gloves Among Older Adults: Moderated Usability Study

BACKGROUND

Digital health technologies have the potential to improve health outcomes for older adults, especially for those recovering from stroke. However, there are challenges to developing these technologies, such as data absenteeism (where older adults' views are often underrepresented in research and development) and technology chauvinism (the belief that sophisticated technology alone is the panacea to addressing health problems), which hinder their effectiveness.

OBJECTIVE

In this study, we aimed to address these challenges by developing a wearable glove integrated with culturally relevant exergames to motivate older adults to exercise and, for those recovering from stroke, to adhere to rehabilitation.

METHODS

We conducted a moderated usability study with 19 older adults, of which 11 (58%) had a history of stroke. Our participants engaged in a 30-minute gameplay session with the wearable glove integrated with exergames, followed by a quantitative survey and an in-depth interview. We used descriptive analysis to compare responses to the System Usability Scale between those who had a history of stroke and those who did not. In addition, we analyzed the qualitative interviews using a bottom-up thematic analysis to identify key themes related to the motivations and barriers regarding the use of wearable gloves for rehabilitation and exercise.

RESULTS

Our study generated several key insights. First, making the exergames exciting and challenging could improve exercise and rehabilitation motivation, but it could also have a boomerang effect, where participants may become demotivated if the games were very challenging. Second, the comfort and ease of use of the wearable gloves were important for older adults, regardless of their stroke history. Third, for older adults with a history of stroke, the functionality and purpose of the wearable glove were important in helping them with specific exercise movements.

CONCLUSIONS

Our findings highlight the importance of providing contextual support for the effective use of digital technologies, particularly for older adults recovering from stroke. In addition to technology and usability factors, other contextual factors such as gamification and social support (from occupational therapists or caregivers) should be considered to provide a comprehensive approach to addressing health problems. To overcome data absenteeism and technology chauvinism, it is important to develop digital health technologies that are tailored to the needs of underserved communities. Our study provides valuable insights for the development of digital health technologies that can motivate older adults recovering from stroke to exercise and adhere to rehabilitation.

The Application of Soft Robotic Gloves in Stroke Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Wearable robotic devices have been strongly put into use in both the clinical and research fields of stroke rehabilitation over the past decades. This study aimed to explore the effectiveness of soft robotic gloves (SRGs) towards improving the motor recovery and functional abilities in patients with post-stroke hemiparesis. Five major bibliographic databases, PubMed, Embase, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database, were all reviewed for enrollment regarding comparative trials prior to 7 March 2023. We included adults with stroke and compared their rehabilitation using SRGs to conventional rehabilitation (CR) on hand function in terms of the Fugl-Meyer Upper Extremity Motor Assessment (FMA-UE), Fugl-Meyer Distal Upper Extremity Motor Assessment (FMA-distal UE), box and blocks test score, grip strength test, and the Jebsen-Taylor hand function test (JTT). A total of 8 studies, comprising 309 participants, were included in the analysis. Compared to CR, rehabilitation involving SRGs achieved better FMA-UE (MD 6.52, 95% CI: 3.65~9.39), FMA-distal UE (MD 3.27, 95% CI: 1.50~5.04), and JJT (MD 13.34, CI: 5.16~21.53) results. Subgroup analysis showed that stroke latency of more than 6 months and training for more than 30 min offered a better effect as well. In conclusion, for patients with stroke, rehabilitation using SRGs is recommended to promote the functional abilities of the upper extremities.